Cholelithiasis in children

I W Gustawan, K Nomor Aryasa, IPG Karyana, IGN Sanjaya Putra

Departemen of Child Health, Medical Faculty Udayana University/Sanglah Hospital,
Denpasar
Abstract
Cholelithiasis
in
children
including rare diseases. Some of the
conditions
associated
with
cholelithiasis ie hemolytic disease of
chronic
(cell
anemia
sickle,
spherocytosis), obesity, disease or ileal
resection, cystic fibrosis, chronic liver
disease, Crohn's disease, parenteral
nutrition
old,
prematurity
complications of surgical or nonsurgical treatment of cancer in
children.
Cholelithiasis
clinical
symptoms vary, even more than 80% of
cases are asymptomatic. Clinical
symptoms are common symptom is
pain and jaun- biliary obstructive dice.
Ultrasound is a selection examination
to check for children and adolescents
with symptoms of upper right
abdominal pain or epigastric pain.
This tool is safe and sensitive for
identifying stones in the gall bladder.
Handling cholelithiasis divided into
two non-surgical and surgical
management, but as the gold standard
treatment
with
symptoms
of
cholelithiasis is Cholecystectomy.
Keywords:
cholelithiasis,
Cholecystectomy
Definition
Cholelithiasis is material or not
shaped crystals that form in biological
empedu.1 composition of cholelithiasis
is a mixture of cholesterol, bile
pigments,
calcium
and
matrix
inorganik.2,3 More than 70% of the
bile duct stones in children are the type
of pigment stones, 15 -20% type of
cholesterol stones and the rest with a

composition that does not diketahui.2

in Western countries, a major
component
of
gallstones
are
cholesterol, so the majority of
cholesterol gallstones containing more
than 80%.
Etiology and Risk Factors
Causes and risk factors for the
formation of gall bladder stones are not
clearly differentiated. Schweizer et al7
children receiving total parenteral
nutrition old, after undergoing
cardiopulmonary
bypass
surgery,
bowel resection, obesity and children
of women who took hormonal
contraceptives are at risk to suffer from
cholelithiasis. Suchy2 mention a few
conditions
associated
with
cholelithiasis is hemolytic disease
chronic
(cell
anemia
sickle,
spherocytosis), obesity, disease or ileal
resection, cystic fibrosis, chronic liver
disease, Crohn's disease, parenteral
nutrition
old,
prematurity
complications of surgical or nonsurgical, anak.2 cancer treatment in
conditions that are predisposing factors
stone formation of black pigment is
chronic hemolytic disease, total
parenteral nutrition, chronic cholestasis
and
cirrhosis,
drug
delivery
(ceftriaxone). Ceftriaxone is found in
high concentrations in the gall bladder
in a state intact. While the predisposing
factors brown pigment stone formation
is the presence of parasitic infestations
such as Ascharis lumbricoides. Brown
pigment stones is very rare in infants
and children. For rock cholesterol, a
risk factor is obesity, ileal resection,
ileal Crohn's disease and fibrosis

kistik.9 Obesity is a significant factor

for the occurrence of gall bladder
stones. In these circumstances the liver
to produce excess cholesterol, then
poured into the gallbladder so that its
concentration in the gallbladder
becomes very saturated. This situation
is a predisposing factor for stone
formation. The incidence of gall
bladder stones is increased in obese
women and pubertas.9,10
The relationship between total
parenteral nutrition with gallbladder
stones, evidenced by Roslyn et al11
were investigated prospectively 21
children receiving total parenteral

Pathogenesis cholelithiasis
The pathogenesis of stone formation
has been investigated in recent years.
Although some aspects that act as the
cause not yet fully known, but the
chemical composition and the presence
of lipids in bile plays an important role
in the process of stone formation.
Approximately 8% of bile lipids in the
form of cholesterol and 15-20% in the
form of phospholipids. Both are
insoluble in water, in the liquid bile
with bile salt bound with 70-80% of
the lipid composition empedu.1

nutrition old, apparently higher

incidence of gallbladder stones is 43%.
Type of rock formed is Nonkolesterol
stone. The risk of cholelithiasis also
found in children with Down
syndrome. Toscano et al12 reported
their cholelithiasis in children with
Down syndrome. Of the 126 children
with Down syndrome who underwent
ultrasonography (USG), 4.7% found
their cholelithiasis. Genetic factors
alleged role in the occurrence of gall
bladder stones. Risk of suffering from
gall bladder stones is increased when
we have a family with gall bladder
stones.

hydrophobic core (insoluble in water) .

