Fig. 40.1
Intraoperative picture showing an open gallbladder with stones
The increasing incidence of cholelithiasis in children is attributed to:
Increased use of ultrasonography with increased detection rate
The growing obesity in children
The incidence of cholelithiasis in children ranges from 0.15 to 0.22 %.
The different types of gallstones in children differ from those in adults, with cholesterol stones being the most common type in adults and pigment stones being the most common type in children.
The distribution of the different types of gallstones in children is as follows:
Black pigment stones (48 %)
Cholesterol stones (21 %)
Calcium carbonate stones (24 %)
Protein-dominant stones (5 %)
Brown pigment stones (3 %)
Black pigment stones :
These make up 48 % of gallstones in children.
They are formed when bile becomes supersaturated with calcium bilirubinate, the calcium salt of unconjugated bilirubin.
Black pigment stones are commonly formed in hemolytic disorders (sickle-cell anemia, thalassemia, hemolytic anemia) and can also develop in children receiving parenteral nutrition.
Calcium carbonate stones:
They are more common in children than in adults
They account for 24 % of gallstones in children
Cholesterol stones :
They are formed from cholesterol supersaturation of bile
They are composed of 70–100 % cholesterol with an admixture of protein, bilirubin, and carbonate
They account for most gallstones in adults but make up only about 21 % of stones in children
Brown pigment stones :
These are rare, accounting for only 3 % of gallstones in children
They form in the presence of biliary stasis and bacterial infection
They are composed of calcium bilirubinate and the calcium salts of fatty acids
They develop more often in the bile ducts than in the gallbladder
Protein-dominant stones:
They make up about 5 % of gallstones in children
Cholelithiasis in children has various predisposing factors:
Hemolytic anemias including sickle-cell anemia and thalassemia, hepatobiliary disease, obesity, prolonged parenteral nutrition, abdominal surgery with ileal resection, and sepsis.
Other less prominent risk factors include: acute renal failure, prolonged fasting, low-calorie diets, rapid weight loss, the use of certain medications, primarily ceftriaxone.
Prior to puberty, the sex ratio of cholelithiasis in children appears to be equal. However, after puberty, the frequency of cholelithiasis is significantly greater in females than in males with ratio of 4:1 female predominance.
The frequency of cholelithiasis in children with sickle-cell anemia is high and increases with age, occurring in approximately 50 % of patients by age 20 years.
Etiology
There are several factors that contribute to the development of gallstones in children, and depending on the cause, gallstones are divided into :
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