H.B. is a 13‐year‐old obese Hispanic boy with generalized sharp abdominal pain for 2 days, nonradiating, 6–7/10 intensity, improved by flexing the trunk, associated with loss of appetite. He had no nausea/vomiting/diarrhea, no fever. Medical history was significant for a similar episode 1 year ago. There were no other medical issues. Vitals were temperature 97.9, blood pressure 108/57, heart rate 66, respiratory rate 20, weight 97th percentile, height 75th percentile, BMI > 95%. PE significant for generalized abdominal tenderness more periumbilical and RLQ, no rebound, no obturator or psoas signs. Appendicitis was initially considered until lab results were reviewed. Labs significant for WBC 6.4, AST/LT 318/280, alkaline phosphatase 513. Evidence of gallbladder involvement led to an abdominal US that showed fatty liver, no biliary dilatation, gallbladder contracted and containing multiple calculi. He was treated with morphine until pain resolved. Nutrition was consulted for dietary counseling. He was discharged home to return for an elective cholecystectomy.
Gallstone disease (GD) in children is due to multiple conditions that predispose to the development of gallstones such as hemolytic disorders, total parenteral nutrition dependence, CF, and certain medications (including ceftriaxone). Recently, with the obesity epidemic, cholelithiasis rates in children without hemolytic causes have doubled. Obesity creates increased cholesterol secretion directly or through insulin resistance. Hispanic ethnicity is also an independent risk factor for GD. In adolescents the symptoms are similar to those of adults with fatty food intolerance and biliary colic. However, many adolescents and most younger children present with nonfocal abdominal pain or jaundice. Acute presentation of cholecystitis, cholangitis, or pancreatitis is uncommon in children (7%–20%). Ultrasound is the imaging study of choice for GD with sensitivity and specificity > 95%. MRCP is useful to exclude choledocholithiasis and avoid intraoperative cholangiography. Rarely, US and MRI are negative despite strong clinical suspicion which raises the possibility of biliary dyskinesia. This can be diagnosed by CCK‐stimulated cholescintigraphy with ejection fraction of <35% at 60 minutes. Acute treatment is pain management and morphine is not contra‐indicated. Indications for surgery are symptomatic cholelithiasis, complicated obstructive disease, and biliary dyskinesia, and asymptomatic gallstones secondary to hemolytic disease. Asymptomatic cases can be followed by serial US. Laparoscopy has become the preferred method for performing cholecystectomies in children in all age groups.
The obesity epidemic in pediatrics has spiked the incidence of adult‐type diseases in children and adolescents. Cholelithiasis without stone producing co‐morbidities is becoming more common. Adolescents often present with classical symptoms but a large minority, as well as younger children, can present with nonspecific or nonlocalized abdominal pain. Cholelithiasis, and therefore an US of the gallbladder, should be considered in obese and/or Hispanic children with abdominal pain.
To cite this abstract:Ballestas‐Revollo M, Rauch D. The Pediatric Obesity Epidemic Strikes Again — Cholelithiasis in a 13‐Year‐Old Boy. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 375. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-pediatric-obesity-epidemic-strikes-again-cholelithiasis-in-a-13yearold-boy/. Accessed July 23, 2019.