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PubMed1975

Cholelithiasis and ileal pathology in childhood.

Primary cholelithiasis is rare in childhood. A particular etiology has appeared over the last few years in connection with unusual physiological situations. Three cases of cholelithiasis after ileal atresia or resection are presented in children of 1, 1, and 7 yr. Another case is presented after abdominal irradiation for Wilms' tumor and ileal resection in a child of 7. The pathogenesis is discussed, raising the question of the interruption of the enterohepatic circulation of bile salts.

Bile Acids and Salts↗
PubMed1989

The spectrum of cholelithiasis in the first year of life.

Cholelithiasis is being diagnosed with increased frequency in the very young. We encountered 12 patients over a 5-year period in whom cholelithiasis was diagnosed prior to age 1 year. The earliest diagnosis was made in utero during the seventh gestational month. While most of the children suffered from complex medical disorders, 4 of the 12 had no recognizable predisposing factors. Eight of the 12 were treated at some point prior to diagnosis with central parenteral nutrition. Three presented with infectious complications requiring prompt operative intervention. Two children underwent elective cholecystectomy nearly 2 years after the diagnosis for symptoms of biliary colic. Of the remaining seven, spontaneous stone resolution was documented in three, while four remain asymptomatic after a minimum of years follow-up. The spectrum of presentations in this series highlights the uncertainties regarding the etiology, natural history, and treatment of this increasingly more common disorder.

Cholelithiasis↗
PubMed1993

Cholelithiasis in infancy: a study of 40 cases.

During a 17-year period, 40 infants less than 1 year of age were investigated for cholelithiasis; 32 infants were seen within the past 10 years. Seventeen of them had no recognizable predisposing factors. In 6 infants, gallbladder lithiasis was a fortuitous finding on a plain radiograph or sonogram with no signs of common bile duct obstruction; under conservative management, no complications of lithiasis were observed on follow-up of 3 infants and spontaneous resolution occurred in 2 others. In the remaining 34 infants with lithiasis of the common duct or cystic duct or both, the initial symptoms were cholestatic jaundice in 21, acholic stools in 8, sepsis in 4, and abdominal pain in 1. Ultrasonography, performed in 33 of them, showed dilation of the biliary tract in 28, and stones in the gallbladder in 13 and in the bile ducts in 10. Percutaneous transhepatic cholangiography or operative cholangiography in 26 infants showed stones in the bile ducts in 23. In 3 infants, no lithiasis was visible, suggesting the spontaneous elimination of stones. Treatment was initially surgical in 9 infants, but starting in 1981 interventional radiologic procedures were attempted in 15 infants and were successful in 12. Spontaneous resolution of cholelithiasis occurred in 10 other infants with cholestasis. Recurrence of biliary stones was observed in 3 infants only after a follow-up of 7 months to 10 years. These results suggest that common bile duct lithiasis should be considered among the causes of cholestatic jaundice in infancy, and that some of the gallbladder calculi found in older children may have resulted from a lithogenic process that occurred during fetal life or shortly after birth. Percutaneous cholangiography with biliary drainage appears to be an effective means of treatment of infants with common bile duct obstruction; surgery can then be restricted to a limited number of cases, especially those with associated strictures of the bile ducts.

Bile↗
PubMed1993

Approaches to the management of cholelithiasis for the medical consultant.

Gallstones constitute a major medical problem in the United States. Patients who are asymptomatic require no therapy. Subsequent symptoms develop in a minority of patients, and the need for cholecystectomy is low. Symptomatic patients with reversible risk factors for gallstones, those who refuse surgery, and those who are poor surgical candidates should be considered for medical therapy. Our approach is outlined in Figure 2. Practical options include oral dissolution agents, contact dissolution agents, and shock-wave lithotripsy. Unfortunately, these therapies are successful in very select patients, and only a small percentage of patients with symptomatic gallstones will be candidates for any combination of these. If successful, the recurrence rate is high. Cholecystectomy is a safe, effective procedure that definitively treats symptomatic cholelithiasis. Patients with frequent symptoms of biliary colic, those with severe symptoms, and those who are young and do not have reversible risk factors for gallstones should be considered for cholecystectomy. If surgical expertise is available, the patient requiring an elective cholecystectomy should be educated regarding the laparoscopic approach that offers a better cosmetic result, shorter hospital stay, and faster return to normal activities. The medical consult must be aware of all the options available for managing patients with cholelithiasis. This will afford greater versatility in medical care or perioperative management.

