**4.2 Common bile duct obstruction**

The exact prevalence of choledocholithiasis in children is not known but they are uncommon in children. Common bile duct stones are mostly associated with gallstones except in few conditions like hemolysis where they can be primary. Presentation of choledocholithiasis include jaundice, acholic stools, and dark urine, sometimes presentation is with acute cholangitis, manifested by fever, jaundice, and right upper quadrant pain. Choledocholithiasis should also be suspected in a patient with gallstones with raised conjugated bilirubin and/or a dilated common bile duct [as per age] on ultrasound.

#### **4.3 Pancreatitis**

Cholelithiasis is one of the leading cause of acute pancreatitis in adults, however the exact incidence of gallstone pancreatitis in children is not known. Patients with gallstone pancreatitis present with epigastric abdominal pain, nausea, and vomiting or jaundice. Sometimes gall stones are detected on evaluation of pancreatitis only. Ultrasound should be the first imaging modality followed by CT scan in doubtful cases. Biochemical investigation shows elevated serum amylase and lipase levels, and elevated conjugated serum bilirubin is often present.

#### **5. Investigation**

Ultrasound is the most accurate imaging study to evaluate for gall stones, can detect as small as 1.5 mm. On ultrasound gallstones appears as hyperechoic, single or multiple and characteristically cast an acoustic shadow in contrast biliary sludge appears echogenic on ultrasound, but does not cast an acoustic shadow. Both sensitivity and specificity of ultrasonography is 95% for gall stones, but it is low for stones in common bile duct [45]. Cholescintigraphy, with Tc 99 m labeled diisopropyl iminodiacetic acid [DISIDA], is the most accurate method of diagnosing acute cholecystitis, non-visualization of the gallbladder in an otherwise patent biliary system suggests acute cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) is being used increasingly to investigate complicated gallstone disease and choledocholithiasis and for delineating pancreatic and biliary tract anatomy. Endoscopic retrograde cholangiopancreatography (ERCP) can be done for both diagnostic and therapeutic in common bile duct stones. Endoscopic ultrasound can be used for diagnosis in children with complicated biliary stone disease CT scan do not have much role in diagnosis of gall stones [46, 47]. There are no specific laboratory tests in diagnosing cholelithiasis, some blood tests are required for making etiological diagnosis and to rule out complications. These include Complete blood count, liver function tests, lipid profile [serum cholesterol (LDL, HDL, VLDL) and serum triglycerides], hemolytic profile [reticulocytes, osmotic fragility, quantitative glucose 6 phosphate dehydrogenase (G6PD) measurement, hemoglobin electrophoresis, direct coombs test], next generation sequencing (if genetic cause suspected) and sweat chloride test (if cystic fibrosis suspected) and serum amylase and lipase, if pancreatitis is suspected.

#### **6. Management**

Management of cholelithiasis is affected by several contributing factors, such as type of stone, anatomical status of gallstone, rate of symptoms in the child, underlying anatomical malformations, other underlying disease, inflammatory changes of the biliary system, and age of the child. Children with gallstones should be divided into two groups, symptomatic and asymptomatic. Symptomatic and complicated gallstones need cholecystectomy [48]. Gallstones which float in the gallbladder, having a diameter of less than 10 mm and are diagnosed incidentally in asymptomatic children, should be investigated for haemolytic diseases and underlying disorders and need to be treated after diagnosis. In infants mostly,

#### *Gall Stones in Pediatric Population DOI: http://dx.doi.org/10.5772/intechopen.99020*

cholelithiasis resolves after several months of monitoring. However, cholelithiasis is not usually resolved spontaneously in older children. In a prospective study of children with nonpigmented gallstones it was found that, 50% remained or became asymptomatic, 32% experienced definite improvement in symptoms, and 18% had continued symptoms but none had any biliary complications [49]. The risk of subsequent hospital admission in children and adolescents with cholelithiasis increases by 5% for every 10 days [50]. Also, one fourth of children with gall stones, presents directly with complications [51]. Therapy with UDCA is recommended in asymptomatic patients with cholesterol stones [52]. However, the role of dissolution therapy in the management of gallstones in children remains to be defined, the use of UDCA therapy is restricted due to the long course of treatment, differential outcome, and the risk of side-effects such as diarrhea and liver dysfunction [53]. Gallstones when located in the common bile duct or around the pupillary sphincter, can cause cholangitis, obstruction of bile flow, and jaundice, stone removal should be done urgently tp relieve obstruction. In centres where pediatric ERCP is offered the endoscopic approach to relieve obstruction is safe and effective, if not laparoscopic exploration is also safe and effective alternative. In recent years, laparoscopic cholecystectomy (LC) has become the treatment of choice in the surgical management of children with cholelithiasis. Approach for mnagemement of gall stones in children given in **Figure 2**. LC is less invasive, has lower morbidity and mortality with shorter hospital stay in comparison to conventional open cholecystectomy [54]. Extracorporeal shock-wave lithotripsy is another therapeutic method, in selective cases like when the patient is asymptomatic or with the radiolucent gallstone.

