Symptoms of gallstone disease

Symptoms of cholelithiasis in childhood are not as typical as in adults, because stones in the bile ducts do not cause acute inflammation in the gallbladder, which has the classic symptoms of calculous cholecystitis or cholangitis. However, children may have several possible clinical presentations of cholelithiasis:

• latent course (asymptomatic stone carriage);
• painful form with typical biliary colic;
• dyspeptic form;
• under the guise of other diseases.

Asymptomatic gallstone carriage is diagnosed when stones in the gallbladder or bile ducts are an accidental diagnostic finding in a child who has no complaints. This clinical stage of gallstone disease accounts for approximately half of patients (41-48%).

Special attention should be paid to children whose attack of "acute abdomen" resembles biliary colic in nature, accompanied by reflex vomiting, less often - icterus of the sclera and skin, discoloration of the stool. Yellowish coloration of the skin and visible mucous membranes is not typical for children with cholelithiasis. When icterus occurs, a violation of the passage of bile is assumed, and when combined with acholic feces and dark urine - mechanical jaundice. Attacks of typical biliary colic are noted in 5-7% of children with cholelithiasis.

The dyspeptic form is the most common clinical variant of cholelithiasis in childhood. Abdominal pain and dyspeptic disorders are the main complaints that allow one to suspect cholelithiasis in a child. The pains are very diverse in nature and can be localized in the epigastrium, pyloroduodenal zone, umbilical region, and right hypochondrium. In pre- and pubertal children, the pains are localized in the right hypochondrium.

The nature of the pain depends on the size of the stones. Multiple, small, easily moving stones, especially in combination with dysfunctional disorders of the hypermotor type, provoke acute pain. Patients with single stones and decreased evacuation function of the gallbladder are characterized by dull, nagging, vague pain in the abdomen.

It is necessary to pay attention to the nature of the clinical picture depending on the localization and mobility of the stones. In children, mobile, floating stones are more often found. It is these stones that cause acute abdominal pain of uncertain localization. Children with immobile stones are bothered by dull, aching pain in the right hypochondrium.

In children with stones in the bottom of the gallbladder, the disease often proceeds asymptomatically with subsequent formation of aching pain, while the localization of stones in the body and neck provokes acute abdominal pain, accompanied by nausea and vomiting. The described clinical symptoms of cholelithiasis are associated with the peculiarities of the innervation of the gallbladder.

As is known, the area of the bladder bottom is the so-called mute (painless) zone. The area of the body is moderately painful; the neck of the bladder, the cystic and common bile ducts have high pain sensitivity. If a calculus gets into sensitive areas, it causes an attack of acute abdominal pain, while a stone in the area of the bladder bottom can exist asymptomatically for a long time.

Pain is preceded by eating fatty foods or physical exertion. Early pain occurs soon after a dietary error, is paroxysmal, and is usually associated with a violation of the passage of bile into the duodenum due to concomitant developmental anomalies, as well as disorders of the gastrointestinal sphincters. Late pain, on the contrary, is dull, aching, and is caused by concomitant diseases of the upper gastrointestinal tract (gastroduodenitis, peptic ulcer, etc.).

There is a connection between the nature of the pain syndrome and the characteristics of the autonomic nervous system. Thus, in vagotonics, the disease occurs with attacks of acute pain, while children with sympathicotonia are characterized by a long course of the disease with a predominance of dull, aching pain. In addition, with an increase in the tone of the sympathetic link of the autonomic nervous system, the contractility of the gallbladder is sharply reduced, which leads to stagnation of bile, disruption of digestion processes and exacerbation of concomitant diseases of the upper gastrointestinal tract. The clinical picture is dominated by symptoms of hypomotor dyskinesia of the biliary tract. In children with vagotonia, various psychoemotional overloads and stresses serve as provoking factors for a pain attack. The parasympathetic section of the autonomic nervous system stimulates contraction of the gallbladder muscles and relaxes the sphincter of Oddi.

Thus, the clinical picture of cholelithiasis in children does not have the characteristic symptoms observed in adults during exacerbation of calculous cholecystitis. In preschool children, the disease resembles an attack of hypertensive dyskinesia of the biliary tract. In older children, cholelithiasis occurs under the guise of esophagitis, chronic gastroduodenitis, peptic ulcer disease, etc.

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