Pediatric Cholecystitis Treatment & Management

Cholecystectomy is the standard of care for cholecystitis. Medical treatment is used in patients who are not candidates for surgery, as well as in certain other settings. Intervention with cholecystotomy or ERCP may be indicated.

Although controversy still surrounds the use of cholecystectomy versus medical management, the morbidity and mortality rates have been the same in patients receiving early surgery as in those in whom surgery was delayed more than 48 hours for stabilization of inflammation. However, because symptoms continued in 24% of patients in whom surgery was delayed, if surgery is the goal of treatment, no advantage to delaying surgery is noted.

Removal of the gallbladder is the standard of care in patients with symptomatic gallstone disease, although some exceptions are noted.

Acute cholecystitis

Critically ill children with acute acalculous cholecystitis may not tolerate anesthesia and operative conditions. ^[1] These children should receive antibiotic therapy, parenteral nutrition, and gastric decompression until their condition improves. These patients may then undergo surgery if symptoms persist; however, many cases resolve with medical therapy alone.

One author reported a 75% resolution of acute acalculous cholecystitis with the use of antibiotics, nasogastric suction, and hyperalimentation. Therefore, antibiotics may be sufficient in critically ill patients who do not tolerate anesthesia and who may be assisted by other procedures, such as cholecystotomy, if gallbladder drainage is necessary.

Observation is also recommended for infants with gallstones, including for those with parenteral nutrition–associated cholestasis and for infants in whom gallstones are incidentally noted. These gallstones often dissolve with maturation of the hepatobiliary system.

The gallbladder should be removed if the patient shows any sign of common duct obstruction, pancreatitis, or cholecystitis. Cholecystectomy should also be performed if gallstones persist longer than 1 year or if long-term hyperalimentation is anticipated, as in Crohn disease, pseudo-obstruction, or short-bowel syndrome.

Chronic cholecystitis

Medical care in chronic cholecystitis or other gallbladder disease is also supportive. Cholecystectomy is recommended in most patients with gallstone disease. Treatment should be aimed at control of any underlying conditions and preparation for surgery.

Contact dissolution and biliary lithotripsy

Other medical management strategies include contact dissolution and biliary lithotripsy.

Percutaneous transhepatic cholecystolitholysis involves the injection of a cholesterol solubilizer, such as methyl-tert -butyl ether, directly into the gallbladder. The time between instillation and aspiration must be conscientiously limited to avoid leakage into the bile duct, causing abdominal pain and duodenitis. This method has been successful in a few children.

Biliary lithotripsy has also been used with limited success. Similar to lithotripsy for nephrolithiasis, biliary lithotripsy uses shock waves to pulverize gallstones. Biliary lithotripsy causes fragmentation of stones in most patients but rarely causes complete dissolution. Because fragments may still cause biliary colic and cholecystitis, additional oral therapy may be necessary.

All management techniques that involve leaving the gallbladder in situ have 1-year recurrence rates of approximately 10% and 5-year recurrence rates of approximately 50%.

Bile acid therapy

Two oral medications that have been used with some success for the dissolution of cholesterol gallstones are chenodiol (chenodeoxycholic acid) and ursodiol (ursodeoxycholic acid). Both medications selectively inhibit hydroxymethylglutaryl-coenzyme A reductase (HMG-CoA reductase), thereby decreasing bile cholesterol supersaturation and lithogenicity.

Chenodiol was shown to achieve complete dissolution of pure cholesterol gallstones in 15% of adult patients and partial dissolution in 28% of adult patients. However, the medications are expensive and cause adverse effects, including diarrhea and hepatotoxicity. These agents have not yet been approved by the US Food and Drug Administration (FDA) for use in children.

Combination treatment may be more effective and allow lower doses of each medication, causing fewer adverse effects. Although ursodiol was found to be unsuccessful in dissolving radiolucent gallstones in 10 children with CF, it has been shown to increase hepatobiliary excretion and may be useful in a cytoprotective and preventative role.

Medical care of the patient with acute cholecystitis centers on stabilization of the patient and preparation for surgery if the patient is a candidate.

The patient should receive nothing by mouth (NPO), and a nasogastric tube should be placed to low-intermittent wall suction for evacuation of gastric contents. This step minimizes stimulation to the inflamed gallbladder and prepares the patient for general anesthesia. Administer pain medications; however, avoid morphine because of its spasmodic effects on the sphincter of Oddi.

Hydration

Administer intravenous (IV) fluids to correct any dehydration and continue as maintenance therapy. Standard regimens include 5% dextrose in 0.2% sodium chloride solution or 5% dextrose in 0.45% sodium chloride solution with 20 mEq of potassium chloride (KCl) per liter at a rate determined by standard pediatric calculations.

