Cholelithiasis in childhood

T HE incidence of choIeIithiasis in chiIdren is not the rare occurrence it was once considered to be. A review of the Iiterature discloses reports of a surprisingIy Iarge cohection of cases by Potter1 and others (SalIick,2 SeidIer and BrakeIy3). This report of a case and review of the Iiterature is made with a view toward adding to the weight of evidence that ChoIeIithiasis is a disease to be considered in the differential diagnosis of the acute or chronic surgica1 condition within the abdomen in chiIdren. Roentgenographic study shouId be encouraged in a11 obscure abdomina1 conditions in chiIdhood; ChoIecystography is we11 toIerated by chiIdren and its more frequent use undoubtedIy wouId uncover many more cases of ChoIeIithiasis. The simiIarity between the symptoms of acute appendicitis and ChoIeIithiasis is some\vhat confusing, and during the operation for appendicitis the gaIlbladder shouId be paIpated for caIcuIi if possibIe. Dr. SaIIick’s2 paper on the subject of choIeIithiasis suggests that the condition be cIassified into three varieties, namely, maIformations, inflammations and those of metabohc origin. In infancy and very earIy chiIdhood biIiary disease may be due to malformations of the biliary passages with atresia or absence of one or more components of the system. Stagnation of biIe due to mechanica factors pIays an important roIe in the formation of concretions which may form in the biIiary system. Inflammation of the gaIIbIadder in Iater chiIdhood with either suppuration or spontaneous recovery does not usuaIIy give rise to the formation of calculi. There is IinaIIy that type of ChoIecystitis and cholelithiasis simiIar to that which occurs in aduIt life and is usuaIIy regarded to be of a metaboIic nature. Congenital abnormaIities as a ruIe are not helped by surgery. The second type usuaIIy recovers without the necessity of an operation and the third or adult type is treated wit? cholecystectomy. The incidence of the dis se in chiIdren is more evenIy distributed between the sexes than it is in the aduIt form of cholelithiasis, the occurrence in femaIes being only slightI?; higher than it is in males. The cases reported further revea1 that the disease occurs more frequently in oIder than in younger chiIdren, the number of patients above eight years being more common than beIow this age. There are congenita1 bihary conditions not considered in this discussion of ChoIeIithiasis which uouIc1, however, make the frequency of biliary tract disease more common in the first few years of Iife, but these cannot be considered as true cases of ChoIeIithiasis as presented herein. The etioIogic factors in the formation of biIiary concretions are commonIy agreed upon by most surgeons who report these conditions. Acute exanthemas and respiratory infections probably pIay a roIe in the pathologic process. Typhoid fever, which was once considered a major etioIogic factor, has diminished in importance due to improvements in sanitation, and the infrequency of typhoid has not diminished the occurrence of ChoIeIithiasis. In Lowenburg and Mitchell’s” series five patients had an associated upper respiratory tract infection. LambIia infestation has been found by a number of surgeons; Smithies5 found this parasite in biIiary drainage (1928) and ZeIditch6 aIso reported tweIve cases of biIiary tract infestation. These, however, were not a11 cases with accompanying cholelithiasis. Extrahepatic biIiary obstruction due to compression by adjacent structures such as Lymph nodes detiniteIy pIays a part in the stagnation of bile and the formation of biIiary concretions. These nodes are usuaIIy situated atthe junction of the cystic and common bile ducts and were found in severa of the cases reported, as we11 as in the case herein presented.