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Key Points

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  1. Gallbladder disease in children can arise from a number of underlying conditions, but the disease is due to cholelithiasis in most cases. Cholelithiasis is usually classified as being either hemolytic or nonhemolytic in etiology.

  2. Gallbladder contractility can be assessed with radionuclide scanning during CCK injection. Most surgeons utilize a gallbladder ejection fraction of less than 35% as an indicator for cholecystectomy in a symptomatic patient. The normal ejection fraction approximates 75%.

  3. Real-time US has an accuracy of approximately 96% for gallbladder disease and is effective in determining hepatic and common bile duct involvement, the presence of thickening of the gallbladder wall, and any abnormalities in the liver or head of the pancreas.

  4. We recommend that patients with symptomatic gallbladder disease who are older than 3 years should undergo laparoscopic cholecystectomy. Younger patients, particularly infants, should be individualized.

  5. The laparoscopic approach has become the standard method for cholecystectomy in children for the past 20 years.

  6. For the majority of pediatric surgeons, the best option may be to perform a preoperative ERCP with sphincterotomy and stone extraction if stones are found preoperatively. If successful, the surgeon can then proceed with laparoscopic cholecystectomy.

  7. SSULS is being utilized more frequently, but when compared with traditional 3 and 4-port/incision laparoscopic surgery, the only advantage of SSULS appears to be cosmesis.

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Gallbladder disease is being increasingly diagnosed in children, although not nearly as often as in adults. Whether the incidence is actually escalating or the diagnostic accuracy is improving because of the increasing use of ultrasonography (US) and cholescintigraphy remains unclear. The disease processes contributing to gallbladder pathology are different in children compared with adults. Hemolytic disease, which is more common in children, is no longer the only prerequisite for the development of gallstones. Moreover, acute and chronic cholecystitis with severe inflammation and/or scarring of the gallbladder and surrounding tissues are less common in children. Fortunately, lessons gained from the vast published experience in adults can be useful in managing children with gallbladder disease.

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Etiology

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Gallbladder disease in children can arise from a number of underlying conditions, but the disease is due to cholelithiasis in most cases. Cholelithiasis is usually classified as being either hemolytic or nonhemolytic in etiology. Hemolytic disease results in consumption of red blood cells leading to increased hepatic metabolism of bilirubin, which precipitates as stone formation. Nonhemolytic disease includes a variety of causes for stone development or symptomatic gallbladder disease without stones.

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Gallstone Formation

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The major chemical components of bile that contribute to its lithogenic potential are bile salts, phospholipids, cholesterol, bilirubin, and electrolyte–water balance. The phospholipid component is mostly lethicin, which, along with bile salts, serve as detergents in the bile. With polar and nonpolar portions to these molecules, they form lecithin–bile acid– cholesterol micelles that keep the cholesterol soluble within the hydrophobic center of the micelle. An imbalance in the concentration of these substances ...

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