A Case of

Cholecystitis
By Hala Al-Khaffaji
Background

o 16 year old female who presented with

Jaundice and pain in the right upper
quadrant.
o
o Previous cholecystitis and a post laparoscopic
cholecystectomy.
o 1.3 paediatric cases occur per 1000 adult
cases.
o Paediatric patients undergo 4% of all
cholecystectomies.
What is cholecystitis?
Causes of Cholecystitis In Children

cholecystitis mainly presents as either acute or chronic.

Both include gall stone involvement.
Gall stones can form when there is saturation of cholesterol or bilirubin crystals.
If this is coupled with stasis the cholesterol or crystals to stay long enough to form gall stones.
In disease, the unconjugated form of bilirubin helps the stone formation process:
o hereditary spherocytosis,
o Sickle Cell Disease
o uncontrolled G-6-PD deficiency.
Other risk factors include children with previous multiple blood transfusions, dehydration, CF,
and chronic UTI.
Types Of Gall Stones Encountered

Cholesterol Gall Stones Pigment Gall Stones

Examinations & Investigations

O/e there is usually upper quadrant tenderness. The classic triad is right upper quadrant
pain, fever, and leukocytosis.
The patient may have abdominal guarding and a positive Murphy sign.
Omental adherence to the inflamed gallbladder + distension palpable mass between
the 9th and 10th costal cartilages.
Charcot's triangle right upper quadrant pain, fever, and jaundice is indicative for
obstruction of common bile duct.
Tests would involve taking bloods, plain abdominal radiography and an abdominal
ultrasound.
Macroscopic Findings

o Distended gall bladder measuring

90x30x20mm.
o The serosa has a punctate, dusky red patches
evidence of haemorrhage.
o One surface had a roughened serosal surface
with granular deposits of soft tissue, probably
attached lived tissue.
o Open surface revealed thin wall measuring
2mm in thickness, but mucosa appeared
roughened and showed a finely granular
appearance w/ visible folds.
o Multiple pigmented stones up to 5mm in
diameter.
Microscopic Findings
Management

Cholecystectomy
Some children may not tolerate anaesthesia and operative conditions.
They should receive antibiotic therapy, parenteral nutrition, and gastric
decompression until their condition improves.
Patients may then undergo percutaneous transhepatic cholecystostomy
surgery if symptoms persist; however, many cases resolve with medical
therapy alone.
References
 Causes of Cholecystitis in children
Acute Cholecystitis
results from a sudden obstruction of the
cystic duct by gallstones, which causes
distension of the sac, edema, and bile
stasis with bacterial overgrowth.
These events lead to inflammation and/or
cause ischemia of the local tissue.
This in turn can cause bacterial
proliferation. Bile cultures are positive in
75% of cases, usually with E coli,
enterococci, or Klebsiella species.
after colonization, the severity of the
disease can dramatically worsen. This
cascade of events quickly leads to pain
and, possibly, a toxic appearance.
Chronic Cholecystitis
Chronic cholecystitis is also most often
related to gallstone disease.
initiating factor is thought to be the
supersaturation of bile, often with
cholesterol crystals and/or calcium
bilirubinate, which contributes to stone
formation and inflammation.
Leads to chronic obstruction, decreased
contractile function, and biliary stasis, which
contribute to further inflammation of the
gallbladder wall.