Vol.2, No.1, 67-69 (2010) Health
Copyright © 2010 Openly accessible at http://www.scirp.org/journal/HEALTH/
Paediatric gallstones and laparoscopic cholecystectomy
D. G. Samuel, N. N. Naguib, A. Y. Izzidien
Prince Charles Hospital, Merthyr Tydfil, UK; daisams@doctors.org.uk
Received 19 October 2009; revised 30 November 2009; accepted 2 December 2009.
Introduction: Gall stones disease is a rare oc-
currence in paediatric patients and the diagno-
sis is often overlooked. Patients often present
with non-specific symptoms of abdominal pain
and the classic features of gallstones are some-
times absent [1]. The aim of our study is to in-
crease the awareness of cholecystitis and acute
pancreatitis being a possible occurrence in the
paediatric age group and should therefore be in
the differential diagnosis of acute abdominal pain
in children. We undertook a retrospective analy-
sis of all the paediatric patients recorded as hav-
ing had a laparoscopic Cholecystectomy per-
formed at Prince Charles Hospital. 8 paediatric
patients underwent Laparoscopic cholecysteco-
my between 2000 and 2008 consisting of 5 fe-
male patients and 3 male patients. The average
age of the cohort was 14.1 years [12-16]. Pre-
morbid obesity was a feature in 4 patients and
all patients reported high fat diet. Abdominal Ul-
trasound used to assess all 8 patients who pre-
sented with acute abdomen showed gallstones
to be present in all. 7 patients underwent an ele-
ctive procedure 3-6 months after the initial di-
agnosis was made and 1 patient had laparosco-
pic Cholecystectomy within 72 hours of initial
presentation. 1 patient was found to have an in-
herited haematological disorder and 2 of the pa-
tients were sisters with a family history of gall-
stone disease. 2 patients presented with acute
pancreatitis. Gallstone related cholecystitis is a
rare occurrence amongst paediatric patients and
is often overlooked as a differential diagnosis.
We report 8 patients over an 8 year period. Con-
clusion: It is important that clinicians include
cholecystitis and biliary colic in the differential
diagnosis of patients presenting with acute ab-
domen in childhood not explained by other di-
agnoses. Laparoscopic Cholecystectomy is the
treatment of choice and has minimal complica-
Keywords: Gallstones; Cholecystitis; Paediatrics;
Laparoscopic Cholecystecomy
Gallstones in children are rare but can become a poten-
tially serious condition [1]. It does not always present itself
in the classical clinical picture of adult gallstones and is
not considered as a typical differential diagnosis of abdo-
minal pain [1,2]. Right upper quadrant pain, nausea and
vomiting may not always be present and initial diagnosis
may be overlooked or delayed. We present our experience
as a paediatric surgical team in managing Paediatric gall-
stones at a District General Hospital in South Wales. In
order to assess how common paediatric gallstones are at a
typical District general Hospital we re- viewed our patient
records was carried at Prince Charles Hospital to identify
any paediatric patient (aged 16 years or under) who had
undergone a Cholecystectomy. Theatre reports and full case
history notes were reviewed and data was extracted ac-
cordingly. Correspondence were also re- viewed to note
the outcome of any subsequent follow up and to identify
any other medical problems which may have arisen after
the procedure or had an impact on the patient developing
gallstones. All 8 patients underwent a laparoscopic Chole-
cystectomy performed by a single Consultant Paediatric
Surgeon (Mr Asal Y Izzidien) at Prince Charles Hospital,
Merthyr Tydfil.
All patients presented with abdominal pain but only 3
(37.5%) patients localised this pain in the right upper
quadrant. All patients eventually underwent Abdominal
Ultrasound examination (USS) which showed the pres-
ence of gallstones. 3 patients underwent a Magnetic Retro-
grade Cholangio-Pancreotography and 1 patient under-
went a HAIDA scan to assess gallbladder function. Every
patient had a full history work up including a family
history screen. Blood tests were assessed in each patient
for the signs of haemolytic abnormalities. 2 patients (25%)
presented with pancreatitis and 1 patient had a known
hereditary haemolytic condition (hereditary spherocytosis).
This patient presented with jaundice and had an obstruc-
tive biochemical pattern.
Appendicitis was the initial working diagnosis in 3 of
our patients and a Urinary tract Infection was suspected
D. G. Samuel et al. / HEALTH 2 (2010) 67-69
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and treated empirically in another 2 patients.
