International Surgery Journal

Bhasin SK et al. Int Surg J. 2017 Jan;4(1):246-251

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20164450
Original Research Article

Evaluation and management of cholelithiasis in children: a hospital

based study
Sanjay Kumar Bhasin*, Ankit Gupta, Sunita Kumari

Department of Surgery, Government Medical College, Jammu, Jammu & Kashmir, India

Received: 16 September 2016

Accepted: 20 October 2016

*Correspondence:
Dr. Sanjay Kumar Bhasin,
E-mail: sanjaykbhasin@yahoo.co.in

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Earlier cholelithiasis was extremely unusual in childhood. Presently there is sharp increase in detection
of cholelithiasis in children, which forms basis to investigate the overall changing pattern of cholelithiasis. This
prospective study in referral centre has been under taken to evaluate childhood cholelithiasis and its management.
Methods: The present prospective study was conducted in the Postgraduate Department of Surgery, GMC Jammu,
Jammu & Kashmir, India over a period of two years. 80 patients in age group of 3-14 years were included in the study
group with ultrasound proved cholelithiasis. Data reviewed with respect to patient demographics profile, clinical
history including risk factors, imaging studies, operative techniques, postoperative complications, postoperative
recovery and primary outcome parameters assessed accordingly.
Results: During the study period 80 children (52 males and 28 females) with cholelithiasis were evaluated and treated
by laparoscopic cholecystectomy. The mean age was 10.1 years (range 5 to 14 years). 75% patients (n = 60) belonged
to rural background and rest to urban set up, 56 patients belonged to hindu religion and rest were muslims. In 47.5%
patients no risk factor could be traced. Fifty two children (65%) had mixed gallstones. 78 patients underwent LC, two
needed conversion and rest 02 children were subjected to mini cholecystectomy. The mean operative duration was
29.92 minutes (range 15-50 minutes). The average duration of hospital stay was 3.82 days (range 3-8 days). No major
intra operative or post-operative complications could be detected except 01 case biliary peritonitis.
Conclusions: Cholelithiasis in children was reported about three centuries back, remained relatively uncommon in
the past but now it is evolving and ever increasing in frequency. In this part of country in almost 50% of patients risk
factors could not be traced, obesity could not be held responsible for cholelithiasis. Male children with low
socioeconomic status, rural area and belonging to Hindu religion were more affected by the disease. In view of high
incidence of serious complications of gall stones in children and because of longer life expectancy we also
recommend that expectant management of gallstones may not be safe and hence laparoscopic cholecystectomy must
be done even in asymptomatic cholelithiasis.

Keywords: Cholelithiasis, Childhood, Laparoscopic cholecystectomy, Mini cholecystectomy

INTRODUCTION increase in the incidence.2 Overall prevalence in Europe

is 0.13% to 0.2% in children. In Japan, it is less than
Cholelithiasis is quite common in adults (10% to 20%) 0.13% of children & about 0.3% in India.3,4 Childhood
with worldwide variability. In India, it is 3% to 6%, more cholelithiasis is evolving with an ever increasing
frequent in north India than in south India.1 As far as frequency of cholecystectomies in children.5 Risk factors
cholelithiasis in children is concerned there is a dramatic in childhood cholelithiasis, can be hemolytic causes (20-
change in the overall spectrum of this disease with global 30%), other known etiology (40-50%) such as total

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 Bhasin SK et al. Int Surg J. 2017 Jan;4(1):246-251

parenteral nutrition, prolonged fasting, ileal disease/ileal RESULTS

resection, frusemide therapy, congenital biliary diseases
such as choledochal cyst, chronic liver disease and In the present study, the age ranged from 03-14 years
progressive familial intrahepatic cholestasis (PFIC). (10.1 years). Forty four patients (55%) were in the age
Around 30% to 40% of cases are idiopathic.6 As is seen group 11-14 years (n = 44), 10% patients (n = 8) were
in adults, gallstones in adolescent girls are also more < 05 years. M:F ratio was 1.85:1, 52 patients being male
often idiopathic.7 Most common presentation is typical and 28 females. Sixty patients (75%) belonged to rural
right upper quadrant pain (50%); and in 25% there may background and rest to urban set up. Furthermore, 70%
be non-specific abdominal symptoms including poorly patients (n = 56) belonged to hindu religion where as
localized abdominal pain and nausea. Around 20% of 30% patients (n = 24) were muslims, 67.5% patients (n =
cases are asymptomatic (incidentally detected stone).8 54) belonged to lower socioeconomic status and 32.5%
Adult symptomatology of cholelithiasis, tends to be (n = 26) from middle class. 24 patients (30%) were
reported in older children.9,10 Ultrasound is the most vegetarians and 70% patients (n = 56) were mixed diet
common diagnostic test with sensitivity and specificity consumers. No history of junk food consumption could
exceeding 95%. Cholescintigraphy with technetium 99m be detected.
labeled di-isopropyl iminodiacetic acid (DISIDA), is the
most accurate method of diagnosing acute cholecystitis.11 Risk factors for cholelithiasis in children

