History and Physical Examination
A variety of clinical findings may be noted in pediatric patients with gallbladder disease, as follows. [16]
Hydrops
Hydrops or acute distention of the gallbladder generally presents following severe sepsis or shocklike states. Acute hydrops has been associated with Kawasaki disease and Henoch-Schönlein purpura.
Acalculous cholecystitis
This is uncommon in children but may arise following successful resuscitation from sepsis or shock when previously unrecognized hydrops of the gallbladder becomes infected. Presentation includes abdominal pain, vomiting, fever, and laboratory findings that may mimic acute cholecystitis.
Cholestasis
Cholestasis generally presents with jaundice, pruritus, xanthomata, hepatomegaly, dark urine, hypopigmented stools, and, possibly, splenomegaly.
Cholelithiasis
Cholelithiasis symptoms usually include vague abdominal pain in a child with obesity. Fatty food intolerance less common in pediatric patients than in adults. Some children may present with classic symptoms of biliary colic, including severe, intermittent, colicky right upper quadrant or epigastric pain following ingestion of fatty foods.
Cholecystitis
Unlike the other processes, cholecystitis presents with persistent pain (generally >8 h) in the right upper quadrant or epigastric region, nausea and vomiting, fever, anorexia, and mild elevation of liver function test findings, particularly alkaline phosphatase, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels. When associated with cholesterol stones, the presentation is generally mild. In patients with sickle cell disease or diabetes, cholecystitis may present as a much more severe illness, resulting in sickle cell crisis, sepsis, or diabetic ketoacidosis.
Cholangitis
The presentation of cholangitis in the pediatric population is similar to that seen in adults. The classic triad of symptoms (ie, the Charcot triad) includes fever, right upper quadrant pain, and jaundice. Without treatment, these symptoms advance to include confusion, hypotension, and sepsis. This condition presents with symptoms that mimic cholecystitis, only with the additional symptoms of jaundice and pain that radiates through to the back.
Complications
Gallstone disease may lead to choledocholithiasis, acute or chronic cholecystitis, cholangitis, gallbladder perforation, or pancreatitis. Pancreatitis is reported in as many as 8% of pediatric patients with gallstones. These potential complications should be discussed with patients with biliary colic due to gallstone disease.
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Gallbladder as seen at time of laparoscopy.
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Gallbladder dissection with visualized cystic duct and cystic artery.
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Gallbladder and contents. Note yellow-green cholesterol stones.
