Volume 5, Case 18
Loren G. Yamamoto, MD, MPH
Kapiolani Medical Center For Women And Children
University of Hawaii John A. Burns School of Medicine
This is a 10-year old with an acute onset of sharp constant epigastric pain without radiation. The pain is worse when lying down and when ambulating. He is unable to jump. He has had three loose stools without blood, mucus, or foul odor. He has some nausea, but no vomiting, dysuria, fever, or cold symptoms.
Exam: VS T36.7 (TM), P80, R18, BP 134/84, oxygen saturation 100% in room air. He is in moderate distress due to pain. He does not appear to be toxic. Eyes normal. Ears normal. There is bilateral maxillary sinus tenderness. Pharynx red with enlarged tonsils (no exudates). Neck supple without adenopathy. Heart regular without murmurs. Lungs clear. Abdomen flat, guarding, moderate non-localized tenderness and rebound. A Murphy's sign cannot be reliably elicited. Bowel sounds are active. No masses. No hernias. Testes are normal. No CVA tenderness. Extremities with good pulses and perfusion. Strength good.
An abdominal series and laboratory studies are ordered. He is given a dose of oral antacids.
View abdominal series [Supine view]
[Upright view]
Laboratory studies: CBC WBC 7,000 with 24% lymphs, 5% monos, and 71% segs. Hgb 13, Hct 34, platelet count 329,000. Amylase 66. UA normal.
The abdominal series shows some dilated bowel. The gas pattern is not distributed well. Most of the gas is in the central abdomen. The flat view shows a small opacification in the right upper quadrant. There may be other small densities overlying the bowel gas inferiorly, but this is not certain. The upright view shows a small opacification on the right but it is located lower than the opacity seen on the supine film. Either this is a different lesion, or the opacification is mobile, and it moves inferiorly with gravity.
Since this is not likely to be a vascular calcification in a 10-year old, the differential includes urolithiasis, cholelithiasis, or a high appendicolith.
View a close-up of the calcifications.
Following the antacid and a period of observation, his abdominal pain subsides without other analgesics. He does not have CVA tenderness and there is no hematuria making urolithiasis unlikely. His exam is now only positive for mild right upper quadrant tenderness without rebound. His bowel sounds are active. He can ambulate well and he tells the staff that he wants to go home. He is given discharge instructions regarding abdominal pain. He is instructed to see his physician in the morning.
In a follow-up visit with his physician, he has continued to improve. However, as a follow-up to identify the cause of the right upper quadrant opacifications, an abdominal ultrasound is performed.
View ultrasound.
This ultrasound transducer is over the anterior abdomen in the right upper quadrant. The liver is shown here. The "S" is the spine. The black arrow points to the gall bladder. A stone is seen in the gall bladder in this view. Note the echo "shadow" cast by the stone. Other views reveal other stones in the gall bladder. There are no stones in the common duct.
Discussion
Gallstones in children are not felt to be common. However, many of them are asymptomatic. While most gallstones in children are classically associated with hemolytic disease and hemoglobinopathies (hereditary spherocytosis, sickle cell anemia, thalassemia, etc.), an increasing incidence of cholesterol stones have been noted. It is now felt that cholesterol stones are more common than pigment stones in children. Cholecystitis and cholelithiasis are more common in childhood than is generally appreciated. Other children at increased risk include premature infants on furosemide and children receiving parenteral nutrition.
The usual clinical presentation of cholecystitis and cholelithiasis is often not present in children. Most children present with non-specific abdominal pain. Liver function studies may be normal. Plain film abdominal radiographs may reveal calcifications, however, they are often normal. Ultrasound is the easiest means of making a definitive diagnosis of cholelithiasis. Acute cholecystitis may require a bile duct flow study such as a nuclear medicine excretion study. Cholecystitis may sometimes occur without cholelithiasis (acalculous cholecystitis).
Pediatric experience with newer therapeutic approaches such as lithotripsy and bile acid stone dissolution are lacking. Treatment has been traditionally surgical, however, this may be evolving.
References