Spontaneous resolution has been reported in about 50% In the present study 52.5% patients (n = 42) patients had
cases of childhood cholelithiasis within 6 months various risk factors for cholelithiasis including 15%
typically in idiopathic gallstones. Cholecystectomy is patients (n = 12) with history of antibiotic use for various
indicated for symptomatic cholelithiasis, asymptomatic clinical conditions like upper respiratory tract infections,
cholelithiasis persisting beyond 12 months and radio- acute gastro enteritis, pyrexia etc., 5% (n = 04) had
opaque calculi.12,13 Laparoscopic cholecystectomy is hemolytic disease, two had sickle cell anemia and two
confirmed to be a safe and efficacious treatment for were thalessemic, 10% patients (n = 08) were
pediatric cholelithiasis with low rate of postoperative overweight, 12.5% patients (n=10) had history of
complications.6,14 cholelithiasis in either mother or father. 2.5% patients
(n = 2) had history in both parents and 2.5% patients
The study was undertaken to evaluate epidemiological (n = 2) had history of cholelithiasis in his brother, 5%
factors as well as management options and their outcome patients (n = 04) had history of prematurity and 5%
in this part of country where incidence of adult patients (n = 02) had hypertriglyceridemia. There were
cholelithiasis is quite high. 47.5% patients (n=38) in whom no risk factors were
found (Table 1).
METHODS
Table 1: Risk factors for childhood cholelithiasis.
The present prospective study was conducted in the
Postgraduate Department of Surgery, GMC Jammu over Risk factor No. of patients Percentage
a period of two years. 80 patients in age group of 3-14 Familiarity 14 17.5
years were included in the study group with ultrasound Hemolytic disorder 04 05
proved cholelithiasis. Patients with congenital heart Antibiotic therapy 12 15
disease, mental retardation, delayed milestones; Hypertriglyceridemia 04 05
coagulopathies and any other co-morbid condition Overweight 08 10
contraindicating general anesthesia were excluded from
History of
the study group. The patients were admitted for pre- 04 05
prematurity
operative evaluation and work up including pre-
No risk factors 138 47.5
anesthetic check-up prior to surgery. All the patients were
operated under general anesthesia. Single dose of
antibiotic was administered to all the patients at the time Symptomatology
of induction. Laparoscopic-cholecystectomy was
completed in 76 patients in supine position with standard In this study 20% of the patients (n=16) were
four port method as is done in case of adults. 02 patients asymptomatic, cholelithiasis being incidental finding on
were subjected to mini-cholecystectomy and 02 were USG while getting investigated in pediatric ward for
converted to open-cholecystectomy. The patients were fever and inability to thrive and later shifted to surgery
permitted to take oral fluids once bowel sounds returned. unit for further management. Of the symptomatic
Injectable analgesics were given to keep the patients pain patients, 60% of the patients (n = 48) presented with
free. The primary outcome parameters assessed were history of vague abdominal pain, 36 patients (45%) each
post-operative pain, duration of hospital stay and time had history of dyspeptic symptoms and acute abdominal
taken to resume normal daily activities as well as symptoms, recurrent abdominal pain (colic’s) was
postoperative complications. observed in 12.5% patients (n = 10) and history of
vomiting was present in 7.5% patients (n = 6). In

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 Bhasin SK et al. Int Surg J. 2017 Jan;4(1):246-251

symptomatic patients duration of symptoms was 6-9 patients (5%) only. Majority of the patients 80% (n = 64)
months. Only 22.5% patients (n = 18) had mild had passed flatus on the first post-operative day and
tenderness in RHC, in rest of them no positive findings hence were allowed oral sips. 64 patients (80%) were
were present. Ultrasound revealed multiple stones in 46 ambulatory by first post-operative day.
patients (57.5%); biliary sludge/concretions with polyps
were noted in 5% patients (n = 4) (Table 2). Complications

Table 2: Symptomatology in patients. Intra-operatively no major complication was encountered.

