Pediatric Cholecystitis (Inflammation of the Gallbladder)

00:02 Let’s shift gears now to talk about cholecystitis or inflammation of the gallbladder.

00:09 Here’s a 15-year-old girl who’s coming in with fever and severe abdominal pain.

00:15 She’s been losing weight despite noticing abdominal bloating.

00:19 And she’s rushed into the OR.

00:21 Notice she has a very high BMI.

00:24 She has acute sharp right upper quadrant pain that radiates to here back and they found gallstones and a thickened gallbladder wall.

00:34 This patient has cholecystitis.

00:38 So cholecystitis is an inflammation and often infection of the gallbladder itself.

00:46 It’s strongly associated with the present of the gallstones inside the gallbladder.

00:52 90% of cases are associated with gallstones.

00:57 It is a common indication for abdominal surgery.

01:00 It is more common in older women than in younger women, but we absolutely see this in adolescents as well.

01:07 There are some rare causes of inflammation of the gallbladder wall that are associated with other systemic diseases like Kawasaki’s disease, which can cause gallbladder enlargement.

01:21 But most of cholecystitis is a result of the obstruction of the neck or a cystic duct usually from a stone and like I said, that’s about 90% of cases.

01:32 The most common reason for emergent cholecystectomy is cholecystitis.

01:40 And we see it typically in children with predisposing risk factors.

01:44 Examples would be sickle cell disease where they have a higher red blood cell turnover.

01:52 So let’s look at some risk factors for gallstones.

01:56 Certainly females are at higher risk.

02:00 Obesity is more common.

02:02 Pregnancy is a risk factor for cholecystitis.

02:06 Patients with hemolysis such as patients with hemoglobinopathies, hereditary spherocytosis or red blood cell membrane fragility.

02:17 Patients with infection are at increased risk.

02:20 A patient with hemolytic uremic syndrome for example is going to have a high rate of red blood cell breakdown, which could result in a gallstone formation and subsequent cholecystitis.

02:31 This is true for patients with red blood cell breakdown for sepsis as well.

02:37 Other examples, patients with TPN or total parenteral nutrition.

02:41 These patients are at increased risk for gallbladders.

02:44 Patients with ileal and resection may also be at increased risk for gallstones.

02:49 Because of that problems with enterohepatic circulation and it can just be idiopathic.

02:55 Some kids just get them and we don’t know why.

02:59 Classic symptoms will include abdominal pain, which is acute, sharp and colicky.

03:05 These patients may have epigastric or right upper quadrant pain around the gallbladder site.

03:13 It can also radiate around to the back, especially in the right scapular region on the back.

03:19 These patients typically will have fever and they may develop nausea and vomiting as well.

03:25 Usually they have anorexia and they have some bloating of their intestinal wall from edema.

03:31 It’s key to understand that nausea and vomiting is common.

03:34 Anorexia is common and their nausea and vomiting is often slightly delayed from when they eat.

03:42 If they are forced to eat or if they decide they have to eat, they’ll have significant pain, maybe a half hour to 45 minutes to an hour later as they have that delay before their gallbladder tries to constrict to extrude the juices necessary for food digestion.

04:03 Physical exam findings, you will note fever and dehydration, right upper quadrant tenderness with guarding and they may have Murphy’s sign.

04:10 Let’s go over Murphy’s sign carefully.

04:12 Basically, what you’ll do is as shown in this picture, you will push down underneath the rib cage on that right side in the right upper quadrant.

04:23 Before you ask the patient to – Before you push down on the patient’s abdominal wall, you will ask the patient to breathe all the way out.

04:33 So that their lungs are collapsed.

04:36 Then you will push in and ask them to take a deep breath.

04:39 That deep breath will push down on the gallbladder as the lungs expand and the gallbladder will be pushed into your hand.

04:48 This is Murphy’s sign.

04:49 And this will be painful as they inhale against that hand which is pressed into the right upper quadrant.

04:58 If you suspect this disease, ultrasound has a high specificity for illness.

05:03 Here, you can see an inflamed gallbladder wall on ultrasound and some biliary sludging.

05:09 So these patients will have findings on ultrasound that are very likely to be diagnostic.

05:17 Treatment is simply surgical removal.

05:21 We have to mitigate risk factors in individuals who are at risk in terms of should we remove their gallbladder prior to having any episodes.

05:32 But generally what’s going to happen is patients will come in with an acute cholecystectomy and it will have to be removed.