Bile Acids and Salts↗
PubMed1997

Cholelithiasis and acute cholecystitis.

Although much is still to be learned about the pathogenesis of cholelithiasis, recent investigations have greatly advanced our knowledge regarding the mechanisms of cholesterol supersaturation and nucleation. Laparoscopic cholecystectomy has lessened the usual peri-operative morbidity of cholecystectomy, but is associated with a higher bile duct injury rate. Acute cholecystitis, the commonest complication of cholelithiasis, is a chemical inflammation usually requiring cystic duct obstruction and supersaturated bile. The treatment of this condition in the laparoscopic era is controversial. Early operation may lessen hospital stay but an increased risk of biliary injury has been reported.

Acute Disease↗
PubMed2003

A multidrug resistance 3 gene mutation causing cholelithiasis, cholestasis of pregnancy, and adulthood biliary cirrhosis.

We describe a 47-year-old patient who developed cholelithiasis in adolescence, followed by recurrent intrahepatic cholestasis of pregnancy, and finally biliary cirrhosis in adulthood. In our patient, the consecutive presentation of the 3 mentioned disorders raised the suspicion of a defect of MDR3, the canalicular protein involved in the transport of phospatidylcholine to bile. Mutational analysis in our patient showed a heterozygous missense mutation of the MDR3 gene that has not been described previously, which occurs in exon 14 at codon 535, and results in the substitution of glycine for aspartic acid. Further analysis of 7 members of the family showed the same mutation in her daughter who, on follow-up, developed cholestasis of pregnancy and persisting high serum levels of gamma-glutamyl transpeptidase and alkaline phosphatase after delivery. Although biliary cirrhosis associated with MDR3 deficiency typically appears before the age of 25 years, in our case, the relatively mild MDR3 dysfunction allowed for a slower progression of the disease with established, well-advanced cirrhosis in the fifth decade of life. The present case, which accumulates the 3 clinical disorders assocaited with MDR3 deficiency, shows that this condition should be suspected not only in children or young people with high gamma-glutamyl transpeptidase cholestasis but also in middle-aged or older patients with chronic idiopathic cholestasis, especially when there is a previous history of cholestasis of pregnancy or juvenile cholelithiasis.

ATP Binding Cassette Transporter, Subfamily B↗
PubMed2001

Cholecystectomy versus cholecystolithotomy for cholelithiasis in childhood: long-term outcome.

BACKGROUND/PURPOSE: The presence of cholelithiasis is being reported with increased frequency in childhood. Little is known about the natural history of the disease, and only a few studies have been published regarding long-term results of treated patients. Controversy still exists regarding optimal treatment. Both cholecystectomy and cholecystolithotomy with gallbladder preservation have been recommended as the preferred operative intervention. The purpose of this study was to compare the long-term outcome of cholecystectomy versus cholecystolithotomy for symptomatic gallbladder disease in children. METHODS: The charts of all patients with symptomatic cholelithiasis treated in the Dublin Paediatric Hospitals during a 25-year period from 1974 till 1999 were reviewed. Data obtained included age, sex, age at presentation of symptoms, methods of diagnosis, indications for operative treatment, time interval between presentation of symptoms and surgery, surgical technique, performance of a preoperative or intraoperative cholangiogram, stone biochemistry, gallbladder histology, radiologic follow-up, the presence of recurrent or residual stones and symptoms, and the need for reoperation. Patient data were grouped according to method of surgery. All parameters were compared and evaluated. Follow-up was by way of telephone contact with all patients and completion of a questionnaire. RESULTS: There were 18 patients over a 25-year period. Eight patients underwent cholecystectomy, and 10 patients had a cholecystolithotomy. Median follow-up was 2 years in the cholecystectomy group and 5 years in the cholecystolithotomy group. All patients in the cholecystectomy group are asymptomatic and have no recurrent or residual stones on follow-up ultrasound scan. Thirty percent of the patients in the cholecystolithotomy group have recurrent right upper quadrant pain, and 30% show recurrent stones 9.5 months (range, 7 to 12 months) postoperatively. One patient underwent cholecystectomy 8.5 months postcholecystolithotomy. CONCLUSIONS: The symptomatic high stone recurrence rate postcholecystolithotomy seen in our series suggest that cholecystectomy is the preferred treatment in patients with symptomatic gallbladder disease.

