Conservative management of choledocholithiasis in the pediatric age: A safe therapeutic approach

Gallstone disease is an entity on the rise in the pediatric population, and it is estimated that 20-30% of these patients present with associated choledocholithiasis. Currently, there is no definitive consensus regarding the optimal treatment for pediatric choledocholithiasis, with different therapeutic strategies having been proposed. The objective of the present work is to evaluate the safety and feasibility of conservative management and analyze the factors associated with spontaneous resolution.

Retrospective observational study of 72 pediatric patients with choledocholithiasis treated between 2021 and 2024. Patients with evidence of choledochal dilation (common bile duct ≥ 7 mm), biochemical alterations (total bilirubin > 1.2 mg/dl, direct bilirubin > 0.3 mg/dl, amylase > 100 U/L, and/or lipase > 36 U/L) were included. Demographic variables, comorbidities, ultrasound findings, biochemical alterations, and time until resolution were analyzed.

The mean age was 12.8 years (range 4-17), with a female predominance (69%). Obesity was the main risk factor (80%). 43.4% of the patients (n= 24) presented with persistent choledocholithiasis and required endoscopic retrograde cholangiopancreatography, with pancreatitis recorded in 3 cases and cholangitis in 1 case as post-procedure complications. 66.6% (n= 48) showed spontaneous resolution. Bilirubin normalization was faster than choledochal diameter normalization (2.6 vs. 4 days). All patients with initial pancreatitis spontaneously resolved their choledocholithiasis. Biliary tract dilation was associated with greater choledocholithiasis persistence (p= 0.0395).

Conservative management with periodic reevaluations constitutes a safe and effective therapeutic alternative in selected pediatric patients, allowing for the reduction of the need for endoscopic retrograde cholangiopancreatography or biliary tract instrumentation and their associated risks.