Gallstone disease in children

Gallstone disease in children is a dystrophic-dysmetabolic disease characterized by the formation of stones in the gallbladder or bile ducts. Gallstone disease in children is a multifactorial disease accompanied by the formation of stones in the gallbladder and/or bile ducts.

ICD-10 codes

• K80. Gallstone disease [cholelithiasis].
• K80.0. Gallstones with acute cholecystitis.
• K80.1. Gallstones with other cholecystitis.
• K80.2. Gallstones without cholecystitis.
• K80.3. Bile duct stones with cholangitis.
• K80.4. Bile duct stones with cholecystitis.
• K80.5. Bile duct stones without cholangitis or cholecystitis.
• K80.8. Other forms of cholelithiasis.

Epidemiology

The incidence of gallstone disease is 10-20% of the adult population, in Ireland - 5%, in Great Britain - 10%, in Sweden - 38%, in Japan - 8-9%. Among North American Indians - up to 32%. The prevalence of gallstone disease among children is unknown.

Cholelithiasis affects 10-20% of the adult population. Gallstones can form at any age, but cholelithiasis is observed less often in children under 10 years of age than in adults. Over the past 10 years, the prevalence of cholelithiasis among children has increased from 0.1 to 1.0%. Gallstone disease is more common in school-age children; among children under 7 years of age, boys get sick twice as often as girls; at the age of 7-9, there are no gender differences in the incidence of the disease; at the age of 10-12, girls get sick twice as often as boys. Most children before puberty have bilirubin stones, and during puberty and adolescence, cholesterol stones.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Causes of Gallstone Disease in Children

Cholelithiasis is a serious medical problem in all economically developed countries. Stones are most often found in the gallbladder, but they can also form in the ducts. Three factors play a leading role in the process of stone formation in children:

• hereditary predisposition;
• general metabolic disorders;
• anomalies in the development of the bile ducts.

Against the background of stone formation in the gallbladder in children, inflammatory changes develop - calculous cholecystitis.

Inflammatory changes in the gallbladder develop in several stages.

1. Initial stage (I) - working hypertrophy of the organ with moderately expressed inflammatory activity and increased reaction of the microcirculatory bed.
2. Transitional stage (II) - initial signs of decompensation, intensification of dystrophic, destructive processes in all layers of the gallbladder wall.
3. Stage of decompensation of the pathological process (III) - development of destructive changes and sclerosis of the muscular and submucosal layer of the gallbladder, circulatory disorders.

Causes of Gallstone Disease

[ 5 ], [ 6 ]

Symptoms of Gallstones in Children

Symptoms of gallstone disease in childhood are varied and often non-specific, half of the patients have low-symptom stone carriage. The nature of clinical manifestations is influenced by the autonomic nervous system. Hypersympathicotonia is characterized by a typical pain form, with asympathicotonia, a low-symptom course is more often observed, with vagotonia, the disease occurs under the guise of other gastrointestinal diseases. The nature of the pain syndrome depends on the localization of the stone, an attack of acute abdominal pain occurs when a calculus enters the neck of the gallbladder. Hepatic colic is rare and is characterized by acute abdominal pain, vomiting, jaundice.

• Course of the disease:
• 1st year - stage I inflammation, disruption of micelle formation, precipitation of stones;
• 2nd year - worsening of metabolic processes in the liver, stage II inflammation, recrystallization process in stones;
• 3rd year - stage III inflammation, disruption of the protein-synthesizing function of the liver, decreased synthesis of albumins, immunoglobulins, inhibition of phagocytic activity;
• more than 3 years of disease - penetration of pigment into the stone, increased probability of infection of the gallbladder, acute and chronic bacterial cholangitis. Metabolic disorders and stone formation are associated with the pathological HLA phenotype - CW3-4; AH, A2, A6, A9, B12, B18.

Symptoms of Gallstone Disease

Classification of gallstone disease

• Stage I - initial or pre-stone:
  • thick heterogeneous bile;
  • formation of biliary sludge with inclusion of microliths; putty-like bile; combination of putty-like bile with microliths.
• Stage II - formation of gallstones:
  • localization: in the gallbladder; in the common bile duct; in the hepatic ducts;
  • number of stones: single: multiple; o composition: cholesterol; pigment; mixed;
  • Clinical course: latent; with clinical symptoms - painful form with typical biliary colic; dyspeptic form; under the guise of other diseases.
• Stage III is the stage of chronic recurrent calculous cholecystitis.
• Stage IV is the stage of complications.

[ 7 ], [ 8 ], [ 9 ], [ 10 ], [ 11 ]

Screening

Detection of gallstones in the gallbladder using ultrasound.

Diagnosis of cholelithiasis in children

Diagnosis of cholelithiasis is based on ultrasound, which allows the detection of stones, and X-ray examination, which allows the determination of the degree of stone calcification.

Diagnosis of cholelithiasis in children

[ 12 ], [ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ], [ 19 ]

Treatment of cholelithiasis in children

Treatment of gallstone disease includes the following measures:

• diet therapy - mechanically and chemically gentle nutrition (exclude egg yolks, fried and fatty foods, fresh baked goods, chocolate, cream, sour cream, salty and spicy dishes);
• prevention of cholekinetic action;
• surgical treatment;
• ursodeoxycholic acid preparations;
• combination treatment.

Ursodeoxycholic acid

Ursodeoxycholic acid has several effects: anticholestatic, litholytic, hypocholesterolemic (the drug is prescribed only for cholesterol stones less than 1.5 cm in diameter, for small suspended stones in quantities of more than 10), antifibrolytic, immunomodulatory (regulation of apoptosis), antioxidant.

Mechanism of action of ursodeoxycholic acid:

• replacement of bile salt deficiency;
• inhibition of the synthesis and absorption of cholesterol (reduction of its concentration in bile);
• prevention of re-formation of cholesterol crystals;
• dissolution of cholesterol-gallstones;
• formation of liquid crystals.

Treatment is carried out for 24 months, continuous administration of the drug in the age-appropriate dose is required with an interval of no more than 7 days. Ultrasound is performed every 3 months.

Optimal dosage regimen of ursodeoxycholic acid in children:

• cholestasis of the newborn associated with total parenteral nutrition - up to 45 mg/(kg x day) once at night;
• neonatal cholestasis - 30-40 mg/(kg x day);
• cholelithiasis - 10-15 mg/(kg x day);
• Primary sclerosing cholangitis - 12-15 mg/(kg x day). Ursodeoxycholic acid preparations: ursofalk, ursosan, chenofalk (capsules of 250 mg).

Side effects: diarrhea, itching, increased transaminase activity, calcification of gallstones.

How is gallstone disease treated?

When taking ursodeoxycholic acid, small stones (up to 0.5 cm in diameter) dissolve in 100% of cases; single stones up to 1 cm in diameter dissolve in 70% of cases; multiple stones up to 1.5 cm in diameter, occupying up to 1/3 of the bladder volume, dissolve in 60% of cases. In children, it is recommended to begin treatment for cholelithiasis with a dose of ursodeoxycholic acid at the rate of 10 mg / kg x day) in 2 doses - 2/3 of the daily dose is taken in the evening, taking into account the increase in cholesterol synthesis at night. The therapy is long-term - from 6 months to 2 years. After the stone dissolves, it is necessary to take a litholytic drug for another 3 months. Litholytic therapy is combined with hepatoprotectors - Essentiale-N, Hepatofalk, etc.