Adolescent↗
PubMed2004

Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis.

BACKGROUND AND STUDY AIMS: The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy. PATIENTS AND METHODS: In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken. RESULTS: The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82 %). Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6 %) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications. CONCLUSIONS: Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.

Adult↗
PubMed1993

[Histopathological changes of gallbladder and liver parenchyma in symptomatic cholelithiasis].

In a retrospective study of 1101 patients (302 men, 799 women; mean age 56,7 [19-88] years) with symptomatic cholelithiasis who had undergone elective cholecystectomy and intraoperative liver biopsy, histological examination revealed inflammatory changes in the gallbladder in 96.7%, chronic fibrotic cholecystitis in 94.5% and a severe form of cholecystitis in 8.8%. Clinically relevant changes in the liver parenchyma were present in 27.9%, most frequently intrahepatic cholangitis (21.8%). The latter was significantly more common in choledocholithiasis than in isolated cholecystolithiasis. 27 patients had signs of severe liver disease, namely viral hepatitis, cirrhosis or fatty liver. Since the gall-bladder in cholelithiasis is almost always inflamed, cholecystectomy is the treatment of choice. Not uncommonly liver biopsy will reveal clinically relevant changes in the liver parenchyma. This will be useful information, especially in the management of symptoms which persist postoperatively.

Adult↗
PubMed1984

[Gallbladder contractility, cholelithiasis and autonomic neuropathy in diabetes mellitus].

Decrease in gall-bladder surface area, as obtained by ultrasound, was measured in 52 patients with insulin-dependent diabetes (27 with and 25 without autonomic neuropathy) 60 minutes after administration of the bile stimulant Biloptin. The post-stimulation area was 33 +/- 6% of initial value in patients with autonomic neuropathy, and 67 +/- 8% (P less than 0.0005) in those without autonomic neuropathy. Comparison with insulin-dependent chronic diabetics matched for sex, age and duration of illness, demonstrated that heart-rate variability in cholelithiasis was less than in the control subjects (P less than 0.05). It is concluded that autonomic neuropathy, measured by the occurrence of spontaneous vagotomy, in insulin-dependent diabetics is an important risk factor in the overall pathogenesis of cholelithiasis.

Adult↗
PubMed1983

[Cholecystectomy, cholelithiasis and cancer of the large intestine].

In a retrospective post-mortem study the connection between the post-cholecystectomy state, cholelithiasis and carcinoma of the large intestine was evaluated in 333 cases and compared with an age and sex matched control group and a group with gastric carcinoma. It was established that cholelithiasis (without cholecystectomy or contracted gallbladder) occurred significantly more frequently (24.9%) in patients with colonic carcinoma than in the control group (15.3%) or the gastric carcinoma group (12.6%) (P less than 0.001). In contrast the rate of cholecystectomy in patients with colonic carcinoma was not significantly increased (6.3%) when compared with both control groups (4.6 and 4.8%). Separate assessment of males and females showed that females had cholecystectomy and contracted gallbladder significantly more frequently (P less than 0.05). These figures suggest that the clinically observed association between cholecystectomy and colonic carcinoma reflects only a - not necessarily causative - connection between gallstone disease and colonic carcinoma.

Aged↗
PubMed1993

Complete abdominal exploration is unnecessary during the treatment of cholelithiasis.

