Cholelithiasis in children : experience from Bangladesh

Most of the time clinicians overlook the diagnosis of cholelthiasis in children because of its atypical presentation. The present study reports paediatric cases of cholelithiasis treated in Gazi Medical College Hospital, Khulna, Bangladesh during the period from 2002 to 2013. In order to assess the frequency of paediatric cholelithiasis cases and treatment outcome, the author reviewed the patient records. The retrospective analysis found 9 paediatric cases who underwent a laparoscopic cholecystectomy performed from 2002 to 2013 at Gazi Medical College Hospital by a single Consultant Surgeon (the author). The cases were 7 females and 2 males. The average age was 8 years. The reports and full case history notes were checked and data were extracted accordingly. Correspondence was done to confirm the outcome of any subsequent follow up. It was found that clinically no one was obese but nutritional deficiency was obvious because all the patients were from poor family. Final diagnosis was made by ultrasonography. All of them recovered uneventfully after laparoscopic cholecystectomy.

presents the cases of cholelithiasis in children treated in Gazi Medical College Hospital, Bangladesh.In order to assess how common paediatric cholelithiasis was as well as the outcome of given treatment, the author reviewed the patient records to identify any paediatric patient (aged 16 years or below) who had undergone a cholecystectomy.The reports and full case history notes were reviewed and data were extracted accordingly.Correspondence was done done to confirm the outcome of any subsequent follow up and to identify any other medical problems which may have arisen after the procedure or had an impact on the patient developing cholelithiasis.This

Mediscope
The Journal of GMC is a retrospective analysis of 9 paediatric patients who underwent a laparoscopic cholecystectomy performed from 2002 to 2013 at Gazi Medical College Hospital, Khulna by a single Consultant Surgeon (the author).The cases were 7 females and 2 males.The average age was 8 years.Some of the cases are presented: The cases Rana, male, 4 years (Fig. 1) He was admitted into Gazi Medical College Hospital with the complaints of non-specific abdominal pain, sometimes around the umbilicus, another time in lower abdomen, sometimes in whole abdomen.Pain was not severe but mild to moderate, not related to meal.He was reluctant to food intake, had occasional dysentery, but no history of vomiting, jaundice, fever, diarrhoea.
According to his mother's statement, those complaints started since last 4 months.He was a caesarean baby, first child of his mother who had bicornuated uterus, underwent caesarean operation at 36 weeks of her pregnancy.There was no history of taking birth control pill by his mother.He belongs to a poor family and his nutritional status was not satisfactory.On examination-General condition is satisfactory.Systemic examination of cardiovascular, respiratory, genitourinary, neurological, psychiatric, locomotor, metabolic system revealed no abnormality.On palpation of abdomen-mild tenderness at right hypochondrium.Ultrasonography-Multiple gall stones with no sign of acute inflammation nor common bile duct obstruction.Other laboratory tests revealed no abnormality.
Ashamoni, female, 8 years (Fig. 2) She was admitted with the complaints of mild upper abdominal pain, anorexia, also had moderate to severe upper abdominal pain with vomiting from 2 months back, was treated at her locality with antibiotics and other drugs and her pain was subsided.She had fever but no jaundice.Ultrsonography of abdomen showed calculus cholecystitis.Her Serum Bilirubin and SGPT were within normal range.She was born through normal delivery at home with no significant intranatal nor postnatal complication.Objective examination showed no abnormal findings except tenderness at right hypochondrium.
Maria, female, 6 years (Fig. 3) The first child of her parents admitted into this hospital with non-specific abdominal pain.She was malnourished.Her mother's history revealed nothing contributory other than taking contraceptive pills.Laboratory  of a boy of 12 years of age whose chief symptoms had been abdominal pain, vomiting and acholic faeces. 5In 1928, Potter presented the first comprehensive report. 6e described four cases of his own and 224 from the literature.In 1938 he collected a further 200 cases published by different authors and reported four additional personal cases.Ulin, Nosal and Martin in 1952 collected 30 new cases from the literature and at the same time made a critical analysis of Potter's cases. 7In their opinion, only 296 of Potter's cases could be regarded.Upto 1960 about 500 cases were described.

Present cases
It was found that clinically no one was obese as found in western literature but nutritional deficiency was obvious because all the patients were from poor families.Final diagnosis was made by ultrasonography.All of them underwent typical 4 ports laparoscopic cholecystectomy and recovered uneventfully.Pigment stones were found in 6 cases and cholesterol-pigmented (mixed) stones found in 3 cases.

Conclusion
Gallstone related disease can often present in a non-specific manner and the classical signs are often absent.Murphy's sign is unreliable and children may find it difficult to describe the typical pain of biliary colic and cholecystitis.Clinicians often misdiagnose the condition as a urinary tract infection and appendicitis also commonly documented in differential diagnoses.Usually, there is a chronic history of generalized abdominal pain of some months or more.Clinicians should therefore hold an index of suspicion for a diagnosis of gallstones in any paediatric presentation of abdominal pain.Malnutrition, helminthiasis, birth control pill taken by mother, enteric fever are the most common predisposing factors to develop cholelithiasis in children in developing country like Bangladesh.
reports showed normal CBC, RBS, LFT, worms in stool and ultrasonography indicated cholelithiasis with no sign of infection.
Imran, male, 13 years (Fig. 4) He was admitted into this hospital with complaints of chronic mild pain in epigastric region, increased after meal sometimes associated with nausea and vomiting for last 2 years.He belongs to lower middle class family.Ultrasonography revealed cholecystitis with cholelithiasis.

Etiology and predisposing factors
Etiological factors for formation of gallstones in children are same as in adults.It was described that 1 out of 8 patients with cholelithiasis had hereditary haemolytic anaemia and another 4 were obese. 3Soderlund et al found a coexistence of haemolytic anaemia with cholelithiasis was also found in 3 of 56 patients, obesity in more than 50% of patients and some relations with hereditary haemolytic anaemia in few patients. 4

History
The first case of gall-stones in a child was published by Gibson in 1734, who performed an autopsy in 1723 and found concretions in the gallbladder and in the common bile duct

Fig
Fig. 2. The picture of Ashamoni (aged 8 years) with Consultant Surgeon after cholecystectomy.