Background. RUQ Ultrasound Normal, Recommend Clinical Correlation. Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children s Hosptial

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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 : 36 cholecystectomies : 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

2 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 2

3 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 Alk phos: 97 AST: 14 ALT: 7 Total bilirubin: 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 3

4 1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter Labs WBC: 16k Amylase: 68 Lipase: 19 Alk phos: 103 AST: 60 ALT: 54 Total bilirubin: 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 4

5 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: 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 5

6 1. Presence of stones/sludge 2. Gallbladder wall thickness 3. Pericholecystic fluid 4. Common bile duct diameter Labs WBC: 24k Amylase: 1843 Lipase: 4128 Alk phos: 176 AST: 167 ALT: 227 Total bilirubin: 1.7 Now that we ve covered the basics 6

7 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 Alk phos: 73 AST: 24 ALT: 28 Total bilirubin: 0.1 7

8 Hydroxy Iminodiacetic (HIDA) Scan Hydroxy Iminodiacetic (HIDA) Scan Gallbladder Ejection Fraction: 17% 8

9 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 9

10 Biliary Dyskinesia Cont d Increasingly common diagnosis in children TCH Review (1/ /2008) Third leading indication for cholecystectomy (16%) 78% female 51% overweight (30% severely obese) Percent of cholecystectomies for biliary dyskinesia compared to historical cohort ( ): 16% vs 0%, p < 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 10

11 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 11

12 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: srshah2@texaschildrens.org 12