Patients who are at risk for vaso-occlusion, including those with sickle hemoglobinopathies, should receive hydration at 1.5 times maintenance dose.

Antibiotic therapy

Antibiotics with biliary excretion covering enteric pathogens may be administered to control infection. The combination of ampicillin, gentamicin, and clindamycin is a common and well-accepted regimen.

The use of antibiotics remains controversial. Some authors assert that antibiotics are not necessary in simple cases and should be reserved for persistent fever or worsening condition.

However, Agrawal et al found a significant reduction in postoperative infection with the use of prophylactic preoperative antibiotics in elective cholecystectomy. ^[17]

Because of the high percentage of cases of acute cholecystitis that are complicated by bacterial colonization, clinicians should maintain a low threshold for the use of antibiotic therapy.

Concomitant sickle cell disease

Children with sickle cell disease present a unique challenge, because their hemoglobinopathy may cause perioperative and postoperative complications. These patients are susceptible to vaso-occlusive crises, pneumonia, sepsis, and pulmonary infarct, most likely secondary to hypoxia, dehydration, and acidosis in response to anesthesia.

Nevertheless, elective LP may be safely performed in children with sickle cell disease. ^[18]

Ware et al observed no complications when preoperative transfusions of packed red blood cells were given to obtain a hemoglobin A ratio greater than 2:1 while the hematocrit level was maintained at 35-45%. ^[19] This required two transfusions given 2 weeks apart in most patients, with partial volume exchange used for those with hemoglobin sickle cell or sickle beta-thalassemia disease.

Although open cholecystectomy (OC) was previously considered the criterion standard, laparoscopic cholecystectomy (LC) is now accepted as the criterion standard and preferred procedure in almost all cases.

Advantages of the laparoscopic approach include reduced pain and hospital stay and improved cosmetic results and patient satisfaction.

Lugo-Vicente found that the length of stay, days that pain medication is taken, and time before a regular diet can be resumed were all reduced by one half with LC. ^[20]

Some concern remains regarding the previously reported higher risk of bile duct injury. However, the incidence of complicated gallstone disease appears less common in the pediatric population than in the adult population, because most children present with symptomatic cholelithiasis without active inflammation. Consequently, the rate of ductal complications is very low.

Acute inflammation of the gallbladder has been a concern, but many authors now agree that acute cholecystitis is not a contraindication; however, the surgeon must be experienced and well skilled with laparoscopic techniques. In addition, conversion to OC can always be performed in difficult cases.

Some authors assert that LC is ideal in infants and children and should be the procedure of choice. In this case, surgical experience with laparoscopy and with infants is essential. Wide spacing of cannulas is helpful in small children to allow for visualization and adequate working distance. Also, with conscientious surgical technique, some authors believe that bile duct injury can be minimized.

In general, OC is reserved for conversion and cases of prior major abdominal surgery. OC is accomplished through a right subcostal incision or a transverse abdominal incision if a splenectomy is also indicated. Laparoscopic entry involves four ports: two subcostal, two subxiphoid, and one umbilical.

The surgical course is usually routine. Patients can be admitted to the hospital the day of surgery and discharged within 48-72 hours. The average postsurgical hospital stay after LC is 36 hours, whereas patients undergoing OC typically need to stay in the hospital for 3 days.

Continue hydration until the patient can tolerate a regular diet, usually the morning after LC. In either procedure, it is recommended to observe the patient postoperatively for complications, including fever, jaundice, ileus, pancreatitis, bile leak, or urinary retention. Jaundice or continued right upper quadrant pain may signify a retained common duct stone or biliary injury and should be investigated using ERCP or hepatoiminodiacetic acid (HIDA) scanning as soon as possible.

Technique for laparoscopic cholecystectomy in children

The technique for laparoscopic cholecystectomy in pediatric patients is very similar to the one described in adult patients; however, a few variables must be considered. ^{[21, 22, 23]}

First, the trocar placement (demonstrated in the image below) is determined by patient size and position of the gallbladder and the liver.

The authors usually start by placing a 12-mm trocar in the umbilical position. A small incision is made from the center of the umbilicus inferiorly, in order to expose the midline fascia at the umbilicus. Local anesthetic is infiltrated at that site.

The authors' preferred approach is to place a STEP trocar (Covidien Surgical; Mansfield, MA) through that site using a Verees needle technique. Starting with a 5-mm STEP trocar is recommended; once the peritoneal cavity is insufflated with carbon dioxide, the trocar is upgraded to a 12-mm STEP placed through the same sleeve as the 5-mm trocar.

