Cholelithiasis in children

Etiology and pathogenesis of cholelithiasis

The formation of calculi in the biliary tract does not occur spontaneously. The pathophysiological basis of stone formation in children is the combined effect of three key factors:

1. General metabolic disorders — metabolic alterations predisposing to an imbalance of bile components.
2. Bile stasis — occurs against the background of hypomotor dysfunction of the gallbladder (decreased contractility).
3. Inflammatory process in the biliary tract — leads to changes in the normal physicochemical properties of the secretion.

Under the influence of this triad, bile components such as bilirubin, cholesterol, and calcium begin to precipitate, followed by crystallization. It is important to consider the age-related characteristics of calculus composition: pigment stones predominantly form in younger children, whereas cholesterol stones are more common in older patients.

Clinical presentation and potential complications

The course of chronic calculous cholecystitis in children can be divided into two main clinical variants:

• Common variant (dyspeptic or painful): proceeds relatively mildly. The child complains of aching pain and a feeling of heaviness in the upper abdomen, often accompanied by belching and a bitter taste in the mouth.
• Rare variant (typical biliary colic): manifests acutely. It is characterized by paroxysmal, recurrent pain localized in the right upper quadrant. The pain attack is accompanied by pronounced autonomic symptoms — the patient experiences nausea, vomiting, and cold sweats.

Complications: The most formidable development is the migration of a calculus, which can cause obstruction (complete blockage) of the bile duct. Clinically, this condition manifests as acute obstructive jaundice syndrome and pale stools (acholic stools).

Diagnostics and conservative therapy

Establishing a diagnosis requires an integrated approach: the evaluation of clinical manifestations is necessarily complemented by instrumental imaging methods. The basic examination methods are ultrasound examination (US) and radiological imaging (cholecystography).

Features of medical treatment:

• Conservative therapy (litholysis) is advisable only in the presence of small calculi with a diameter of 0.2–0.3 cm of cholesterol or pigment origin.
• During an exacerbation of calculous cholecystitis, the inclusion of ursodeoxycholic acid (UDCA) preparations is indicated in the pharmacotherapy regimen.
• Prognosis: Even with successful medical dissolution of stones, there remains an extremely high risk of recurrence. This is due to the fact that the underlying pathogenetic mechanisms (metabolic disorders and chronic hypomotor dysfunction of the biliary tract) do not disappear.

Surgical treatment and related conditions

If the conservative phase is ineffective, patient management tactics are revised in favor of surgical intervention. Absolute indications for surgery include:

• Resistance to ongoing medical therapy.
• Frequently recurring course (constant exacerbations).
• Development of complications (e.g., duct obstruction).

The gold standard and method of choice is laparoscopic cholecystectomy.

For differential diagnosis, it is important to remember the basic patterns of related biliary pathologies:

• Biliary dysfunction (hypertonic type): manifests as short-term, paroxysmal pain syndrome in the right upper quadrant.
• Hypotonic type dysfunction: in the exacerbation phase, the use of cholekinetics (drugs stimulating gallbladder tone) is pathogenetically justified.
• Acute (acalculous) cholecystitis: the leading trigger in children is an infectious agent rather than a metabolic disorder.

Class and exam questions

What else to study on this topic

• Criteria for choosing between conservative and surgical treatment when stone sizes exceed 0.3 cm.
• Features of the use of ursodeoxycholic acid (UDCA) preparations in pediatrics.
• Differential diagnosis of pain syndrome: hypertonic dysfunction vs. biliary colic.
• The role of the infectious agent in the development of acute acalculous cholecystitis.

Other topics in "Chapter 7. Digestive System Diseases"

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