20 vesicle is a spherical formation of
phospholipid bilayers consisting of two

Bile is an aqueous fluid

comprising a hydrophobic insoluble fat
(cholesterol and phospholipids), which
then can be dissolved with the help of a
bile acid empedu.9 composed of water,
bile salts, bilirubin, cholesterol, fatty
acids, leshitin / phospholipid, Na + , K
+, Ca2 +, Cl, HCO-.18Kolesterol in
bile mixes with bile salts and
phospholipids form micelles and
vesikel.3 mixture of micelles is a
collection of fat that has walls that
hydrophilic (water soluble) and a
The maximum equilibrium
solubility
of
cholesterol
was
determined by the ratio of cholesterol ,
phospholipids and bile salts , expressed
as a saturation index kolesterol.1,3,9
micelles formed if the cut point relative
concentrations of the three components
( cholesterol , lecithin and bile salts )
Clinical symptoms of cholelithiasis
Cholelithiasis clinical symptoms vary
from no symptoms until the
appearance of symptoms. More than
80% of gallbladder stones symptoms
arise
asimptomatik.19
Clinical

nonpolar chain hydrocarbon chain is

facing and polar chain leads to a
solution. In a state of high
concentration of cholesterol that carries
cholesterol in the number of vesicles
besar.3
relationship
between
cholesterol, phospholipids and bile
salts is described in a triangle which is
often called the Triangular Coordinats
depicting
the
concentration
of
cholesterol solubility in a mixture with
phospholipids and bile salts (figure 1).
are located in areas micellar , This
situation was in stable condition to
prevent stone formation . If the point
of intersection of the concentration of
bile located outside the area of the bile
is litogenik . Various conditions can
cause instability of the composition of
these three components , as shown in
Table 2.1
symptoms in adults are usually found
in
non-specific
dyspepsia,
fatcontaining food intolerance, epigastric
pain are not clear, discomfort in the
right upper abdomen. These symptoms
are not specific because it can occur in
adults with or without kolelitiasis.9 In
children, the clinical symptoms

frequently encountered is the presence

of pain and obstructive biliary
jaundice.5 typical biliary pain in
patients with biliary colic is
characterized by symptoms of pain
severe in more than 15 minutes to 5
hours. The location of pain in the
epigastric, upper right abdomen spread
to the back. Pain often occurs at night,
recurrence in the not beraturan.19
abdominal pain upper right is a picture
of
an
important
recurring
kolelitiasis.2,9 Generally the pain is
localized in the right upper abdomen,
but the pain may also be localized in
the epigastric. Pain in cholelithiasis is
usually spread to the upper shoulder.
Mechanism alleged pain associated
with obstruction of the ducts. The
pressure on the gallbladder grow in an
effort to fight obstruction, so that at the
time of the attack, the right upper
abdomen or epigastric usually in a state
of tegang.9 Studies conducted by

Kumar et Al2 gained the

upper right abdominal
pain are repeated with or
without
nausea
and
vomiting reaches 75 % of
clinical symptoms arise,
the rest covering the
upper right abdominal
pain that is acute,
jaundice, failure to thrive,
abdominal
discomfort
complaints. Only 10%
found with symptoms
asimptomatik.6
Nausea
and vomiting are also
common
terjadi.6,9,21
Fever is common in
children aged less than 15
years.
Episodic
pain
occurs irregularly and
severity of attacks are
very bervariasi.9
On
physical
examination abnormalities
may be encountered. At
third of patients with
inflammation
precedes
necrosis, followed by perforation or
empyema of the gall bladder. Passage
of gallbladder stones cause gall bladder
obstruction, cholangitis ducts and
pankreatitis.9 first manifestations of
cholelithiasis is often a symptom of
acute cholecystitis with symptoms of
fever, upper right abdominal pain that
may radiate to the scapula and is often
accompanied by palpable on the future
location of the pain. 2 on physical
examination found tenderness in the
right upper abdomen that may radiate
to the epigastric region. Distinctive
sign (Murphy's sign) in the form of
breath pause due to the pain when
palpation in the area subkosta kanan.22
Supporting investigation
Laboratory tests include a complete
blood count, liver function tests, lipase
and amylase levels in serum. In a state

of chronic or episodic biliary colic

some patients had levels or laboratory
values were normal, especially in
patients who are asymptomatic at the
time of diperiksa.9,23 While the acute
situation, particularly in cases with
stones in the bile duct will be increased
aminotransferase
levels,
alkaline
phosphatase and bilirubin.23 patients
with
complications
of
acute
cholecystitis will show an increase in
leukocytes, 15% of these patients have
mild elevations of aminotransferase,
alkaline phosphatase and bilirubin. In
patients
with
complications
of
pancreatitis will be increases in serum
amylase and li- pase and hepatic
function tests were abnormal. 23
radiological examination to help
establish the diagnosis of gall bladder
stones can by ultrasonography (USG),
and
plain
abdominal
Cholescintigraphy. In general, an
ultrasound examination to check the
selection of children and adolescents
with complaints of right upper
abdominal pain or epigastric pain.
Ultrasound is a safe and sensitive
examination to identify the presence of
stones in the gall bladder. When the
gallbladder is identified when an
ultrasound, then the success rate of
finding rocks can reach 98% .9,23,24
plain abdominal examination can
identify stones if the stones are made
of calcium radioopak24 or in a
concentration
tinggi.9
cholecystography examination and
cholangiography rarely performed in
children
anak.24
scintigraphy
examination using techne- tium-99mlabeled aminodiacetic acid, very
accurate in evaluating patients with
kolesistitis.9 in detecting stones,
particularly in patients receiving
parenteral nutrition old, ultrasound is
more accurate than the skintigrafi.23
Diagnosis