Postoperatively 5% patients (n = 04) had nausea/vomiting
No. of which was managed by single calculated dose of injection
Symptoms* Percentage
patients ondensetron. 7.5% patients (n = 06) had shoulder tip pain.
Vague upper abdominal pain 24 60 5% patients (n = 04) had wound infection. No worrisome
Acute pain rt. hypochondrium 18 45 late complications were noted except scar tenderness in 6
Jaundice 01 2.5 patients that was managed by reassurance & analgesics
Dyspeptic symptoms 18 45 alone. One 4 years old male patient residing in far flung,
Abdominal colics (recurrent) 05 12.5 hilly area presented after 8 weeks of laparoscopic
Vomiting and indigestion 03 7.5 cholecystectomy with loss of vigor, loss of appetite and
fever. Biliary Peritonitis was diagnosed and laparotomy
Asymptomatic (admitted for
08 20 was done after proper workup for general anesthesia. 500
fever in pead ward)
ml bilious fluid was drained from peritoneal cavity and
Note: More than one symptom observed in single patient.
cystic duct ligated with 2-0 vicryl from where liga clips
had slipped. Post-operative period was uneventful and
Intra-operative findings
patient was discharged on 4th P.O.D. On long term
follow up for 01 year, no complications were observed.
Intra-operatively multiple adhesions were present in 14
patients. Mucocele of gallbladder was seen in 03 patients
Histo-pathological findings
whereas empyema of gallbladder was present in one
patient with dense adhesions obscuring calot`s triangle
Forty eight patients had normal mucosal pattern, 25%
requiring conversion to open. In 01 female patient aged
(n = 20) had findings of chronic cholecystitis and 12.5%
12 years thick walled contracted gallbladder with difficult
(n = 10) had mild acute cholecystitis and 02 patients had
calot`s triangle anatomy led to conversion to open
histological features suggested of xantho granulomatous
cholecystectomy.
cholecystitis.
Type of stones
Duration of post-operative hospital stay and RTW
More than Half of the patients had Mixed stones i.e, 65%
In the present study, the maximum duration of hospital
patients (n = 52). 20% patients (n = 16) had pure pigment
stay observed after surgery was 5 days and minimum
stones while only 15% patients (n = 12) had pure
was 1 days with mean duration of hospital stay being
cholesterol stones.
1.75 days. The mean interval to return to daily routine
was 3.82 days (3-8 days). Majority of the patients
Operative time
(n = 64) returned to their routine daily activity by 4 th day.
In the present study, the mean operative time was 26.92
DISCUSSION
minutes (15-50 minutes). In 03 patients it was more than
40 minutes that included 02 cases of conversion to open
Although cholelithiasis in children was reported by
cholecystectomy.
Gibson in 1737 for the first time yet it remained relatively
uncommon in the past. However, presently cholelithiasis
Postoperative parameters
in children and adolescents is evolving and studies
suggest its ever increasing frequency and resultant
Mild pain was observed in 70% of the patients (n = 56) cholecystectomies at early age.15 The higher incidence of
on Ist POD, whereas; severe pain was present in 5% obesity in children and the increased use of USG have a
patients (n = 4). In our study post-operative pain was significant effect in the diagnosis of gallstones.
assessed according to the demand of analgesics by the Pathogenesis of gallstones and sludge in children is still
patients and or their parents as VAS was crude indicator unclear.8 As little is known about natural history of
of pain assessment in pediatric population. Inj diclofenac childhood cholelithiasis hence guidelines for
sodium I/M in calculated doses were used in > 7 years of management are lacking. It has been observed that most
age whereas, in < 7 years of age, paracetamol suppository of the time the gallstones remain un-detected in pediatrics
or inj paracetamol was used as analgesic. Majority of the population until complications develop.16 As non-surgical
patients (n = 38) required only 02 doses of analgesics approaches have proved ineffective due to severe
whereas; maximum of 08 doses were required in 04 restriction on their applicability hence laparoscopic

