Managing the Pediatric Patient With Asymptomatic Gallstones
Managing the Pediatric Patient With Asymptomatic Gallstones
What is the recommended management for children with asymptomatic gallstones?
The most frequent scenario in which asymptomatic gallstones are detected in children is during the work-up for abdominal pain. There is no question that gallstone identification now occurs more frequently owing to an increase in the number of patient visits for the complaint of abdominal pain as well more liberal use of ultrasonography in these patients. Thus, one question immediately arises: If the child is truly asymptomatic, why was the (presumed) work-up initiated? And, for a child with abdominal pain, the parent, patient, and clinician are faced with the dilemma of how they can be sure that the gallstone is not the cause of the pain. This scenario complicates the decision regarding management strategy.
Laparoscopic cholecystectomy has become the preferred method of management for symptomatic gallbladder disease in children. Laparoscopic cholecystectomy is associated with a shorter hospital stay after surgery, rapid diet resumption, and reduced postoperative discomfort, with minimal morbidity. However, laparoscopic cholecystectomy has not been critically evaluated in children and further study is still required to assess the benefits. The procedure is associated with some risk, such as a higher rate of injury to the biliary tree compared with open cholecystectomy. In addition, postcholecystectomy symptoms have been reported in children. Thus, the decision as to whether to recommend cholecystectomy should be weighed carefully.
An issue to consider in planning a management strategy is whether there is any underlying disease/condition that would predispose to cholelithiasis, such as sickle cell disease, hemolysis, prolonged parenteral nutrition, etc. For example, children with sickle cell disease have an increased risk of developing pigment gallstones that initially may be asymptomatic but may be the cause of recurrent abdominal pain and can lead to acute symptoms of cholelithiasis. Nonoperated patients and those treated on an emergency basis have a high morbidity rate (> 50%). An elective laparoscopic cholecystectomy procedure is recommended for pediatric patients with sickle cell disease to avoid the risk of an emergency cholecystectomy procedure. Another key question is whether ductal dilatation is present (suggesting obstruction); this must be evaluated.
Little is known about the natural history of asymptomatic cholelithiasis, and only a few studies have been published regarding long-term results of treated patients. In one large study, 82 children with cholelithiasis detected by ultrasonography were evaluated with regard to cause, symptomatology, and treatment outcome. Idiopathic gallstones were found in 23% of patients, and 39% had gallstones in association with a hemolytic disease. Predominant factors associated with the development of gallstones and clinical presentation differed with age. Cholecystectomy was performed in 41 patients and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction was performed in 9 patients; 32 children were not treated. After a follow-up (mean, 4.6 years), 46% of the children who had cholecystectomy or therapeutic ERCP experienced clinical recurrence of abdominal symptoms. In the patients who did not receive surgical or endoscopic therapy, no complications occurred, and only 1 patient experienced abdominal symptoms during follow-up. Thus, it appears that pediatric patients with gallstones that are asymptomatic can be safely followed. However, cholecystectomy is recommended when medically possible for children with underlying medical diseases.
The bottom line is that although less is known about the natural history of asymptomatic gallstones in children (compared with the wealth of data from adult studies), I believe that most clinicians would support a strategy of nonoperative management for a patient who is truly asymptomatic, yet is found to have cholelithiasis.
What is the recommended management for children with asymptomatic gallstones?
The most frequent scenario in which asymptomatic gallstones are detected in children is during the work-up for abdominal pain. There is no question that gallstone identification now occurs more frequently owing to an increase in the number of patient visits for the complaint of abdominal pain as well more liberal use of ultrasonography in these patients. Thus, one question immediately arises: If the child is truly asymptomatic, why was the (presumed) work-up initiated? And, for a child with abdominal pain, the parent, patient, and clinician are faced with the dilemma of how they can be sure that the gallstone is not the cause of the pain. This scenario complicates the decision regarding management strategy.
Laparoscopic cholecystectomy has become the preferred method of management for symptomatic gallbladder disease in children. Laparoscopic cholecystectomy is associated with a shorter hospital stay after surgery, rapid diet resumption, and reduced postoperative discomfort, with minimal morbidity. However, laparoscopic cholecystectomy has not been critically evaluated in children and further study is still required to assess the benefits. The procedure is associated with some risk, such as a higher rate of injury to the biliary tree compared with open cholecystectomy. In addition, postcholecystectomy symptoms have been reported in children. Thus, the decision as to whether to recommend cholecystectomy should be weighed carefully.
An issue to consider in planning a management strategy is whether there is any underlying disease/condition that would predispose to cholelithiasis, such as sickle cell disease, hemolysis, prolonged parenteral nutrition, etc. For example, children with sickle cell disease have an increased risk of developing pigment gallstones that initially may be asymptomatic but may be the cause of recurrent abdominal pain and can lead to acute symptoms of cholelithiasis. Nonoperated patients and those treated on an emergency basis have a high morbidity rate (> 50%). An elective laparoscopic cholecystectomy procedure is recommended for pediatric patients with sickle cell disease to avoid the risk of an emergency cholecystectomy procedure. Another key question is whether ductal dilatation is present (suggesting obstruction); this must be evaluated.
Little is known about the natural history of asymptomatic cholelithiasis, and only a few studies have been published regarding long-term results of treated patients. In one large study, 82 children with cholelithiasis detected by ultrasonography were evaluated with regard to cause, symptomatology, and treatment outcome. Idiopathic gallstones were found in 23% of patients, and 39% had gallstones in association with a hemolytic disease. Predominant factors associated with the development of gallstones and clinical presentation differed with age. Cholecystectomy was performed in 41 patients and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction was performed in 9 patients; 32 children were not treated. After a follow-up (mean, 4.6 years), 46% of the children who had cholecystectomy or therapeutic ERCP experienced clinical recurrence of abdominal symptoms. In the patients who did not receive surgical or endoscopic therapy, no complications occurred, and only 1 patient experienced abdominal symptoms during follow-up. Thus, it appears that pediatric patients with gallstones that are asymptomatic can be safely followed. However, cholecystectomy is recommended when medically possible for children with underlying medical diseases.
The bottom line is that although less is known about the natural history of asymptomatic gallstones in children (compared with the wealth of data from adult studies), I believe that most clinicians would support a strategy of nonoperative management for a patient who is truly asymptomatic, yet is found to have cholelithiasis.
