Pediatric Gallbladder Disease Surgery Workup

Updated: May 26, 2016
  • Author: Holly L Neville, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Workup

Laboratory Studies

In any patient with suspected biliary or gallbladder disease, obtain blood type and screen, a complete blood count (CBC), and a complete metabolic panel, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, total bilirubin, direct and indirect bilirubin, amylase, and lipase levels. In patients who are obese, screen for cholesterol and triglyceride abnormalities, and perform glucose screening to evaluate for diabetes.

Leukocytosis with a left shift may be observed in cholecystitis. ALT and AST levels are used to evaluate the presence of hepatitis and may be mildly elevated in cholecystitis or with common bile duct (CBD) obstruction. Significant elevation is usually indicative of hepatitis and should prompt a hepatitis serology profile.

Bilirubin and alkaline phosphatase assays are used to evaluate evidence of CBD obstruction. Bilirubin should be broken down into direct and indirect bilirubin. This is of particular use in patients with hemolysis or hemolytic diseases, such as sickle cell disease. These patients may have a chronically elevated indirect bilirubin level that is not indicative of hepatobiliary disease. Choledocholithiasis with CBD obstruction results in elevation of total bilirubin and direct bilirubin levels. The indirect bilirubin levels remain within the reference range in this case.

Amylase and lipase assays are used to evaluate for the presence of pancreatitis. Amylase levels may also be mildly elevated in cholecystitis. An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.

Urinalysis is used to rule out pyelonephritis and renal calculi, which are included in the differential diagnosis of right-upper-quadrant pain.

All females of childbearing age should undergo a pregnancy test.

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Imaging Studies

Ultrasonography

In all children and infants, ultrasonography can reveal the size and echogenicity of the liver as well as detect stones and sludge in the bile ducts and gallbladder and cystic or obstructive dilatation of the biliary system. Ultrasonography may be limited by morbid obesity and patient cooperation. Ultrasonography is the best imaging study for initial evaluation of a pediatric patient with suspected biliary and gallbladder disease.

Findings in patients with biliary atresia may include triangular cord or periportal echogenicity representing a cone-shaped fibrotic mass cranial to the portal vein or a “ghost” triad, which includes a gallbladder length less than 1.9 cm, lack of smooth mucosa lining, and an indistinct wall. The triangular cord sign and the presence of gallbladder abnormalities are probably the most accurate ultrasonographic findings for diagnosing or excluding biliary atresia. [17]

In patients with cholecystitis, ultrasonography reveals pericholecystic fluid and gallbladder-wall thickening of more than 4 mm. It can be used to reveal a sonographic Murphy sign. Ultrasonography is 90-95% sensitive and 78-80% specific in these patients.

In patients with choledocholithiasis, ultrasonography reveals a dilated CBD (defined as ≥8 mm).

Plain radiography

Plain radiography reveals calcified gallstones in only 10-25% of cases but can be useful in ruling out pneumonia, which may have a similar presentation. This study can also be used to evaluate for calcification of stones in patients who may be treatable by medical means.

Computed tomography

Computed tomography (CT) can provide information similar to that provided by ultrasonography; however, it involves radiation and may require reconstructions in order to gain detailed information. CT may be useful in exploring the surrounding anatomy if the diagnosis is uncertain. It is also useful in assessing the pancreas in cases of severe gallstone pancreatitis.

Magnetic resonance cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is used to assess the biliary tract in all age groups. It is 90% sensitive and 77% specific in revealing extrahepatic biliary atresia. MRCP is particularly useful in patients with congenital anomalies and in evaluating suspected choledocholithiasis. It has the added benefit of avoiding radiation exposure; however, it may require sedation or anesthesia in order to obtain an optimal study, particularly in younger patients.

Nuclear medicine studies

Hepatobiliary scintigraphic imaging agents, such as technetium-99m iminodiacetic acid derivatives, may be helpful in assessing cystic duct patency in a patient with a hydrops of the gallbladder or cholelithiasis. The most sensitive test for acute cholecystitis involves intravenous (IV) injection of radiolabeled hepatobiliary iminodiacetic acid (HIDA) secreted into the biliary tree. In acute cholecystitis, HIDA enters the CBD but does not enter the gallbladder; thus, the gallbladder is not filled at completion of the study.

If the gallbladder is not visualized, IV morphine administration can improve the accuracy of HIDA scanning by increasing resistance to flow through the sphincter of Oddi, resulting in filling of the gallbladder if the cystic duct is patent.

In a newborn, if a hepatobiliary scintiscan fails to reveal tracer movement from the biliary tree into the small bowel and liver biopsy findings reveal interlobular bile duct proliferation, exploration with intraoperative cholangiography (see More Invasive Procedures) is necessary to rule out biliary atresia.

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More Invasive Procedures

Other diagnostic options to be considered in this setting include more invasive procedures such as liver biopsy, intraoperative cholangiography, and endoscopic retrograde cholangiopancreatography (ERCP).

Liver biopsy may be performed percutaneously, under ultrasonographic guidance, or via an open technique. This procedure is not usually required for isolated diseases of the gallbladder but may be necessary in some patients.

Intraoperative cholangiography may be required in patients with gallbladder disease who have suspected anomalous anatomy, choledocholithiasis, or masses in the CBD. This procedure is often performed in conjunction with laparoscopic or open cholecystectomy. In newborns, this procedure is performed to determine the biliary ductal anatomy and to differentiate among biliary atresia, Alagille syndrome, and cholestasis.

ERCP is an endoscopic procedure commonly performed by either surgeons or gastroenterologists who specialize in the procedure. The benefit of this procedure is that it is both diagnostic and therapeutic. In this procedure, the CBD is cannulated, and stone retrieval or biopsy may be performed. Papillotomy is often performed to permit release of entrapped stones and debris and to prevent impaction of stones in the future. Additionally, stents may be placed for obstructive disease or to assist in resolution of duct injuries. This test requires fluoroscopy.

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Histologic Findings

The histology of gallbladder disease may range from acute inflammation to chronic inflammation with lymphocytic and/or neutrophil infiltration, depending on the chronicity of illness. When stones are present, they are either cholesterol or pigmented stones; pigmented stones are indicative of hemolytic disease.

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