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 Bhasin SK et al. Int Surg J. 2017 Jan;4(1):246-251

cholecystectomy is considered the gold standard cholecystectomy. Abkari et al in their study converted
treatment in children also.17,18 17% (n = 11) patients to open cholecystectomy due to
difficult anatomy, adhesions and thick walled gallbladder.
In the present our study, the mean age of the patients was Deepak J et al and Curro et al in their study converted 01
10.1 years (03-14 years). Majority of patients (n = 44) patient each to open cholecystectomy.6,31,32
were in the age group of 11-14 years. It is consistent
with similarly situated studies in the literature.5,6,19,20 The Multiple stones were seen in 46 patients (57.5%), 28
male: female ratio in our study was 1.85: 1 (52 vs 28). patients (35%) had single stones and 06 patients had
Strausse et al in his study observed females dominance biliary sludge/cholestrosis associated with gallbladder
i.e. 11 females and 2 males whereas; Pokorny et al and polyps. No patient had stones in common bile duct.
Malik et al in their study reported higher of gallstones in Miltenburg et al in their study found that 15.8% of
boys.21-23 However same incidence in both sexes was patients had associated stones in the common bile duct.33
observed in other studies.13,14 Gumiero et al observed in their study that 88 patients had
multiple stones and 12 patients had one single gallstone.24
Geographically 75% patients (n = 30) belonged to Dooki and Norouzi reported in their study that 19 (29%)
rural/hilly background and 70% (n = 56) were hindu. patients had solitary gallstones and in 47 patients (71%)
Furthermore, 67% of the patient (n = 27) belonged to there were multiple gallstones, moreover 3% of the
lower socioeconomic strata and 32.5% (n = 26) belonged patients had stones simultaneously in the common bile
to middle income group. These are new epidemiological duct (CBD) and 1.5% in cystic duct.30 Furthermore, 52
parameters studied and added to the surgical literature on patients (65%) had mixed stones. 16 patients (20%) had
the subject as medline/pub med search could not reveal pure pigment stones while only 12 patients (15%) had
any such study. 12.5% patients (n = 10) had history of pure cholesterol stones. Holcomb et al in his study
cholelithiasis in either mother or father. 2.5% patients (n observed that in majority of the patients, the gallstones
= 2) had history in both parents and 2.5% patients were composed of cholesterol primarily and varied in
(n = 2) had history of cholelithiasis in siblings. color from pale yellow to dark yellowish brown with a
Familiarity has also been reported in other studies.8,24 few having greenish color.9 Similarly, Deepak J et al
Association of junk food consumption with childhood observed that 20 patients had pigmented stones and 02
cholelithiasis could not be established. Obesity in many patients had cholesterol stones.6
studies has been documented as major risk factor.25-27
Mean operative time in present study was 26.92 minutes
No risk factor could be established in 38 patients (47.5%) (15 to 50 minutes). This was much less than OT reported
in present study. However 12 patients (15%) had history by other available studies in the literature.32,35-37 In the
of antibiotic consumption for use for various clinical present study, post-operative pain was assessed as per the
conditions, 4 patients (5%) had hemolytic disease and 8 demand of the patient or the parents/attendants for
patients (10%) were overweight, 14 patients (17.5%) had analgesic as VAS is a crude indicator of pain assessment
positive family history. Corte et al in their study reported in children. On an average 2.12 doses (02 to 08 doses) of
that 95 patients (52.5%) had no risk factors, 24% patients analgesics were required in the postoperative period with
(n = 51) had family history, 16 patients (7.6%) had mean length for their use as 1.2 days (01 - 04 days).
hemolytic disorders, obesity in 14 patients (6.7%) and Jawad et al observed mean length for use of parenteral
antibiotic consumption in 11 patients (5%). 8 Malik et al analgesia as 0.47 days (range 0.3 to 1 day). 36 Others have
observed no risk factor in 18 (78%) patients while 02 also reported similar findings.39,40
(9%) patients has sickle cell disease and 03 (13%)
patients had a positive family.23 Similarly, Gocke et al in There was no major intra-operative complication
their observed no identifiable risk factors in 43.5% observed in our study. 04 (5%) patients had intra-
children, whereas; 16.1% were having familial history, operative gallbladder perforation and spillage of bile.
12.9% hemolytic diseases, 8.1% were overweight and Post-operatively, nausea/vomiting was observed in 04
12% children had history of antibiotic intake. 28 20% (5%), 04 (5%) patients had shoulder tip pain, 02 (5%)
(n = 16) of the patients were asymptomatic in this study. patients had wound infection confined to epigastric port,
Prevalence of asymptomatic gallstones have been 01 patient of bilioma presenting 8 weeks after
reported to be 17-50.5% in various studies and our results laparoscopic cholecystectomy was managed with
were consistent with the literature.5,8,9,20 In symptomatic laparotomy under general anesthesia cystic duct ligated
group, 60% (n = 48) patients presented with history of with 2-0 vicryl from where liga clips had slipped, post-
vague abdominal pain, 45% (n = 36) each had dyspeptic operative period was uneventful and patient was
symptoms and intermittent colic. Vomiting was present in discharged satisfactorily on 8th day. Al-Abkari et al
6 patients. Our observations were consistent with other reported bile leak in 9 patients (25%) with sickle cell
studies.29,30 Laparoscopic cholecystectomy was anemia. Other available series have hardly reported any
successfully performed in 78 patients, 02 were converted postoperative complications.6,23,31,37
to open cholecystectomy due to multiple adhesions and
empyema of GB and in another 02 mini-cholecystectomy Hospital stay after surgery was 1-5 days (1.75 days) in
was done when attendants refused for laparoscopic the present study. Ranendra et al (387, reported POHS of