Typically, the peritoneal cavity is insufflated with carbon dioxide using the following pressure limits:

• Obese teenaged patients - 16 mm Hg

• Normal-sized, healthy teenaged patients - 14 mm Hg

• Patients aged 8-12 years - 12 mm Hg

• Patients younger than 7 years - 10 mm Hg

If the patient had any previous abdominal surgery or is significantly obese, the authors prefer to use an open technique for the initial trocar placement. In such cases, creating an opening on the inferior aspect of the umbilicus until the muscle fascia and the linea Alba can be visualized is important.

Stay sutures of 2-0 Vicryl are placed on each side of the muscle fascia, which is then opened under direct visualization. Additional Vicryl sutures may be needed in order to elevate the fascia until the peritoneal membrane can be visualized and entered.

Once the peritoneum is open, a 12-mm trocar can be inserted under direct visualization, and the peritoneal cavity is insufflated with carbon dioxide. The authors perform most LCs with a 5-mm, 30°-angled laparoscope. However, in patients who are significantly obese, a 10-mm trocar should be used to perform the cystic duct dissection, as the small 5-mm laparoscope does not generate enough light inside the large abdominal cavity of an obese patient and may compromise the surgeon’s ability to clearly visualize all vital structures surrounding the cystic duct.

Considering that most complications related to laparoscopic gallbladder surgery occur during the dissection and exposure of the cystic duct, one should never work under poor light and inadequate visualization at that point in the operation. Beginning the procedure with the 10-mm laparoscope in place via the 12-mm trocar is fairly easy, as is changing to a 5-mm laparoscope once the dissection and exposure of the cystic duct and artery are completed.

Second, subsequent trocar placement in children must be determined individually once the gallbladder fundus is visualized with the laparoscope. A 5-mm trocar is typically placed in the subxiphoid region. Another 5-mm trocar should be placed in the mid-right upper quadrant of the abdomen (at the level of the midclavicular line) in a way that allows the introduction of a laparoscopic instrument used to manipulate the neck of the gallbladder. This trocar is usually placed about 2 cm below the costal margin. However, in small children, it must be placed closer to the costal margin.

The last trocar should be a 5-mm trocar placed laterally in the right upper quadrant. This trocar is used for placement of a grasping instrument, such as a McKernan grasping-locking forceps, that is placed on the fundus of the gallbladder for retraction. For that reason, the trocar should not be placed too far from the costal margin. (See the image below.)

Once the gallbladder fundus is grasped, it must be displaced towards the patient’s right shoulder, above the right lobe of the liver. This maneuver allows for exposure of the neck of the gallbladder. One assistant should keep the fundus of the gallbladder pushed toward the patient’s shoulder region at all times. This elevates the neck of the gallbladder together with the cystic duct and artery, facilitating dissection and exposure.

The third important step is the exposure and dissection of the neck of the gallbladder. If significant inflammatory changes are identified, the authors prefer to perform an intraoperative cholangiography to help define the anatomy of the cystic duct and its relationship to the gallbladder and common bile duct.

Other indications for intraoperative cholangiography are a history of jaundice, pancreatitis, dilation of the common bile duct, and the presence of small gallstones. The benefits of using cholangiography have not been proven for routine cholecystectomy, routine screening for congenital anomalies, or assessment of the common bile duct for obstruction in the absence of clinical suspicion.

Cholangiography can be performed intravenously or percutaneously. The authors prefer to perform a cholangiography through the gallbladder. This can be easily performed by placing a percutaneous catheter in the gallbladder under laparoscopic visualization. The gallbladder is filled with water-soluble dye, and radiographic images are obtained with live fluoroscopy.

Intraoperative cholangiography allows the surgeon to identify any points of biliary obstruction and determine whether any evidence of common bile duct stones is present. In addition, it provides information about the length and relative location of the cystic duct, facilitating dissection and minimizing the risk of injury to the ducts.

The dissection for exposure of the cystic duct and artery is started at the neck of the gallbladder. Initially mobilizing the visceral peritoneum and any inflammatory adhesions away from the neck of the gallbladder is important. This can be easily performed using a hook with electrocautery. The authors usually have the surgeon manipulate the laparoscopic camera, with a hook or Maryland dissector in the right hand placed via the subxiphoid trocar.

The assistant should be retracting the fundus of the gallbladder toward the right shoulder at all times and should also have a blunt grasper in the right hand to manipulate the neck of the gallbladder. This manipulation involves moving the neck back and forth, toward the patient’s right and left side, providing dynamic exposure for the surgeon. The assistant should never keep the neck of the gallbladder in a fixed and locked position.