In children receiving TPN especially longer duration should be assessed for gallstones. On discontinuation of TPN regimen and start of oral diet leads to establishment of bile flow which resolves bile sedimentation. TPN needs to be continued in cases where enteral feeding cant be done such as intestinal pseudo-obstruction or short bowel syndrome, in these patients therapeutic cholecystectomy should be done in presence of gallstones [55].

The approach to cholelithiasis in infancy is different as spontaneous resolution has been reported in a significant proportion of cases (cholelithiasis ̴50% and choledocholithiasis 30%). Spontaneous resolution within 6 months is more common ̴

**Figure 2.** *Approach for management of gallstones in children.*

with idiopathic and or asymptomatic gallstones than in patients with known predisposing factors. Cholecystectomy is indicated for symptomatic cholelithiasis, asymptomatic cholelithiasis persisting beyond 12 months and radiopaque calculi [56, 57].

#### **6.1 Management of cholelithiasis in hemolytic disease**

In children with hemolytic anaemias, screening for gall stones with Ultrasound is recommended from 5 years of age. Screening is also recommended before splenectomy as both splenectomy and cholecystectomy to be done in single setting in presence of gallstones [58, 59]. In sickle-cell disease, prophylactic cholecystectomy is recommended even for asymptomatic gallstones as it is difficult to differentiate an acute abdominal crisis from acute cholecystitis, and the morbidity and mortality of emergency cholecystectomy in acute crisis is much higher than in elective cholecystectomy [58]. To avoid sickling during the perioperative period hypotension, hypoxia, hypothermia, dehydration, and acidosis should be avoided and hemoglobin S should be kept below 30% and total hemoglobin should be at least of 11 g/dL [60, 61]. Many studies recommended LC in asymptomatic patients with hemolytic diseases to avoid the complications of urgent cholecystectomy and the chance of gallstone complications among the asymptomatic patients is upto 50% within 5 year of diagnosis [62]. Inflammation and infection of the gallbladder also increases the chance of a hemolytic crisis. Oral hydroxyurea reduces the frequency of cholelithiasis in some haemolytic diseases, such as thalassemia intermedia or major.

## **7. Prevention of gall stones**

Gallstones are formed due to interaction of multiple factors like genetic, anatomical, systemic and metabolic abnormalities. However, there are some preventive factors especially for cholesterol gallstones which include regular diet, lifestyle, physical exercise, and intake of vitamin C. Lifestyle should include physical activity, ideal weight maintenance and weight reduction among overweight and obese children to prevent gall stones. It has been found that physical activity decreases the risk of symptomatic stones by about 30–70%. Regular exercise reduces insulin levels, insulin resistance, triglyceridemia, and fatty acid-dependent hypersecretion of gallbladder mucin. Also, physical activity has a prokinetic effect on the intestine and cholecystokinin-dependent gallbladder contraction. High fiber and regular eating pattern diets decrease hydrophobic bile acids, and reduces gallbladder stasis by increasing gallbladder emptying. Regular vitamin C supplementation or diet containing higher amount of vitamin C have a protective effect on gallstone formation. Situations associated with rapid loss of weight like very low-calorie diet or bariatric surgery, temporary oral UDCA may be recommended to prevent gall stone formation as the risk of cholelithiasis is much higher in these situations. There is also some role of fish oil polyunsaturated fatty acids on prevention of gall stones in obese patients. In sickle cell anemia hydroxyurea has been found to have some preventive role for pigment stones.

#### **Conflict of interest**

The author declare no conflict of interest.

*Gall Stones in Pediatric Population DOI: http://dx.doi.org/10.5772/intechopen.99020*