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 Bhasin SK et al. Int Surg J. 2017 Jan;4(1):246-251

2 days (range 2 - 4 days), Deepak J et al reported 4.1 days 7. Schweizer P, Lenz MP, Kirschner HJ. Pathogenesis
(range 3-6 days), whereas; Curro et al and Jawad reported and symptomatology of cholelithiasis in childhood a
comparatively longer POHS.6,22,36 The mean interval of prospective study. Dig Surg. 2000;17(5):459-67.
days to return to daily routine was 3.82 days (3-8 days) in 8. Wesdrop I, Bosman D, Graaff A, Aronson D.
our study. In the study by Bogue, the children resumed Clinical presentations and predisposing factors of
their normal activities almost immediately after returning cholelithiasis and sludge in children. J Pediatr
home. In long term follow up of 1 year no complications Gastroenterol Nutr. 2000;31(4):411-7.
or bothering symptoms could be observed.5 50% (n = 40) 9. Holcomb GW, Holcomb GW. Pediatric
patients are still under our follow up for long term cholecystectomy: clinical significance of cases
assessment of effect of GB removal on the patients. unrelated to hematologic disorders. Pediatr
Gastroenterol Hepatol Nutr. 2015;18(2):115-20.
CONCLUSION 10. Paul SP, Remorino R. Acute cholecystis
presentating as intussuception in infant: case report
Cholelithiasis in children was reported about three and literature review. West London Med J.
centuries back, remained relatively uncommon in the past 2009;1(4):1-6.
but now it is evolving and ever increasing in frequency. 11. Millar AJW, Prasad H. Gallstone disease in
In this part of country in almost 50% of patients risk children. Indian Pediatric. 2010;47(11):945-53.
factors could not be traced, obesity could not be held 12. Puliqandla PS, Nquyen LT, Vil D, Flageola H.
responsible for cholelithiasis. Male children with low Gastrointestinal duplications. J Pediatr
socioeconomic status, rural area and belonging to Hindu Gastroenterol. 2003;38(5):740-4.
religion were more affected by the disease. In view of 13. Debray D. Cholelithiasis in Infancy: a study of 40
high incidence of serious complications of gall stones in cases. J Pediatr Gastroenterol. 1993;122(3):385-91.
children and because of longer life expectancy we also 14. Tannuri CA, Gonçalves AJ, Velhote M, Gonlçalves
recommend that expectant management of gallstones may ME, Tannuri U. Management of gallstone disease in
not be safe and hence laparoscopic cholecystectomy must children: a new protocol based on the experience of
be done even in asymptomatic cholelithiasis. In view of a single center. J Pedia Surg. 2012;47:2033-8.
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factor in this part of globe, we recommend that further hydroic cystitis. Medical assays and observations.
community based larger studies are needed to establish Philos Soc Edin. 1737;2:352.
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