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Pediatric Cholecystitis

Background

Cholecystitis is defined as inflammation of the gallbladder and is traditionally divided into acute and chronic subtypes. These subtypes are considered to be two separate disease states; however, evidence suggests that the two conditions are closely related, especially in the pediatric population.

Most gallbladders that are removed for acute cholecystitis show evidence of chronic inflammation, supporting the concept that acute cholecystitis may actually be an exacerbation of chronic distension and tissue damage. Cholecystitis may also be considered calculous or acalculous, but the inflammatory process remains the same.

Cholecystitis, which has long been considered an adult disease, is quickly gaining recognition in pediatric practice because of the significant documented increase in nonhemolytic cases over the last 20 years. Gallbladder disease is common throughout the adult population, affecting as many as 25 million Americans and resulting in 500,000-700,000 cholecystectomies per year (see Epidemiology). The image below illustrates the technique for laparoscopic cholecystectomy.

Diagram illustrating the technique for laparoscopi

Diagram illustrating the technique for laparoscopic cholecystectomy. The gallbladder is retracted with grasping 5-mm laparoscopic instruments, and clips are applied over the cystic duct and artery.

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Although gallbladder disease is much rarer in children, with 1.3 pediatric cases occurring per every 1000 adult cases, pediatric patients undergo 4% of all cholecystectomies. In addition, acalculous cholecystitis, uncommon in adults, is not that unusual in children with cholecystitis.

Because of the increasing incidence of gallstones and the disproportionate need for surgery in the pediatric population, consider cholecystitis and other gallbladder diseases in the differential diagnosis in any pediatric patient with jaundice or abdominal pain in the right upper quadrant, particularly if the child has a history of hemolysis (see Presentation).

Cholelithiasis is the most common cause of acute or chronic cholecystitis in adults and children. (See Etiology)

Abdominal ultrasonography has become the diagnostic tool of choice in evaluating cholelithiasis, although it is less accurate in cholecystitis (see Workup). 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 (see Treatment).

Types of Gallstones

Three major types of gallstones may form in cholelithiasis: cholesterol, pigment, or brown. However, most gallstones have components of more than one type.

Cholesterol gallstones (shown below) are radiolucent and are composed of cholesterol (>50%), calcium salts, and glycoproteins. They form within the gallbladder and migrate to the bile duct.

Photograph of a gallbladder filled with numerous s

Photograph of a gallbladder filled with numerous small cholesterol stones.

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Pigment gallstones are black, often radiopaque, and are usually associated with hemolytic diseases. Radiopacity and color are related to an increased concentration of calcium bilirubinate, which interacts with mucin glycoproteins to form gallstones. These gallstones also form within the gallbladder and migrate to the ductal system.

Brown gallstones, in contrast, form within the ductal system and are orange, soft, and greasy. They are composed of calcium salts of bilirubin, stearic acid, lecithin, and palmitic acid. These gallstones are more often associated with infection.

Go to Cholecystitis and Acalculous Cholecystitis for more complete information on these topics.

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