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Asymptomatic Cholelithiasis in Children: Management Dilemma
1Department of Pediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India.
Insights
Pediatric gallstones are rising. Elective cholecystectomy is recommended for asymptomatic children to prevent complications, though ursodeoxycholic acid may be an option for younger children.
Area of Science:
- Pediatric surgery
- Gastroenterology
- Hepatology
Background:
- Cholelithiasis incidence is increasing in children, with both symptomatic and asymptomatic cases.
- Management of asymptomatic pediatric gallstones lacks consensus, posing a challenge for clinicians.
- Non-hemolytic conditions and idiopathic causes contribute to pediatric gallstone formation.
Purpose of the Study:
- To evaluate the efficacy of elective cholecystectomy in asymptomatic pediatric gallstone cases.
- To assess the potential of preventing gallstone-related complications through early surgical intervention.
- To compare management strategies for asymptomatic gallstones in different pediatric age groups.
Main Methods:
- A 12-year retrospective study of 178 children with cholelithiasis, divided into two age groups (under 5 and 5-12 years).
- Asymptomatic cases in the younger group were initially managed with ursodeoxycholic acid (UDCA) for 6-12 months.
- Cholecystectomy was advised for all older children and symptomatic younger children, with follow-up on outcomes.
Main Results:
- In asymptomatic children under 5, UDCA led to stone disappearance in some, symptom development in others, and recurrence after cholecystectomy in a few.
- Elective cholecystectomy was performed in older children and symptomatic younger children.
- Asymptomatic older children who declined cholecystectomy experienced complications, necessitating intervention.
Conclusions:
- Ursodeoxycholic acid may be considered for younger children (<5 years) with gallstones, but recurrent stone formation is a possibility.
- Elective laparoscopic cholecystectomy is the preferred management for asymptomatic pediatric gallstone cases to prevent future morbidity.
- Early surgical intervention in asymptomatic pediatric gallstone patients can effectively mitigate complications.
Aims And Objectives:
The incidence of cholelithiasis is now increasing in children. Besides hemolytic diseases, there are also nonhemolytic conditions and idiopathic group. A large number of children belong to asymptomatic group who do not present with gallstone-related symptoms. There is no consensus in the management of these children. The aim of this study is to evaluate the role of elective cholecystectomy in asymptomatic cases to prevent complications which leads to more morbidity.
Materials And Methods:
One hundred and seventy-eight children were treated over a period of 12 years and they were divided into two groups according to their age at presentation. Sixty-four children below 5 years belonged to Group A and 114 children between 5 and 12 years belonged to Group B. About 71.8% of children of Group A and 49.1% of children of Group B were asymptomatic. Cholecystectomy was advised in all cases of Group B and all symptomatic cases of Group A. In Group A asymptomatic cases, ursodeoxycholic acid (UDCA) was given for 6-12 months and followed up.
Results:
Laparoscopic cholecystectomy was performed in all cases except in five cases where conversion to open surgery was done as there was gross adhesions due to previous laparotomy. Of 46 asymptomatic cases of Group A, the stone disappeared in seven cases, 12 children developed symptoms, and there was no change in 27 patients. Stone reappeared again in three of seven children who were managed by cholecystectomy. Cholecystectomy was also performed in 12 cases that developed symptoms. In the rest of the 27 children, cholecystectomy was advised after 1 year trial of UDCA. Cholecystectomy was advised in both symptomatic and asymptomatic cases of Group B. Sixteen of 56 asymptomatic cases did not agree for cholecystectomy and 12 of them returned with complications. Endoscopic retrograde cholangio-pancreaticography (ERCP) and stone extraction was performed in four cases. In all the acute cases, cholecystectomy was performed after a period of conservative management.
Conclusion:
UDCA can be tried in the smaller age group below 5 years, but there is a chance of recurrent stone formation. Elective laparoscopic cholecystectomy should be the choice in all asymptomatic cases to prevent complications.
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