Introduction
Bile is a substance produced by the liver which aids in food digestion. The gall bladder is the storage organ of bile. The gallbladder secretes the bile into the intestine through ducts when a person eats. The incidence of gallstone formation in children is between 0.1 to 1.9 %. The risk factors for developing gallstones are hemolytic disease, long-term parenteral nutrition, genetic disorders, trauma, sepsis, antibiotics, and obesity. Cholecystectomy is a gold-standard treatment for gallstone removal among children. Removal of the gallbladder can cause adverse effects on biliary tract function or pressure. However, some pediatric patients develop post-cholecystectomy syndrome post-treatment.
What Are the Symptoms of Gallstone?
Gallstones do not always cause symptoms. Some children may develop pain in the upper right and central region of the abdomen, just below the ribs. The pain tends to worsen after consuming fatty foods. The intense abdominal pain may also extend to the back and right shoulder.
What Is the Procedure to Remove Gallbladder in Children?
Conventional and laparoscopic techniques remove gallbladder in children. In the conventional approach, a 4 to 6-inch incision is created on the upper right abdomen. The position of the gallbladder is explored by the surgeon and removed. The laparoscopic technique requires three to four small incisions on the abdomen. A laparoscopy made of a thin and long tube fitted with a video camera within the tube is used as a surgical tool. The surgical tool is inserted through the incision. The operating doctor monitors the laparoscopy by watching a TV display. One of the incision helps remove the gallbladder. The procedure is less invasive and has minimal bleeding and small incisions. The recovery period also tends to be shorter.
What Are the Adverse Effects of Cholecystectomy in Children?
Cholecystectomy's adverse effects are similar both in children and adults. The children reported common symptoms like stomach pain, eating discomfort, fatty food intolerance, trouble swallowing, indigestion, diarrhea, jaundice, bloating, heartburn or reflex, nausea and vomiting, constipation, and blood in the stool. Diarrhea and bloating are caused by the gallbladder’s loss of reservoir function and is often due to cholecystectomy procedure.
What Is Post-Cholecystectomy Syndrome?
Post-cholecystectomy syndrome is a phenomenon where there is persistence or development of new abdominal symptoms post-cholecystectomy. It is not uncommon in children; one-third of pediatric patients with cholecystectomy presented with abdominal symptoms. Obesity is considered a risk factor for developing post-cholecystectomy syndrome. The syndrome's symptoms can clinically present immediately following surgery or several months to years after surgery.
Most children undergoing cholecystectomy get relief from abdominal symptoms. However, some children with co-morbidities tend to develop post-cholecystectomy syndrome. The clinical presentation of the syndrome can be mild or severe in children.
What Causes Post-Cholecystectomy Syndrome in Children?
Earlier anatomic abnormalities were considered a cause for developing post-cholecystectomy syndrome. However, recent research suggests the following causes:
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Non-biliary causes include irritable bowel syndrome (gastrointestinal disorder) or functional dyspepsia (indigestion) are common causes of non-biliary symptoms. Other causes include reflux esophagitis, peptic ulcer disease, and pancreatitis (pancreas inflammation). Increased bile flow to the upper gastrointestinal tract causes the patient to develop duodenal-gastric biliary reflux, which causes symptoms like gastric or duodenal ulcer, dyspepsia, and nausea. The non-biliary causes are the predominant factor for developing post-cholecystectomy syndrome.
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Pancreatic causes include pancreatic tumors, hepatitis, esophageal disease, mesenteric disease, diverticulitis (inflammation in pouches within the colon), and peptic ulcer.
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Biliary causes include retained calculi and stenosis. Biliary causes are further classified as early and late. Early symptoms develop secondary to surgical complications of cholecystectomy and include biliary duct injury, biliary leak, retained cystic duct, bile duct stones, and bile-salt-induced diarrhea. Late symptoms develop due to bile duct strictures, recurrent bile duct stones, and dysfunction of the sphincter of Oddi.
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Other causes like psychiatric and neurologic disorders, intercoastal neuritis (neuropathic pain), wound neuroma, coronary artery disease, and unexplained pain syndrome also result in post-cholecystectomy syndrome in children.
How Is Post-Cholecystectomy Syndrome Diagnosed in Children?
Initially, the children must undergo a complete blood work-up to rule out infectious causes. A metabolic panel assessment is done with amylase, lipase, and prothrombin time estimation to check for any pancreatic or hepatobiliary cause. Other laboratory work-ups such as hepatitis panels, thyroid function, and cardiac enzyme estimation are recommended.
Using a chest scan for radiologic examination, track pulmonary and mediastinal disorders. An abdominal ultrasound helps with diagnosis. CT (Computed Tomography) scans help diagnose pancreatitis and its associated complications. Nuclear imaging, such as a Hepatobiliary Iminodiacetic Acid (HIDA) scan, can identify a biliary leak or sphincter of Oddi dysfunction. Manometry is a gold standard for diagnosing functional disorders that cause post-cholecystectomy syndrome.
How Is Post-Cholecystectomy Syndrome Treated in Children?
The treatment methods include pharmacological and surgical approaches. The treatment approach can vary among children depending on the underlying cause.
1. Pharmacological Approach -
The main aim of this treatment is to prevent complications post-cholecystectomy and reduce morbidity risk.
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Children with irritable bowel syndrome require bulking agents, antispasmodics, or sedatives.
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Patients having diarrhea are treated with Cholestyramine.
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Patients having gastritis or gastroesophageal reflux disease are treated with antacids, histamine-2 blockers, or proton pump inhibitors.
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Children having dyspeptic symptoms can benefit from bile acid binders.
2. Surgical Approach -
Surgery is deemed if a confirmed etiology is known to respond to operative intervention. Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly preferred surgical procedure. It could be diagnostic or therapeutic. Children who develop post-cholecystectomy syndrome due to Mirizzi syndrome (impaction of large gallstones in the gallbladder) or remnant cystic lithiasis require stone extraction through endoscopic therapy. Some children require the excision of cystic duct remains to stop post-cholecystectomy syndrome from developing in the future. Endoscopic sphincterotomy provides relief from recurrent pain caused by sphincter of Oddi dysfunction.
What Is the Prognosis for Post-cholecystectomy Syndrome in Children?
Among children, abdominal pain is a predominant indication for undergoing cholecystectomy in children. Almost 90 % of children undergoing the procedure had total relief from abdominal pain postoperatively. Children who develop post-cholecystectomy syndrome complain of gastric issues in the first three years after the procedure, but biliary complaints occur after the third year.
Conclusion
There is limited study about post-cholecystectomy in children. It could be due to reduced diagnosis or reporting of symptoms from patients. Therefore, medical professionals must be trained to diagnose and treat the syndrome's symptoms adequately.
