9 December 2008

Dear Editor,


The authors would like to report a case of cholelithiasis complicated with chronic cholecystitis, an uncommon condition in childhood, in a 10-year-old girl who presented with recurrent abdominal pain.

N presented with a 1-year history of recurrent abdominal pain. The pain occurred in the morning intermittently especially before going to school and would usually disappear after 2 h of being in school. The attack progressed from two to three times in a week to almost every day within a period of 7 months. Despite being able to attend school, her academic performance gradually deteriorated. During this time, she had consulted several general practitioners but was told it could be functional abdominal pain. She was also given paracetamol and antacids but neither improved the pain.

After about several months of the onset of pain, she began to experience intermittent bouts of fever. The fever occurred for 5 to 6 days every month. On one occasion, she developed severe abdominal pain during her febrile illness and this brought her to the hospital. Physical examination, however, did not reveal any abnormality except her temperature was 39oC with mild epigastric tenderness. Full blood count, renal and liver profile and blood cultures were all negative. She was discharged after a day in the hospital.

Following that, the pain and febrile episodes persisted. The physician, then, decided to perform an ultrasound of abdomen.

N was born normally. At the age of 5 years old, she was diagnosed to have Hb E B thalassaemia major. Subsequently, she underwent a bone marrow transplant the following year. She was well and did not require blood transfusion after the transplant until the onset of the pain.

The ultrasound revealed multiple stones in the gallbladder and the cystic duct (Fig. 1). She was then referred to the surgeon. Intraoperatively, besides the stones, the gallbladder was found inflamed with a lot of adhesion formation. Total cholecystectomy was performed. The pathology report came back as chronic cholecystitis.


Figure 1. An ultrasound of the abdomen demonstrated multiple stones in the gallbladder and the cystic duct.

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Cholelithiasis is an uncommon condition in childhood. In a hospital series of gallstone cases in 1938, Linnemann found only one child as against 3600 adults.1

The first case of cholelithiasis in a child was published by Gibson in 1734, who performed an autopsy in 1733 and found stones in a 12-year-old boy whose chief complaints had been abdominal pain and vomiting.1

From 1734 until 1960, there were 500 cases described either presented or published; Linnemann, 1938; Lindsten, 1939; Nathhorst, 1939; Linden, 1944; Willenius, 1951; Forshall and Rickham, 1954; Glenn and Hill, 1954; Kaijser, 1954; Babbitt, 1956; Bengmark and Radberg, 1956; Ahrens, 1957a, b; Jensen, 1957; Walker, 1957; and Seiler, 1960. In 1961, Sodurlund and Zetterstrom from Sweden reported in their series of 60 children, aged 6–15 years old operated upon, from January 1950 to April 1961, that 34 children had cholelithiasis complicated with cholecystitis. This series is larger than any series reported earlier.1

Bakhotmah from the University Hospital in Jeddah reported eight cases of symptomatic cholelithiasis in the record over a 10-year period between January 1986 and July 1996. Five children in this series were found to have chronic cholecystitis.2 Ganesh et al. reported an observation of 13 675 children of Kanchi Kamakoti CHILDS Trust Hospital in Chennai, India, who had abdomen ultrasound from January 1999 to December 2003, and only 43 (0.31%) were detected to have gallstones. Of these, only two were symptomatic and underwent cholecystectomy, whereby one presented with recurrent abdominal pain and the other with fever and vomiting. However, histopathology of both cases were not reported.3

There were few documented associated factors to the occurrence of cholelithiasis in the literatures; haemolytic anaemias being the most common, children who were on total parenteral nutrition and those taking immunosuppression drugs. Family history of cholelithiasis and obesity were observed as related factors.4,5

With regard to symptoms, recurrent abdominal pain was found to be one of the commonest presentations in many reports.4 Other documented symptoms were fever, jaundice, vomiting and diarrhoea and one literature reported appendicular pain.4,6

Ultrasound remains the main diagnostic tool to diagnose cholelithiasis. Its advantage is that it is non-invasive and inexpensive. Plain abdominal X-ray can be helpful if stones are radio-opaque.

Little is known about the natural history of cholelithiasis in children. Children with cholecystitis or obstructive jaundice will require surgical intervention; cholecystectomy or endoscopic retrograde cholangiopancreatography with stone extraction. In one literature, it was suggested that children with risk factors, for example haemolytic anaemia, will require screening for gallstone.7 However, the consequence on long-term follow-up needs to be determined especially with regard to its complication.

We wish to highlight that although cholelithiasis complicated with chronic cholecystitis is an uncommon cause for recurrent abdominal pain in the paediatric age group, it should be considered especially when there is underlying medical illness which poses as a risk factor.


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  2. References
  • 1
    Soderlund S, Zetterstrom B. Cholecystitis and cholelithiais in children. A paper read at a meeting of the British Association of Paediatric Surgeons in Stockholm, 1961.
  • 2
    Bakhotmah MA. Symptomatic cholelithiasis in children: a hospital review. Ann. Saudi. Med. 1999; 19: 2512.
  • 3
    Ganesh R, Muralinath S, Sankaranarayanan VS, Sathiyasekaran M. Prevalence of cholelithiasis in children – a hospital-based observation. Indian J. Gastroenterol. 2005; 24: 85.
  • 4
    Wesdorp I, Bosman D, De Graaff A, Aronso D, Van Der Blij F, Taminiau J. Clinical presentations and predisposing factors of cholelithiasis and sludge in children. J. Pediatr. Gastroenterol. Nutr. 2000; 31: 41117.
  • 5
    Friesen CA, Roberts CC. Cholelithisis. Clinical characteristics in children. Case analysis and literature review. Clin. Pediatr. (Phila) 1989; 28: 2948.
  • 6
    Cozcolluela Cabrejas MR, Sanz Salanova LA, Martínez-Berganza Asensio MT et al. Childhood cholelithiasis in a district hospital. An. Pediatr. (Barc) 2007; 66: 61114.
  • 7
    Miltenburg D, Schaffer R, Breslin T, Brandt M. Changing indications for pediatric cholecystectomy. Pediatrics 2000; 105: 12503.