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Cholecystitis Acalculous – (Gallbladder inflammation without gallstones)

Acalculous cholecystitis may occur as a complication during treatment of various diseases. This condition may occur in newborns but is more common in older children. Boys and girls are affected equally. Patients are often severely ill as a result of prior surgery; a severe burn; extensive trauma; massive blood transfusion; and various infections, including pneumonia, a generalized infection (sepsis), typhoid, salmonella, otitis media with meningitis, giardiasis, and Kawasaki disease. The cause is unknown, but may be in part due to dehydration, ileus (a condition where the bowel does not squeeze properly), gallbladder stasis (bile not being squeezed out of the gallbladder), treatment with total parenteral nutrition (TPN), and breakdown of blood from multiple transfusions.

Symptoms include fever, right upper abdominal pain, nausea, vomiting, and sometimes diarrhea. The abdomen may be tender during examination. A mass can sometimes be felt and must be distinguished from acute hydrops (see above section). The white blood cell count may be increased (evidence of inflammation or infection) and jaundice (the skin and whites of the eyes have a yellow hue) are often seen. The amylase level (an enzyme from the pancreas) may be increased. The diagnosis is confirmed by ultrasound. The treatment for mild cases includes placement of a tube through the nose into the stomach to help relax the intestine, fluids by IV, and antibiotics if needed. The patient’s condition is followed by ultrasound examinations. An operation may be needed if the gallbladder does not return to normal or if the patient gets worse.

TREATMENT

In the 1980s and 1990s, many therapies other than surgery were introduced for the management of gallstones. This included dissolving cholesterol gallstones with a medicine called chenodeoxycholic acid, or the use of extracorporeal shock-wave lithotripsy, a method using sound waves to blast gallstones into small pieces so that they would pass on their own. The success rate for dissolving gallstones was found to be less than 15% after 2 years. Only 15% to 20% of patients with gallstones qualified for extracorporeal shock-wave lithotripsy. No studies have been performed in children with these therapies, and they largely have been abandoned at this time.

Laparoscopic gallbladder removal has become the routine management for children with gallstones causing symptoms. Preoperatively an ultrasound examination is performed on each patient to confirm the diagnosis of gallstones and to check for the presence or absence of main bile duct involvement. Children with stones in the main bile duct often have jaundice, severe pain, or inflammation of the pancreas. If there is suspicion that the main bile duct to the liver is involved an ERCP may be recommended before surgery. There is some controversy whether to perform ERCP before or after surgery if main bile duct stones are suspected and some surgeons may decide to do ERCP first while others will proceed first with surgery. The controversy exists because the diagnosis of main bile duct stones prior to surgery in children may not be exact.

Surgery is usually performed laparoscopically using 4 small incisions in the abdomen though some problems may still require a single large open incision. One of the laparoscopic incisions near the belly button is used to pass a telescope placed into the abdomen and the other 3 are for passing small instruments used to take out the gallbladder. Each of these incisions is between 3 and 10 mm in size depending on the size of the child. Children go to sleep under general anesthesia so that the surgery can be performed. In addition to removing the gallbladder many surgeons will perform a study called cholangiography. This is a dye study of the bile ducts performed in the operating room while the child is asleep. It is performed through the same 4 small incisions that are used to remove the gallbladder. The purpose of the study is to make sure no gallstones have fallen out of the gallbladder into the main bile duct. If they have, it may be possible to remove these main bile duct stones laparoscopically, however this may be very difficult in small children with small bile ducts. Many surgeons prefer to wait until another time and perform an ERCP to remove these stones as mentioned above.

The advantages of laparoscopic surgery may include less pain after surgery and a faster recovery from the operation. Many children may be able to leave the hospital in one to two days after surgery. Recovery and return to school and athletic activities will depend on the recommendation of the surgeon and the general condition of the child but in general recovery is fairly quick. Removal of the gallbladder usually does not cause many future problems for children. Bile is used to help digest fat in foods. Even when the gallbladder is removed the liver continues to make bile which drains into the intestine. The gallbladder acts a reservoir for bile so that extra bile is available for digestion when we eat. Because this reservoir of bile is gone, some patients will experience mild loosening of the stool after the gallbladder is removed while others will have no symptoms. In general patients may eat normally and make any adjustments to the diet only if needed.