The development of laparoscopic and non-operative methods for the management of cholelithiasis has been based on the premise that abdominal exploration during cholecystectomy is unnecessary. In the current study, 305 patients undergoing complete abdominal exploration during routine cholecystectomy were evaluated to assess the incidence and significance of intraabdominal pathology found at the time of exploration. While 41 patients (13.4%) were found to have additional diagnosis at the time of exploration, the majority of these were either minor in nature or would easily have been recognized utilizing laparoscopic techniques. Only one patient would have had significant intraabdominal pathology missed by laparoscopic techniques. It can be concluded that abdominal exploration at the time of treatment of cholelithiasis is unnecessary and that laparoscopic cholecystectomy will not compromise patient care in this regard.

Cholecystectomy, Laparoscopic↗
PubMed1992

Cholelithiasis in patients treated with a very-low-calorie diet.

One hundred seventy-nine obese patients (mean body mass index = 36.3) were retrospectively evaluated for the development of cholelithiasis associated with the use of a 2530-kJ/d (605-kcal) very-low-calorie diet (VLCD). Nine percent of patients had preexisting gallstones and 11% of patients developed gallstones either during or within 6 mo of completing the diet. Six percent had subsequent cholecystectomy. Ursodeoxycholic acid administered to one patient resulted in spontaneous stone dissolution whereas spontaneous dissolution occurred in three patients. Surveys of patients at three other programs using the same diet yielded similar incidence of gallstones. We conclude that rapid weight loss associated with the use of VLCD is associated with a significant incidence of gallstone formation. VLCD should be physician supervised because resolution of cholelithiasis spontaneously, with stone passage, or dissolution with ursodeoxycholic acid therapy may reduce the need for cholecystectomy.

Cholecystectomy↗
PubMed1996

Selections from current literature: cholelithiasis, cholecystectomy and the risk of colorectal cancer.

The study by Ekbom et al. clearly demonstrates that, overall, there is no increased risk of colorectal cancer following cholecystectomy. However, it is noted that women have a slight increase in the risk of proximal colon cancer following cholecystectomy. The reasons for this finding remain unclear. However, since this finding has been consistent in several studies, it is probably not an artifact, but a true association that may warrant further investigation. It is possible that the association noted between cholecystectomy and colorectal cancer is due not to the cholecystectomy, but to the reason why cholecystectomies are performed, namely the presence of gallstones. The cholecystectomy itself may simply be a surrogate for cholelithiasis, which may be a true risk factor for colorectal cancer. Excess secondary bile acids may be carcinogenic or the factors which cause the formation of cholelithiasis may also increase the risk for developing colorectal cancer. An answer to the separate question of whether excessive laparoscopic cholecystectomies are being performed, or whether newer indications make the increased number of laparoscopic cholecystectomies appropriate, remain outstanding. This new procedure, despite being cheaper than the open cholecystectomy, has resulted in greater utilization of the world's dwindling health care resources. In conclusion, the decision to perform a cholecystectomy should be made only with consideration of the patient's current medical condition. There is no need to be concerned about any future increased risk of colorectal cancer following a cholecystectomy.

Aged↗
PubMed2001

Hamsters predisposed to sucrose-induced cholesterol gallstones (LPN strain) are more resistant to excess dietary cholesterol than hamsters that are not sensitive to cholelithiasis induction.

