Acute cholecystitis in children

Etiology and predisposing factors

Acute inflammation of the gallbladder wall in children is most often of bacterial origin. The primary pathogens are the bowel's own microflora: Escherichia coli, staphylococci, streptococci, and enterococci (less commonly Proteus and Klebsiella). Viruses (adenoviruses, enteroviruses) or parasitic infestation (giardiasis) can also act as trigger mechanisms.

Lifestyle factors contribute to the development of inflammation:

• Dietary errors;
• Hypodynamia (lack of physical activity);
• Psychoemotional stress.

Pathogenesis

The key predisposing factor is biliary stasis. It occurs against the background of biliary tract developmental anomalies, pathway dysfunction, or increased bile viscosity itself.

Infection can enter the gallbladder through three pathways:

1. Ascending enterogenic — from the intestine via the common bile duct (ductus choledochus).
2. Hematogenous — from distant foci.
3. Lymphogenous — predominantly from the intestine.

Bacterial enzymes disrupt the normal dehydroxylation of bile acids. This leads to massive desquamation (shedding) of the gallbladder epithelium and a breakdown of neurohumoral regulation.

Clinical presentation

Typical acute cholecystitis includes three main syndromes: pain, dyspeptic, and intoxication syndromes.

• Pain syndrome: sudden, severe pain occurs in the right upper quadrant and epigastrium (in preschoolers it is often diffuse, without clear localization). The pain is associated with overdistension of the gallbladder walls and a block in bile outflow. In childhood, radiation to the back, scapula, or collarbone is rare.
• Intoxication and dyspepsia: body temperature rises to febrile levels, and toxicosis rapidly increases. Nausea and vomiting are noted in 50% of children. Younger schoolchildren often exhibit forced behavior, constantly changing body position to relieve pain.

On physical examination, moderate abdominal distension is revealed, with the right half of the abdominal wall lagging behind in the act of breathing. Palpation in the right upper quadrant is painful. A positive peritoneal irritation sign (Shchetkin-Blumberg sign) and transient skin jaundice due to cholestasis are characteristic.

Diagnostics

The diagnosis is based on clinical data and instrumental examination results. The main method is abdominal ultrasound. A characteristic ultrasound picture includes thickening and structural heterogeneity of the gallbladder walls, as well as the presence of sludge (sediment) in its lumen.

Differential diagnosis must be carried out with other urgent pathologies ("acute abdomen"):

• Acute appendicitis;
• Acute pancreatitis;
• Right-sided pneumonia.

Treatment and follow-up

Treatment tactics depend on the clinical form (depth of wall destruction).

Conservative therapy is used for the catarrhal (superficial) form:

• Regimen: strict bed rest until pain and fever subside.
• Diet: therapeutic diet Table No. 5 (calorie intake reduced by 10–15%, frequent meals, 5–6 times a day).
• Medications: broad-spectrum antibiotics, analgesics, and antispasmodics.
• Rehabilitation (during the subsiding phase): therapeutic exercise to improve bile outflow and physiotherapy (microwave therapy, electrophoresis to the liver area, thermal applications).

Surgical treatment is indicated exclusively for destructive complications — phlegmonous (purulent) and gangrenous (necrotic) cholecystitis.

Upon discharge, children are subject to clinical follow-up (dispensary observation) for 3 years. This includes a strict diet, sanitation of infection foci, spa treatment, and courses of specific therapy (quarterly during the first year).

Class and exam questions

What else to study on this topic

• Classification of cholecystitis by the depth of wall destruction
• Regimens of conservative antibiotic therapy
• Physiotherapeutic rehabilitation methods
• Features of clinical follow-up (secondary prevention)
• Impact of the premorbid background on the disease prognosis

Other topics in "Chapter 7. Digestive System Diseases"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.