Cholecystitis in children

Inflammation of the gallbladder, or cholecystitis in children, is most often of bacterial origin, and sometimes occurs secondarily with biliary dyskinesia, the presence of gallstones, or parasitic infestations.

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Causes of cholecystitis in children

The main causes of inflammatory cholepathies (cholecystitis, cholangitis):

1. non-immune causes - changes in the composition of bile, infection, parasites;
2. autoimmune processes (primary sclerosing cholangitis, biliary cirrhosis).

Non-immune cholecystitis and cholangitis are divided into acute and chronic by course, and into calculous (associated with cholelithiasis) and acalculous by etiology. By the nature of the pathological process, acute cholecystitis is divided into catarrhal, phlegmonous and gangrenous. In some patients, these forms can be considered as stages of disease development. The leading role in the development of acute cholecystitis belongs to infection. The most common pathogen is E. coli; less often, the disease is caused by staphylococci, streptococci and enterococci. Cholecystitis also occurs with autolytic damage to the mucous membrane of the gallbladder as a result of pancreatic juice reflux into its cavity. Inflammation is possible with helminthic invasions (ascariasis). It is important to remember that infected bile does not cause inflammation of the gallbladder without predisposing factors - stagnation and damage to the walls of the organ. Stagnation is facilitated by organic disorders of the bile outflow tract (compression or bending of the neck of the gallbladder and ducts, blockage of the ducts by a stone, mucus or helminths), as well as dyskinesia of the gallbladder and bile ducts under the influence of a violation of the diet (rhythm, quantity, quality of food, overeating, consumption of fatty foods). The role of psycho-emotional stress, stress, physical inactivity, metabolic disorders leading to a change in the chemical composition of bile is great. Inflammation of the gallbladder can occur reflexively with a disease of other organs of the gastrointestinal tract as a result of viscero-visceral interactions. Damage to the wall of the gallbladder is possible due to irritation of its mucous membrane by bile with altered physical and chemical properties (lithogenic bile), due to trauma from stones, helminths, pancreatic enzymes flowing into the common bile duct (during spasm of the sphincter of Oddi).

An infectious agent enters the gallbladder in three ways:

• ascending pathway from the intestine - enterogenous pathway with hypotension of the sphincter of Oddi;
• hematogenous route (via the hepatic artery in case of lesions of the oropharynx and nasopharynx or from the intestine via the portal vein in case of disruption of the barrier function of the small intestinal epithelium);
• lymphogenous pathway (in appendicitis, pneumonia).

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Symptoms of cholecystitis in children

The main symptoms of cholecystitis are nonspecific:

• abdominal pain localized in the right hypochondrium, radiating to the right shoulder;
• nausea, vomiting;
• signs of cholestasis;
• signs of intoxication.

The pain syndrome occurs suddenly, often at night after eating fatty foods. The duration of the pain syndrome is from several minutes (biliary colic) to many hours and days. Particularly persistent pain is caused by acalculous cholecystitis. The pain is accompanied by reflex vomiting with bile, chills, febrile fever, tachycardia. Positive symptoms of Ortner, Mussi, Murphy, Ker are detected by palpation. The liver is enlarged, the edge is smooth, painful.

How to recognize cholecystitis in a child?

Blood tests reveal leukocytosis, neutrophilia, toxic granularity of neutrophils, increased ESR, increased bilirubin concentration (bound fraction) and aminotransferase activity, and the appearance of C-reactive protein.

Oral cholecystography is not used, since the concentration function of the gallbladder is reduced and there is no accumulation of contrast. It is possible to use intravenous cholangiography, ultrasound. During ultrasound, the wall of the gallbladder is loose, thickened by more than 3 mm due to inflammatory edema, the contour is doubled; additional echo signals are determined in the liver parenchyma around the gallbladder (perifocal inflammation), thickening of bile in the bladder (a sign of cholestasis).

During duodenal probing, an increase in protein concentration, the appearance of leukocytes and epithelial cells, and a decrease in the concentration of bile acids and bilirubin are determined in portions of bile. Bile culture reveals coccal pathogens and E. coli.

Chronic cholecystitis is a chronic inflammation of the gallbladder. It is the outcome of acute cholecystitis. In everyday pediatric practice, the diagnosis of "chronic cholecystitis" is made relatively rarely (10-12%) due to the lack of clear and accessible diagnostic criteria. The following factors play a major role in the pathogenesis of chronic cholecystitis: dysfunction of the biliary tract, concomitant pathology of the digestive organs, frequent viral infections, food allergies and food intolerances, the presence of foci of chronic infection, poor diet, metabolic disorders.

Classification

• Severity: mild, moderate, severe.
• Stage of the disease: exacerbation, decreasing exacerbation, stable and unstable remission.
• Complications: complicated and uncomplicated chronic cholecystitis.
• Nature of the course: recurrent, monotonous, intermittent.

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Treatment of cholecystitis in children

Treatment of cholecystitis and cholangitis in children depends on the etiology. Antibacterial or antiparasitic therapy is prescribed, and glucocorticoids are used in autoimmune processes. Etiotropic therapy is supplemented by detoxification, correction of water-electrolyte and metabolic disorders, desensitization, correction of biliary tract motility disorders (including antispasmodics), anti-cholestatic therapy and hepatoprotectors.

To relieve pain, M-chollin blockers (platifillin, metocinium iodide, tramadol, belladonna preparations), myotropic antispasmodics (mebeverine) are used. In case of vomiting, metoclopramide (2 ml intramuscularly) or domperidone (20 mg orally) are prescribed. In the remission phase, cholekinetics are indicated - chophytol* and hymecromone (odeston). Of the antibacterial drugs, given the sensitivity of the isolated microorganism, preference is given to cephalosporins and macrolides excreted with bile.