Following diagnostic confirmation of gallstones, all 8
patients underwent laparoscopic Cholecystectomy. 7 pa-
tients underwent the procedure electively 4-6 months after
the initial diagnosis was made and one patient had the
procedure within 72 hours of initial presentation. When
we reviewed the histopathology of our sample all 8 pa-
tients had evidence of acute cholecystitis changes in their
gallbladder with oedematous, thick walled gallbladders.
Stones were analysed and in 7 patients the stones were
reported as being mixed cholesterol pigment stones. 1
patient had pigmented stones in keeping with their he-
reditary haemolytic condition.
Our only short term complication was one patient who
developed an infection in his umbilicus portal site scar.
This was treated with Augmentin 250/62 mg tds. He
recovered and was discharged without any further prob-
lems. One patient developed keloid at one of her scar sites
although no further action was taken and the patient was
Paediatric gallstones and pancreatitis are rare occurrence
and in most cases, caused by trauma or chronic illness
[1-3]. Gallstone related disease can often present in a
non-specific manner and the classical signs are often
absent. Murphy’s sign is unreliable and children may find
it difficult to describe the typical pain of biliary colic and
cholecystitis. Clinicians often misdiagnose the condition
as a Urinary tract infection and Appendicitis is also com-
monly documented in differential diagnoses [1,2]. Usu-
ally there is a chronic history of generalised abdominal
pain of some months or more. In several cases, this had
not been followed up to identify an underlying cause.
Clinicians should therefore hold an index of suspicion for
a diagnosis of gallstones in any paediatric presentation of
abdominal pains, raised White cell count and fever [3].
Patients should undergo screening and evaluation for
hereditary haemolytic conditions [1] as an increased break-
down of haemoglobin can produce large amounts of pig-
mented gallstones. Other underlying causes such as obe-
sity, hypercholesterolemia, chronic liver disease and Cystic
fibrosis may also be the primary cause of paediatric gall-
stones and should be excluded. There may be also a need
to investigate for genetic predisposition as 2 of the cases
were sisters and had strong family history of gall stones.
In the paediatric group non-invasive investigations
should be the preferred choice if possible. Abdominal
Ultrasound provides an effective method of identifying
gallstones [2,4]. MRCP may be used to exclude stones in
the common bile dict [5].
Weight loss is almost always advised in adult patients
and the same rule appears to hold true for the paediatric
population. Most of our patients were obese and being
overweight is recognised as a risk factor for developing
gallstones. Modern diets are often high in fat and with an
obesity epidemic being predicted by some corners of
medical society, the medical profession needs to be aware
that gallstones are likely to become more common in
children in years to come. Other factors associated with
gallstones include use of the Oral contraceptive pill [4]
and pregnancy at an earlier age may also contribute to a
rise on paediatric gallstones in years to come.
There is increase in the incidence of gallstones in the
paediatric age group possibly due to the worldwide epi-
demics of obesity but genetic predisposition may be a
factor that needs more study to explore. Our study shows
that the condition remains an uncommon presentation but
should be considered in children presenting with abdo-
minal symptoms, especially when other diagnoses have
been excluded. Laparoscopic Cholecystectomy app- ears
to be and appropriate and safe procedure to carry out on
paediatric patients and has a low incidence of morbidity.
It should therefore be considered as the procedure of
choice in paediatric patients [6,7] with gallstones. Due to
early development of gall stones, hence the longer span of
this pathology, paediatric patients may be more prone to
developing complications including pancreatitis. It is
paramount to prevent this condition as this carries a high
risk of morbidity and mortality in the paediatric cohort
[5,8,9].We advocate carrying out surgery at the earliest
opportunity. However, decisions should be taken on an
individual basis if the clinical status of the patient dictates
that more immediate surgery would be appropriate. At
present our hospital has not performed Endoscopic pro-
cedures on paediatric patients and cases are typically
referred to tertiary centres. However, if the incidence of
paediatric gallstones continues to rise in line with child-
hood obesity, the likelihood of having to performing Endo-
scopic retrograde Cholangio Pancreatography (ERCP) will
increase. This will in itself will have implications for ser-
vice provision, patient safety and long term implications
for patients.
D. S. carried out the relevant literature review and wrote the paper. He
also analysed the patient data and reviewed the patient notes. N. N. and
A. I. reviewed the paper and critically analysed the data. A. I. performed
all the operative procedures
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