The diagnosis of cholelithiasis

based on history, physical examination
and ultrasound as the primary choice
for diagnosis (Figure 5). Ultrasound
can not distinguish between types of
stone. Best examination to determine
the type of stone is kolesistografi

oral.19,22 ultrasound examination is

the primary diagnostic examination in
patients suspected of suffering from
cholelithiasis. The probe sensitivity in
detecting this stone is 96%. The picture
that occurs is the focus eklogenik
distinctive shadow. Ultrasound can
also differentiate their gallbladder wall
thickening due to the inflammatory
process. Tract stones, gall bladder can
also be detected on examination USG.
Differential Diagnoses

symptomatic cholelithiasis.
The differential diagnosis of pain due
to cholelithiasis is peptic ulcer disease,
gastroesophageal reflux, non-ulcer
dyspepsia, esophageal dysmotility,
irritable bowel syndrome, colic ginjal.
diagnosis of acute cholecystitis is acute
appendicitis, acute pancreatitis, acute
hepatitis, ulcer perforation, perforation
and peptic ulcer disease other acute
intestinal. To distinguish acute
pancreatitis, acute pancreatitis usually
pain is more localized and rarely with
acute peritoneal signs. Pain to the back,
disappeared when the sitting position is
typical
for
acute
pancreatitis.
Symptoms of fever and leukocytosis
may be the same in both cases, but the
increase in serum amylase levels were
significantly higher in a state of acute
pancreatitis. In a state of severe
pancreatitis, the patient looked very
toxic. However, in patients with acute
cholecystitis with complications of
acute pancreatitis ultrasound is
necessary to immediately distinguish
the circumstances tersebut.22 To
distinguish with cholecystitis, on the
state of hepatitis usually on laboratory
tests showed serum levels of liver
enzymes will be much higher than with
acute cholecystitis. In a state of acute
appendicitis, characterized by typical
pain in the lower right abdomen,
starting from the vicinity of the
umbilical later settled in the lower right
abdomen. In the state of intestinal
perforation,
on
radiological
examination often found their free air
on plain radiography abdomen.
Management cholelithiasis
Handling cholelithiasis divided
into two non-surgical and surgical
management. There is also a divide
based on the presence or absence of
accompanying
symptoms
cholelithiasis, namely the management
of the cholelithiasis simp- tomatik and

Non Surgical Management

In the adult alternative nonsurgical therapy include destruction of
stone
with
drugs
such
as
chenodeoxycholic or ursodeoxycholic
acid,
extracorporeal
shock-wave
lithotripsy
with
continuous
administration of drugs, drug planting
directly in the bladder empedu.
Surgical Management
Cholecystectomy is still the gold
standard in the treatment of
cholelithiasis with gejala.3,9,21 The
question is when to do surgery.
Research on this it was found that
patients with recurrent abdominal pain
is an indication for immediate surgery
can cause complications serius.9
Cholecystectomy procedures consist of
some type of action that is
Laparoscopic Cholecystectomy, Choleopen
cystectomy,
open
Cholecystectomy with bile duct
exploration, open Cholecystectomy
with bile duct exploration and
choledochoenterostomy and choledochoenterostomy followed open
Cholecystectomy.25
Laparoscopic Cholecystectomy has
more advantages compared with
conventional Cholecystectomy. In
children,
an
indication
Cholecystectomy
Laparoscopic
Cholecystectomy same as conventional
kolelitiasis especially in children with
symptoms or in children who also
suffer hemoglobinopati9 or in children
with asymptomatic cholelithiasis aged
less than 3 years, which have gained
oral food for at least 12 months. 21 this
technique is useful in patients with
familial hyperlipidemia, hereditary
spherocytosis, glucose-6-phos- phatase
deficiency,
thalassemia,
glicogen
strage disease and sickle cell anemia.9

this procedure is not recommended in

children with acute cholecystitis
cholelithiasis
accompanied,
pancreatitis or the possibility of
suffering adhesions usus.9
In children suffering from sickle cell
anemia with cholelithiasis, elective
laparoscopic cholecystectomy is the
main option. Actions preferred elective
cholecystectomy compared with the
actions of emergency due to avoid the
risk of complications such as
intraoperative complications (vasoocclusive),
postoperative
complications (pneumonia) and other
complications such as cholangitis,
cholecystitis koledokulitiasis or akut.

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RE,

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DE,

Kaplan

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Conclusion
Complications of prematurity with
surgical or non-surgical treatment of
cancer in children. Cholelithiasis
clinical
symptoms
vary
from
asymptomatic until their symptoms.
More than 80% showed symptoms of
gall bladder stones are asymptomatic.
Clinical symptoms are frequently
encountered is the presence of biliary
pain
and
obstructive
jaundice.
Ultrasound is a selection examination
to check for children and adolescents
with complaints of abdominal pain or
pain in the upper right epigas- suit.
Ultrasound is a safe and sensitive
examination to identify stones in the
gall bladder. Handling cholelithiasis
divided into two non-surgical and
surgical
management.
Cholecystectomy is the gold standard
in the treatment of cholelithiasis with
symptoms.
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