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Clinical presentations and predisposing factors of cholelithiasis and sludge in children
I Wesdorp1, D Bosman, A de Graaff
1Department of Pediatric Gastroenterology, Emma Children's Hospital AMC, Amsterdam, The Netherlands.
Insights
Pediatric gallstones and sludge epidemiology is poorly understood. Conservative management for pediatric sludge and careful selection for cholelithiasis treatment, avoiding routine surgery, is recommended due to symptom recurrence after intervention.
Area of Science:
- Pediatric Gastroenterology
- Hepatobiliary Surgery
- Pediatric Epidemiology
Background:
- Limited understanding of pediatric cholelithiasis and sludge epidemiology.
- Lack of established therapeutic guidelines for pediatric gallstone disease.
Purpose of the Study:
- To investigate the epidemiology, causes, and treatment outcomes of cholelithiasis and sludge in children.
- To evaluate the long-term efficacy of different management strategies.
Main Methods:
- Retrospective study of 82 children with cholelithiasis and 75 with sludge (ages 0-18).
- Analysis of etiological factors, clinical presentation, and treatment outcomes (cholecystectomy, ERCP, conservative management).
- Follow-up of 50 patients for a mean of 4.6 years.
Main Results:
- Idiopathic gallstones in 23%, hemolytic disease association in 39%.
- Predisposing factors for sludge included parenteral nutrition and infection; sludge is dynamic.
- 46% recurrence of symptoms after cholecystectomy or ERCP; conservative management showed no complications.
Conclusions:
- Pathogenesis of cholelithiasis and sludge may differ in children.
- Sludge is a dynamic condition, not a direct precursor to gallstones.
- Cholecystectomy should be reserved for high-risk patients; conservative management is effective for many.
Background:
In contrast to adults, little is known about the epidemiology and the best therapeutic regimen for cholelithiasis and sludge in children.
Methods:
Eighty-two children with cholelithiasis detected by ultrasonography were studied from 0 to 18 years of age with regard to cause, symptomatology, and treatment outcome. Seventy-five children with sludge within the same age group were studied as well.
Results:
Idiopathic gallstones were found in 19 (23%) patients, and 32 (39%) had gallstones in association with a hemolytic disease. Predominant factors associated with the development of gallstones and clinical presentation differed with age. In patients with sludge, total parenteral nutrition and systemic infection or administration of antibiotics were most frequently found to be possible predisposing factors. Sludge can develop and disappear within a few days. Complications of cholelithiasis were observed in 13 patients. Cholecystectomy was performed in 41 patients and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction in 9 patients; 32 children were not treated. After a follow-up (mean, 4.6 years) in 50 patients, 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 during the follow-up, no complications occurred, and only one patient experienced abdominal symptoms during follow-up.
Conclusions:
The difference in associated conditions may indicate that the pathogenesis of cholelithiasis and sludge differ as well. Furthermore, sludge should be viewed as a dynamic condition not predisposing for the development of gallstones, per se. Cholecystectomy should not be performed routinely but only after careful selection in patients at risk for complications.