Medical Care
Expectant management with periodic clinical and ultrasonographic surveillance is appropriate for asymptomatic cholelithiasis. Surgical removal of asymptomatic gallstones is currently not standard practice. [10] Spontaneous resolution without specific treatment is most commonly observed in asymptomatic cholelithiasis, however some medications may be beneficial.
An exception is in children with sickle cell anemia, in whom laparoscopic cholecystectomy is currently recommended for asymptomatic gallstones, in order to prevent potential complications of cholelithiasis, which tend to be more common in children with sickle cell anemia. [21]
Ursodeoxycholic acid therapy
Ursodeoxycholic acid can be useful in the medical management of cholelithiasis. [22] One study in which pediatric patients received 25 mg/kg/d of ursodeoxycholic acid for a median period of 13 months demonstrated resolution of clinical discomfort in 83.7% of patients. However, complete disappearance of gallstones was observed in only 7.2%, and the cholelithiasis recurred in 50% of these patients. All children did complete the therapy with no adverse effects.
Ursodeoxycholic acid has not been approved by the US Food and Drug Administration for use in pediatric patients. Nevertheless, it has a long history of use as adjunctive therapy in the management of adolescents with cystic fibrosis and in infants and children with hereditary cholestasis syndromes, biliary atresia, and cholestasis associated with parenteral nutrition.
The primary disadvantage with ursodeoxycholic acid therapy is the high incidence of gallstone recurrence. Therefore, this treatment is not recommended in patients with symptomatic cholelithiasis and is indicated only for patients either unfit or unwilling to undergo surgical intervention.
Surgical Care
Consultation with a general surgeon is appropriate in patients with symptomatic cholelithiasis or with evidence of cholecystitis.
Laparoscopic cholecystectomy is currently the criterion standard in the treatment of symptomatic cholelithiasis. It has been proven to be safe and effective in children, with a low rate of postoperative complications. [2, 23, 24]
Postcholecystectomy syndrome involves the persistence or recurrence of symptoms experienced prior to surgery and may include new symptoms. The incidence of postcholecystectomy syndrome in children is not currently known. [6] One multicenter study reported recurrence of symptoms after cholecystectomy (postcholecystectomy syndrome) in only 4.7% of patients.
Indications for laparoscopic cholecystectomy in cholelithiasis include symptoms of biliary colic or chronic abdominal pain or the presence of cholecystitis.
Removal of the gallbladder in asymptomatic children with cholelithiasis is not standard practice, with the exception of those with sickle cell anemia. Laparoscopic cholecystectomy has also been demonstrated to be safe and effective in patients with sickle cell disease. [16] In addition, because gallbladder sludge is frequently documented in patients with sickle cell anemia and most patients with sickle cell disease who have biliary sludge go on to develop gallstones, elective cholecystectomy has been recommended for those patients with evidence of biliary sludge, with or without stones.
Surgical complications of laparoscopic cholecystectomy include common bile duct injury and bile leaks, as well as complications of hemolytic disease in patients who are at risk. Postoperative complications such as biliary tract obstruction tend to be more common in patients with sickle cell disease. [25]
Laparoscopic cholecystectomy with intraoperative cholangiography has demonstrated promise as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive common bile duct stones (choledocholithiasis). [26]
Prevention
A decrease in the consumption of fatty foods and controlled weight reduction in patients with obesity may be effective in preventing the development of cholesterol stones. [7]
In prospective cohort studies, Leitzmann et al found that an increase in exercise reduced symptomatic gallstones in women and men by approximately 20%. [27, 28] This reduction may be extrapolated to the pediatric population.
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Pediatric Gallstones (Cholelithiasis). Transverse view of the gallbladder reveals multiple stones, without gallbladder wall thickening, edema, or surrounding fluid accumulation.
