CHOLELITHIASIS CHOLECYSTITIS

With the increase use of sonography in the work-up of abdominal pain, cholelithiasis is diagnosed more frequent in children. Gallstones occur as consequence of loss of solubility of bile constituents. Two types are recognize: cholesterol and bilirubin. Those of cholesterol are caused by supersaturation of bile (lithogenic) by cholesterol overproduction or bile salt deficiency. Bilirubin stones occur due to hemolysis (Sickle Cell, thalassemia) or bacterial infection of bile. Other etiologies include: Ascaris Lumbricoides infestation, druginduced (Ceftriaxone), ileal resection, TPN. etc. Gallbladder sludge is a clinical entity that when it persists can be a predisposing factor for cholelithiasis and cholecystitis. Laparoscopic Cholecystectomy (LC) has become the procedure of choice for the removal of the disease gallbladder of children. The benefit of this procedure in children is obvious: is safe, effective, well tolerated, it produces a short hospital stay, early return to activity and reduced hospital bill. Several technical differences between the pediatric and adult patient are: lower intraabdominal insufflation pressure, smaller trocar size and more lateral position of placement. Complications are related to the initial trocar entrance as vascular and bowel injury, and those related to the procedure itself; bile duct injury or leak. Three 5 mm ports and one 10 mm umbilical port is used. Pneumoperitoneum is obtained with Veress needle insufflation or using direct insertion of blunt trocar and cannula. Cholangiography before any dissection of the triangle of Calot is advised by some workers to avoid iatrogenic common bile duct injuries during dissection due to anomalous anatomy, it also remains the best method to detect common bile ducts stones. Treatment may consist of: (1) endoscopic sphincterotomy, (2) opened or laparoscopic choledochotomy, or (3) transcystic choledochoscopy and stone extraction. Children with hemolytic disorders, i.e. Sickle cell disease, have a high incidence of cholelithiasis and benefit from LC with a shorter length of postop stay and reduced morbidity.

Acalculous cholecystitis (AC) is more commonly found in children than adults. Two-third of cases appear as a complication of other illness: trauma, shock, burns, sepsis, and operative procedures. Contributing causes mentioned are: obstruction, congenital tortuosity or narrowing of the cystic duct, decreased blood flow to the gallbladder, and long-term parenteral nutrition. Males are more commonly affected than females. Fever, nausea, vomiting, diarrhea, dehydration and marked subhepatic tenderness are the most common symptoms. Other less common sx are jaundice, and abdominal mass. Labs show leucocytosis and abnormal liver function tests. Recently (APSA 95), two distinct forms of this disease have been recognized: acute, with symptom duration less than one month and chronic, with sx greater than three months. US is diagnostic by demonstrating hydrops of gallbladder, increase wall thickness and sludge. HIDA scan with CCK stimulation may help diagnose chronic cases. In both situations management consist of early cholecystectomy which can be executed using laparoscopic techniques.