Using careful dissection, the surgeon must achieve the so-called "critical view." This refers to the visualization of the cystic duct and artery as they enter the gallbladder.

Dissecting towards the common bile duct and exposing the duct is not necessary. Once the point of entry of the cystic duct is clearly visualized on the gallbladder, the duct can be clipped and divided. The authors prefer to place one 5-mm clip on the cystic duct next to the gallbladder and two clips towards the common bile duct.

Again, the dissection and exposure of the cystic duct is kept very close to the gallbladder, which should minimize the risk of injury to the common bile duct. The cystic artery can be simultaneously clipped with the cystic duct or can be separately clipped, depending on its proximity to the duct.

Completely dissecting the artery and fully exposing it is not necessary, because this may lead to bleeding from small branches. In young children, cauterizing the artery is possible. Controlling the artery with a LigaSure or Harmonic scalpel is also possible. However, such devices are rarely necessary during LC.

Once the cystic duct is divided with laparoscopic scissors, its lumen should be inspected to make sure that no evidence of any abnormalities suggests the presence of an injury to the common bile duct. At this point in the operation, the surgeon should use an electrocautery hook to divide the visceral peritoneum at the plane between the gallbladder and the liver. Again, the assistant moves the gallbladder back and forth, providing continuous exposure of that plane until the gallbladder is completely free.

If a hole is accidentally made in the gallbladder wall, the leakage of bile and gallstones can be controlled by placing the grasping instrument over the hole. Any stones that leaked should be removed using a suction irrigation device.

Occasionally, a gallbladder is partially intrahepatic. In such cases, removing a wedge of liver tissue with the gallbladder is necessary. Electrocautery dissection at high settings should provide sufficient hemostasis. Once the gallbladder is completely disconnected from the liver, the authors move the laparoscope to the subxiphoid port and insert a 10-mm endopouch through the umbilical port. The gallbladder is placed inside the bag and brought into the trocar.

In most cases, the gallbladder is too big to be removed through the 12-mm port. The authors prefer to enlarge the umbilical incision and expose the muscle fascia, which is then divided with electrocautery. This allows extraction of the pouch that contains the gallbladder. The fascia can then be reapproximated with Vicryl sutures.

After the gallbladder is removed, the authors prefer to reinspect the liver bed to make sure that no evidence of bleeding or bile leaking is present. Any residual bile is suctioned. At this point, all trocars are removed under direct laparoscopic visualization, and the operation is completed. The fascia at the 5-mm trocar sites does not need to be closed, unless the patient is younger than 5 years.

Mini-laparoscopic technique

Experience has demonstrated the feasibility of a mini-laparoscopic technique for removal of the gallbladder in pediatric patients. The laparoscopic operation can be achieved using 3-mm instruments and minimal use of ports. A 3-port mini-approach has been reported.

However, patient selection is essential when performing this operation with mini-instruments. One should not sacrifice good visualization and optimal exposure of the vital structures. The risk of iatrogenic injury to the common bile duct outweighs any benefit that can be achieved with mini-scopes and mini-instruments. Inflammation and adhesions, frequently seen in symptomatic patients, may limit the use of the mini-laparoscopic approach.

Complications of cholecystectomy

LC is associated with some risks. Major complications include bleeding, pancreatitis, leakage from the duct stump, and major bile duct injury. The risk of ductal injury increases from 0.1-0.2% in OC to 0.5-1% in LC.

However, Holcomb et al reported no iatrogenic injuries with LC in their first 100 patients. ^[24] They stated that with conscientious surgical care, morbidity related to the laparoscopic approach can be minimized.

Other procedures used in conjunction with cholecystitis also carry risks. Choledochotomy and endoscopic papillotomy may be performed independently or in conjunction with cholecystectomy to aid in the treatment of choledocholithiasis. The overall mortality rate from choledochotomy (also applied to papillotomy) was determined to be 2.1%; however, by excluding patients with preexisting cholangitis or pancreatitis, the mortality rate decreased to 1.2% and the morbidity rate was 6-8%. The most serious complications resulting from these procedures have been hemorrhage, cholangitis, and pancreatitis.

In general, the complication rates of cholecystitis and cholecystectomy are low in the absence of critical illness. The ability to tolerate general anesthesia and operative conditions for cholecystectomy has become the most significant indicator of outcome in cholecystitis. As a rule, children recover well once appropriate operative treatment has been established.

One alternative to cholecystectomy is percutaneous transhepatic cholecystostomy. In this approach, a catheter is threaded directly into the gallbladder and placed to allow gravity drainage.

