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1/29/16
1
RUQ Ultrasound Normal, Recommend Clinical Correlation
Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children’s Hosptial
Background • Incidence of pediatric gallbladder disease continues to rise
U.S. Pediatric Data 1997: 5500 cholecystectomies 2013: 8500 cholecystectomies HCUPnet, 2013
TCH Data 1960 – 1980: 36 cholecystectomies 1980 – 1997: 128 cholecystectomies Jan 2005 – Oct 2008: 455 cholecystectomies Mehta et al, Pediatrics 2012
• Increasing incidence correlates with change in most common etiologies and risk factors in children Mehta et al, Pediatrics 2012
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Common Scenarios
16-year-old male with recurrent postprandial RUQ and epigastric pain
• Associated nausea • Worse after high fat meals
Physical Exam: • No abdominal tenderness
Diagnostic Studies to Order: RUQ ultrasound and labs
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1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter
Labs WBC: 10.5k Amylase: 68 Lipase: 19 Total bilirubin: 0.1
Alk phos: 97 AST: 14 ALT: 7
15-year-old female with 24 hours of worsening RUQ pain • Associated nausea • Prior postprandial pain episodes
Physical Exam: • RUQ tenderness • + Murphy’s sign
Diagnostic Studies to Order: RUQ ultrasound and labs
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1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter
Labs WBC: 16k Amylase: 68 Lipase: 19 Total bilirubin: 0.5
Alk phos: 103 AST: 60 ALT: 54
13-year-old female with 5 day history of intermittent RUQ and epigastric pain
• Associated nausea, occasional vomiting • Prior postprandial pain episodes
Physical Exam: • Minimal epigastric tenderness
Diagnostic Studies to Order: RUQ ultrasound and labs
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1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter
Labs WBC: 9.7k Amylase: 74 Lipase: 36
Total bilirubin: 2.4 Alk phos: 145 AST: 58 ALT: 97
16-year-old female with 48 hour history of epigastric pain • Associated nausea and vomiting • Decreased appetite • Prior postprandial pain episodes
Physical Exam: • Significant epigastric tenderness
Diagnostic Studies to Order: RUQ ultrasound and labs
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1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter
Labs WBC: 24k Amylase: 1843 Lipase: 4128 Total bilirubin: 1.7
Alk phos: 176 AST: 167 ALT: 227
Now that we’ve covered the basics…
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14-year-old female with several week history of recurrent postprandial RUQ pain
• Associated nausea • Worse after high fat meals • Lasts 1-2 hours after most meals
Physical Exam: • No abdominal tenderness
Diagnostic Studies to Order: RUQ ultrasound and labs
1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter
Labs WBC: 6.5k Amylase: 34 Lipase: 23 Total bilirubin: 0.1
Alk phos: 73 AST: 24 ALT: 28
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Hydroxy Iminodiacetic (HIDA) Scan
Hydroxy Iminodiacetic (HIDA) Scan
Gallbladder Ejection Fraction: 17%
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What is the diagnosis?
Biliary Dyskinesia
What is your plan?
Refer for outpatient surgical evaluation
Biliary Dyskinesia • Defined as a gallbladder ejection fraction <35%
• Ejection fraction is determined by HIDA scan with cholecystokinin (CCK) analog infusion
• Poor gallbladder contractility leads to bile stasis, microscopic bile crystallization, and mucosal irritation
• Majority of gallbladder specimens after cholecystectomy demonstrate histopathologic evidence of chronic cholecystitis
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Biliary Dyskinesia Cont’d
• Increasingly common diagnosis in children
• TCH Review (1/2005 – 10/2008) – Third leading indication for cholecystectomy (16%) – 78% female – 51% overweight (30% severely obese) – Percent of cholecystectomies for biliary dyskinesia compared to
historical cohort (1980 – 1996): 16% vs 0%, p < 0.0001
Treatment Success for Biliary Dyskinesia
• Meta-analysis in adults demonstrated that patients with RUQ pain, absence of gallstones, and low gallbladder EF on HIDA scan demonstrated that cholecystectomy was more effective (96%) than medical treatment (4%) in improvement of symptoms Mahid SS et al, Arch Surg 2009
• Pediatric data is less clear (smaller studies) – 70 – 98% reported symptom relief with cholecystectomy
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Other Acalculous Conditions Gallbladder Hydrops:
• Acute distention and edema of the wall of the gallbladder without evidence of gallstones or congenital anomalies
• Most often associated with severe sepsis or shock • Most resolve with conservative management
Gallbladder Polyps: • Rare in children • Current recommendations are to proceed with laparoscopic
cholecystectomy for symptomatic patients or for polyps ≥ 1 cm
Summary • The incidence of gallbladder disease in children is rising
• Initial diagnostic studies for suspected gallbladder disease should include a RUQ ultrasound and labs
• The most common reasons for laparoscopic cholecystectomy are symptomatic cholelithiasis and complications from gallstone obstruction; however, biliary dyskinesia is increasingly more common
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Summary Cont’d • A normal RUQ ultrasound and labs does not eliminate
gallbladder disease from the differential
• A HIDA scan and clinical correlation are important in the diagnosis of biliary dyskinesia
• Patient / family counseling are important in setting expectations for treatment success with laparoscopic cholecystectomy for biliary dyskinesia
Questions?
Sohail R. Shah, MD, MSHA, FACS, FAAP Division of Pediatric Surgery Office Phone: 832-822-3135 [email protected]