We compared the effects of cholesterol feeding in male hamsters from two strains with different propensities to sucrose-induced cholelithiasis; Laboratoire de Physiologie de la Nutrition (LPN) hamsters are predisposed to developing biliary cholesterol gallstones, whereas Janvier (JAN) hamsters are not. When fed a basal control diet, LPN hamsters had a lower cholesterolemia (-21%, P = 0.01) than JAN hamsters, and a higher activity of 3-hydroxy-3-methyl glutaryl coenzyme A reductase in liver (+148%, P = 0.018) and intestine (+281%, P < 0.0001). After feeding the same diet enriched with 0.3% cholesterol for 5 wk, cholesterolemia increased more dramatically in JAN hamsters (+235%, P < 0.001) than in LPN hamsters (+108%, P < 0.001), as did the liver concentration of cholesterol, which reached 152.30 +/- 13.00 and 44.41 +/- 9.06 micromol/g, respectively. Only JAN hamsters displayed hepatomegaly, with an increased cholesterol saturation index of the gallbladder bile (+100%, P < 0.01), due to the cholesterol challenge. In liver, cholesterol feeding reduced cholesterol 7alpha-hydroxylase activity and mRNA level, and stimulated sterol 27-hydroxylase and oxysterol 7alpha-hydroxylase activities. Hepatic levels of LDL receptor decreased by approximately 60% in both strains, whereas HDL receptor scavenger class B type 1 (SR-BI) levels were unaffected by dietary cholesterol. The greater resistance of LPN hamsters to the hypercholesterolemic diet can be explained by a lower capacity to store cholesterol in the liver and greater efficiency in reducing the activity of 3-hydroxy-3-methyl glutaryl coenzyme A reductase in response to cholesterol feeding [from 11263 to 261 pmol/(min x organ) in LPN hamsters and from 4530 to 694 pmol/(min x organ) in JAN hamsters]. These results highlight the usefulness of this two-strain model, which offers some analogy with the inverse association between the predisposition to cholelithiasis and the risk of atherosclerosis in humans.

Animals↗
PubMed1980

Cholecystitis, cholelithiasis and common duct stenosis in children and adolescents.

A study of 100 patients from 14 months through 18 years of age with extrahepatic biliary tract conditions who have been treated from 1950 through 1979 is reported. For discussion, these have been classified into four groups including acalculous cholecystitis, nonhemolytic cholelithiasis, hemolytic cholelithiasis and stenosis of the common duct. Ninety-nine patients were operated on and there were no deaths. Except for unusual contraindications, cholecystectomy is preferred for acute noncalculous cholecystitis. The largest number having gallstones were those patients (87%) without hemolytic disease. Only 13% had an associated hemolytic disorder. Cholecystectomy is the preferred treatment and common duct exploration is utilized when indicated. Six children with chronic relapsing pancreatitis secondary to stenosis of the ampulla of Vater and two with common duct stenosis are analyzed. Although extrahepatic biliary disorders are usually not considered in the differential diagnosis of children and adolescents with vague abdominal pain, it is evident by this large number of patients that there should be greater emphasis placed on earlier diagnosis in the future.

Acute Disease↗
PubMed1991

Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis.

Our initial experience with laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis has involved 152 patients. Patient age ranged from 17 to 83 years; most were female (78%). Their average weight was 170 pounds (range, 75 to 365 lbs.). Twenty-two per cent had a single gallstone, while 9% had two to three stones and 64% had more than three stones. Exclusion criteria initially included upper abdominal scarring, severe acute cholecystitis, choledocholithiasis, and inability to tolerate general anesthesia. The first two of these are now only relative contraindications with increased experience. Thirteen of the one hundred fifty-two procedures (8.5%) required conversion to an open operation. Average time of operation was 138 minutes. Intraoperative cholangiography was attempted in 78% of cases and was completed successfully in 66% of those attempted. There have been no deaths. The complication rate has been low: 4% major, 0% life-threatening, and 7.2% minor complications. Postoperative analgesic requirements are remarkably low: 36% of patients required no narcotics after leaving the recovery room. Eighty-seven per cent of patients successfully undergoing LC were discharged by the first postoperative day. Most patients resumed normal activities within 1 week after discharge. Laparoscopic cholecystectomy offers the majority of patients with symptomatic cholelithiasis an improved treatment option, resulting in significantly less postoperative pain, hospitalization, and recuperation time.

Adolescent↗
PubMedDate not supplied

Unusual presentation of cholelithiasis on T1-weighted MR imaging.

Cholelithiasis usually appears on magnetic resonance as a signal void contrasting with the high signal of surrounding bile. We describe the appearance of two intraluminal gallstones as high-signal areas on a heavily T1-weighted scan and, based on infrared spectroscopic analysis of the stones, believe the fatty-acid content of the stones accounts for this unusual result. Increased focal intraluminal signal on strongly T1-weighted sequences does not, therefore, preclude a diagnosis of cholelithiasis.

Aged↗