Gallstone disease in children

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

ICD-10 codes

• K80. Gallstone disease [cholelithiasis].
• K80.0. Stones of the gallbladder with acute cholecystitis.
• K80.1. Stones of the gallbladder with another cholecystitis.
• K80.2. Stones of the gallbladder without cholecystitis.
• K80.3. Stones of bile duct with cholangitis.
• K80.4. Stones of bile duct with cholecystitis.
• K80.5. Stones of bile duct without cholangitis or cholecystitis.
• K80.8. Other forms of cholelithiasis.

Epidemiology

Morbidity of cholelithiasis is 10-20% of the adult population, in Ireland - 5%, in the UK - 10%, in Sweden - 38%, in Japan - 8-9%. The Indians of North America - up to 32%. The prevalence of cholelithiasis among the children is unknown.

Chololithiasis affects 10-20% of the adult population. Gallstones can form at any age, but in children under 10 years old, cholelithiasis is observed less frequently 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 schoolchildren, among boys up to 7 years, boys are 2 times more likely than girls, at the age of 7-9 years there is no sex difference in the incidence of the disease, in 10-12 years, girls are 2 times more likely than boys. In most children, before pubertal age, bilirubin stones are detected, and in puberty and adolescence, cholesterol stones are detected.

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

Causes of cholelithiasis in children

Chololithiasis is a serious medical problem in all economically developed countries. Stones are more often found in the gallbladder, but they can form in the ducts. In the process of stone formation in children, the leading role is played by three factors:

• hereditary predisposition;
• general metabolic disorders;
• anomalies in the development of biliary tract.

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

Inflammatory changes in the gallbladder develop in several stages.

1. The initial stage (I) is the working hypertrophy of the organ with a mildly pronounced activity of inflammation and an intensification of the 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 decompensation pathological process (III) - the development of destructive changes and sclerosis of the muscular and submucosal layer of the gallbladder, impaired blood circulation.

Causes of cholelithiasis

[5], [6]

Symptoms of cholelithiasis in children

Symptoms of cholelithiasis in childhood are diverse and often nonspecific, in half of patients observe low-symptomatic calcification. The nature of clinical manifestations is affected by the autonomic nervous system. For hypersympaticotonia typical painful form is characteristic, with asympticotonia more often observed malosymptomnoe flow, with vagotonia, the disease occurs under the mask of other gastrointestinal diseases. The nature of the pain syndrome depends on the location of the stone, an attack of acute pain in the abdomen occurs when the stone falls into the neck of the gallbladder. Liver colic is rare and is characterized by acute pain in the abdomen, vomiting, jaundice.

• Course of the disease:
• I year - inflammation of stage I, violation of micelle formation, loss of stones;
• 2 year - aggravation of metabolic processes in the liver, stage II inflammation, process of recrystallization in stones;
• 3 year - inflammation of stage III, impaired hepatic function of liver, decreased synthesis of albumins, immunoglobulins, inhibition of phagocytic activity;
• more than 3 years of the disease - penetration of the pigment into the stone, increased probability of infection of the gallbladder, acute and chronic bacterial cholangitis. Metabolic disorders and stone formation are associated with a pathological HLA phenotype - CW3-4; AN, A2, A6, A9, B12, B18.

Symptoms of cholelithiasis

Classification of cholelithiasis

• I stage - initial or pre-stone:
  • dense heterogeneous bile;
  • formation of biliary sludge with inclusion of microlites; putty bile; Combination of putty bile with microliths.
• II stage - formation of gallstones:
  • localization: in the gallbladder; in the common bile duct; in the hepatic ducts;
  • number of concretions: single: multiple; about the composition: cholesterol; pigmented; mixed;
  • clinical course: latent; with clinical symptoms - painful form with typical biliary colic; dyspeptic form; under the mask of other diseases.
• III stage - the stage of chronic recurrent calculous cholecystitis.
• Stage IV - stage of complications.

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

Screening

Detection of concrements in the gallbladder with ultrasound.

Diagnosis of cholelithiasis in children

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

Diagnosis of cholelithiasis in children

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

Treatment of cholelithiasis in children

Treatment of cholelithiasis includes the following activities:

• diet therapy - mechanically and chemically sparing food (exclude egg yolks, fried and fatty foods, fresh buns, chocolate, cream, sour cream, salty and spicy dishes);
• prevention of cholekinetic action;
• surgery;
• preparations ursodeoxycholic acid;
• combined 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, with fine suspended stones in the amount of more than 10), antifibrolitic, immunomodulating (regulation of apoptosis), antioxidant.

The mechanism of action of ursodeoxycholic acid:

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

Treatment is carried out for 24 months, continuous reception of the drug in the age-related dose is necessary with an interval of no more than 7 days. Every 3 months, ultrasound is performed.

The optimal dosage regimen of ursodeoxycholic acid in children:

• cholestasis of newborns, associated with complete parenteral nutrition, - up to 45 mg / (kghsut) once a night;
• neonatal cholestasis - 30-40 mg / (kghsut);
• cholelithiasis - 10-15 mg / (kilogram);
• primary sclerosing cholangitis - 12-15 mg / (kghsut). Preparations of ursodeoxycholic acid: ursofalk, ursosan, henofalk (250 mg capsules).

Side effects: diarrhea, itchy skin, increased activity of transaminases, calcification of gallstones.

How is cholelithiasis treated?

When receiving ursodeoxycholic acid, small concretions (up to 0.5 cm in diameter) are dissolved in 100% of cases; Single stones up to 1 cm in diameter are dissolved in 70% of cases; multiple stones up to 1.5 cm in diameter, occupying up to 1/3 of the volume of the bladder, are dissolved in 60% of cases. In children, it is recommended to start treatment of cholelithiasis with a dose of ursodeoxycholic acid from the calculation of 10 mg / kght) in 2 doses - 2/3 of the daily dose is taken in the evening, taking into account the increase in cholesterol synthesis at night. Long-term therapy - from 6 months to 2 years. After dissolution of the stone, it is necessary to take a litholytic preparation for another 3 months. Litholitic therapy is combined with hepatoprotectors - Essential-H, hepatofalk, etc.