Cholecystitis in Overweight Mexican American Children
Myths and FactsFrancisco J Cervantes MD
Laredo Pediatrics & Neonatology PAAncestral Health Symposium, Atlanta GA.
August 2013
www.LaredoPediatrics.com
A Rational Approach During 2001 we recommended the SAD Diet
(Standard American Diabetes Association) low fat, high Carbs. It didn't work
August 2002: Modified Diet, basically: lower sugar intake, more protein and vegetables, diet drinks or water. Blood work and diet recommended at school to Overweight kids and close f/u
September 2003: Results of First 1000 classified patients
April 2004: Update to 3000 patients
Patient Distribution by Age and BMI
BMI scale for Adult Population
Screening
• CMP, GGT, Lipid profile, Liver Function Test: Alkaline phosphatase, ALT, AST, Bilirubin,
• HbA1c, Insulin, THS and T4• Biometric information; Weight, Height, BMI,
Waist and hip circumference and Percentage of body fat
• Blood pressure• Ultrasound of the liver if altered liver enzymes,
or complaining of RUQ pain or discomfort
Facts About Diabetes 80% in our children has at least 1 close relative
with diabetes10% has one of the parents with diabetes1% has both parents with diabetesMexican American have poor tolerance to
carbohydratesAs the intake of carbohydrates increases so are
the levels of insulin, visceral fat and acanthosis.
THE GOOD NEWS: IT IS REVERSIBLE!!
MAXIMUM DAILY TOLERANCE OF CARBOHYDRATESIN MEXICAN AMERICAN CHILDREN
50 – 100 GRAMS OF CARBOHYDRATES
3 Fruits (10X 3 = 30 grams) a banana accounts for 30 to 40 grams1 cup plain cereal = 30 grams2 to 3 glasses of 8 oz of regular milk = 30 grams ( Regular = 10; 2% 11; Skim 15 grams)
Criteria for screening for liver disease
• Persistent Overweight BMI 85 to 90 %tile
• BMI above 95 %tile
• Rapid Increase in BMI no matter where it starts • Family history of Lipid disorder, liver or gallbladder disease and Diabetes
• RUQ or epigastric discomfort
Local Experience•2555 patients, about equally divided, boys (1230, 48.1%) and girls (1325, 51.9%)•First generation American-born children of Hispanic descend.•Patients were followed because of changes in BMI then the discovery of the fatty liver and subsequently Gallbladder disease.• All patients have at least one metabolic screen.•BMI groups normal BMI 75, 85, 95,97 and ≥99
WWW.Laredopediatrics.com
Liver Enzymes and BMI in Boys
Liver Enzymes in Children with Normal BMI
Causes of GB disease in ChildrenHistory of cardiac or abdominal surgery
Prolonged parenteral nutrition Hemolytic disease
Hepatobiliary obstructive disease Obesity
Rapid decreases in weightSystemic InfectionAcute renal failure Prolonged fasting Low calorie diet
Certain medications Organ transplant
women—especially pregnant, use of hormone replacement therapy, or birth control pills (decrease gallbladder movement)people over age 60 (As people age, the body tends to secrete more cholesterol into bile)American Indians (Pima Indians of Arizona, 70% of women have gallstones by age 30)Mexican Americans overweight or obese ( Bile salts Cholesterol GB emptyingpeople who fast or lose a lot of weight quickly people with a family history of gallstones (possible genetic link)people with diabetes (high levels of fatty acids called triglycerides)people who take cholesterol-lowering drugs
Who is at risk for gallstones?
The Classic 4 F’s still apply: Female, Fertile, Forty, Fat
Signs and Symptoms
• Typical symptoms of RUQ pain, nausea, vomiting.• Tenderness to palpation or mass at RUQ• Leukocytosis and jaundice • The pain and tenderness are less localized in younger
children• Epigastric pain mimic RUQ pain• Epigastric pain or discomfort postprandial• Atypical presentation: Sleep apnea and sleep
disturbance
Fact about GB polypsResembling growth in the gall bladder wall
True polyps are abnormal accumulation of mucous membrane tissues that would normally be shed by the body
Main types of polypsCholesterol Polyp/Cholesterosis
Cholesterosis with fibrous dysplasiaAdenomyomatosis
Hyperplastic cholecystosis Adenocarcinoma
It affects 5% of adult, the causes uncertain, but there is a correlation between increase age, and presence of Gall stone.
The polyps are detected by abdominal ultrasound performed for another reason
Cholesterosis might contribute to the formation of the GB polyps
Figure 1. Focal hepatic steatosis.
Prasad S R et al. Radiographics 2005;25:321-331
©2005 by Radiological Society of North America
Screening Criteria for Gallbladder Disease in Children
•Acute or persistent epigastric or non-specific abdominal pain, postprandial•Rapid decline in BMI•Family history of Gall bladder disease•persistently elevated GGT or Total Bilirrubin
Normal Findings of HB Scan
• Hepatocytes take up the radiopharmaceutical in minutes after injection
• Hepatic ducts seen in fifteen minutes• Gallbladder seen within 45 to 60 minutes• GB Ejection Fraction >40• Small intestine seen by 30 minutes
Liver Size in Children
Liver Size by BMI Groups
Hepatomegaly and Fatty Liver
NL
Fatty Liver
Ultrasound
Surgical Gallbladder Cases
• 404 in 4,000,000 in 4 years = 1 in 40,000 per year at Texas Children’s Houston (2005-2008) 73% women
• 11 in 2000 in 1 yr = 1 in 200 per year at Laredo Pediatrics (2010 -2011) 63% women
• 8 other reported at local pediatric meetings
Conclusion •Incidence of Gallbladder disease is on the rise on overweight children. •Gallbladder disease should be in the differential diagnosis of any pediatric patient who presents with localized pain in the epigastric, RUQ or ill-defined, Jaundice or dyspepsia and asymptomatic patients with BMI of ≥85•Consider Liver ultrasound as primary tool over more expensive and invasive procedures •HB Scan helps identify adequate GB function