Pediatric Cholecystitis Clinical Presentation

Updated: Oct 20, 2017
  • Author: Steven M Schwarz, MD, FAAP, FACN, AGAF; Chief Editor: Carmen Cuffari, MD  more...
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Presentation

History

Symptoms of cholelithiasis often precede those of cholecystitis, although patients may have acute cholecystitis on initial presentation. Cholelithiasis causes biliary colic. Patients may complain of intermittent abdominal pain of inconsistent severity in the right upper quadrant, with possible radiation to the scapular region of the back, or pain may be diffuse or localized to the epigastrium.

Discomfort is more likely to be nonspecific in infants and younger children. Patients of this age group often present with irritability, jaundice, and acholic stools.

The classic history of patients with gallstones is postprandial right upper quadrant pain associated with nausea and vomiting, but this is usually observed only in older children. Jaundice in pediatric cholelithiasis is much more frequent than in adults and can occur in the absence of gallstone obstruction of the common bile duct. Most likely, the stone causes inflammation of the ductal tissue, creating an edematous obstruction to bile flow.

Patients with chronic cholecystitis usually present similarly to patients with biliary colic, with an intermittent and indolent history of pain. Therefore, differentiation must be made on the basis of findings from the physical examination and diagnostic tests.

Acute cholecystitis pain resembles biliary colic but is usually more severe and constant, lasting for several days. The pain may begin as a vague discomfort; however, as inflammation spreads and affects the surrounding peritoneum, the pain localizes to the right upper quadrant.

Patients often report a recent history of nausea, vomiting, anorexia, and a low-grade fever. Onset of symptoms usually occurs approximately 1 week prior to presentation, although the patient may report years of the less severe symptoms of biliary colic and chronic cholecystitis.

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Physical Examination

The physical examination in acute cholecystitis usually reveals right upper quadrant tenderness. The classic triad is right upper quadrant pain, fever, and leukocytosis. The patient may have abdominal guarding and a positive Murphy sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder combined with distension may create a palpable mass between the 9th and 10th costal cartilages.

The ductal system may become inflamed, causing cholangitis. In 50% of these cases, the examiner may find a Charcot triad. This combination of right upper quadrant pain, fever, and jaundice indicates obstruction of the common bile duct and the presence of acute cholangitis. The Charcot triad is considered to represent a medical emergency, and patients require immediate intervention.

Performing a physical examination may be the only way to distinguish biliary colic from chronic cholecystitis. In chronic cholecystitis, the patient usually complains of tenderness to palpation in the right upper quadrant; however, the differentiation may be trivial, given the high likelihood of chronic cholecystitis in the presence of recurring biliary colic.

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