Cholecystostomy is especially useful in acalculous cholecystitis and in seriously ill patients with simple gallstones in whom obstruction of the common bile duct is ruled out. Because cholecystectomy is the standard of care for cholecystitis, cholecystostomy is usually reserved for seriously ill patients who may not tolerate surgery.

Dietary recommendations in gallbladder disease differ according to the stage of disease. The two available strategies include acute management and preventive measures. The patient with acute cholecystitis should ingest nothing by mouth (NPO) and undergo nasogastric evacuation of gastric contents. The goal in this stage of disease is to eliminate unnecessary stimulation to the biliary system and to reduce infectious exposure. Additionally, preparations can be more readily made for surgery.

No widely accepted dietary therapy exists for the prevention of cholecystitis; however, the contemporary Western diet and obesity have been implicated as predisposing factors in the development of gallstone disease. Certainly, diet and exercise are influential, and the West is infamous for poor dietary and exercise habits.

Results from a Jamaican cohort study by Walker et al indicated a link between diet and cholecystitis. The authors examined a population of patients with sickle cell disease similar to that examined by Winter et al in the United States. The progression of biliary sludge to cholecystitis and the need for cholecystectomy was significantly decreased in the Jamaican population. Walker et al theorized that dietary differences in the two countries were causal. These cultural influences affect the adolescent and adult populations. ^[25]

Presumably, a decrease in cholesterol and fatty food consumption would lower the risk of cholecystitis, but no specific data supporting this have been collected. Dietary restriction to achieve weight reduction may minimize risk in children with obesity. Weight loss should be controlled and gradual, because rapid reduction may increase bile cholesterol saturation and gallbladder stasis, actually promoting stone formation.

Dietary management of chronic gallbladder disease in the absence of surgery also follows this preventive approach, with the added goal of preventing symptoms. Although biliary colic in children is less likely to directly correspond to fatty food consumption than it is in adults, the patient should still be advised to avoid high-fat meals.

Finally, in patients with hyperalimentation-associated gallstones, administer low-dose enteral feedings, which may prevent stone formation by stimulating contraction of the gallbladder and reduction of bile stasis.

Cholecystitis does not directly affect activity. Children should remain as active as their condition, comfort, and development allow. Postoperatively, activity recommendations correspond with the general precautions recommended for abdominal surgery. Ambulation, as soon as tolerable, improves outcomes, although patients should restrict lifting to less than 5 pounds for several weeks.

Treat the pediatric patient with cholecystitis at a facility with the services of a pediatrician and a staff proficient in the care of children. A pediatric surgeon should be available, preferably one proficient at LC. In addition, appropriate radiologic and gastroenterologic procedures (eg, cholangiography, ERCP) should be readily available.

If these resources are deficient, consider transfer to an appropriate institution. Outcomes for children with cholecystitis who are given proper care are generally excellent, although complications can occur; the prognosis plummets with neglect. Clinicians caring for these children should be experienced in treating gallbladder disease and have all necessary resources at their disposal.

The focus of prevention of cholecystitis is the minimization of controllable risk factors. Because most of these factors for pediatric cholecystitis are related to underlying disease processes, options are limited, but conscientious treatment by the primary provider, knowledge of risks, and close observation for symptoms are helpful.

Reduction of risk factors

As previously mentioned, weight control in the child with obesity may decrease the risk of cholelithiasis and many other long-term sequelae.

The use of pancreatic enzymes and bile acid supplements in patients with CF decreases the saturation and lithogenicity of bile.

Limited enteral feedings in children who require long-term hyperalimentation decrease the biliary hypofunction observed in prolonged fasting.

The addition of ursodeoxycholic acid (Actigall) in settings of chronic biliary stasis may mitigate the potential for cholelithiasis to develop.

Seriously consider the risks associated with medications, (eg, oral contraception, furosemide, ceftriaxone, octreotide, cyclosporine) before using them in patients who are at risk.

Use a team approach to achieve proper care of the patient with cholecystitis. Consult a pediatric gastroenterologist and surgeon early in the treatment of the patient. The assistance of a dietitian may be very useful if observation without surgery is to be used. In addition, consulting a radiologist is helpful if percutaneous cholecystotomy is considered.

The surgeon should follow up with the patient 2 weeks after surgery to monitor wound healing and to ensure no postoperative complications are present. The clinician should be sensitive to any indication of biliary injury or obstruction and investigate any such signs quickly. The patient should be aware that common bile duct stones may still occur in the absence of the gallbladder.

Evaluate future abdominal pain in the right upper quadrant, because it may represent residual or recurrent common bile duct stones. If unrecognized, bile duct stones may lead to biliary obstruction and hepatocyte damage.