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The West London Medical Journal 2010 Vol 2 No 2 pp 11- 14
ACALCULOUS CHOLECYSTITIS IN 14-YEAR OLD
BOY WITH NO PREDISPOSING FACTORS
Amanda Shreders[1], Colin Michie[2]
ABSTRACT
The natural history of cholecystitis varies with the age and sex of the
patient. This condition most commonly presents in adult women with
cholesterol gallstones in the cystic duct. In men the condition is usually
acalculous without obvious stone, but it tends to follow another illness.
Cholecysitis is very uncommon in children and is usually acalculous (1,2,3).
We present a case of acalculous cholecystitis (AC) that was atypical in that no
antecedent abnormality was identified.
Financial Declarations: none
Keywords: acalculous, paediatric, cholecystitis, adolescent abdominal pain
CASE REPORT
A 14 year old boy presented with a sharp non-radiating pain in the right
upper quadrant. He had no chronic medical problems nor preceding illness.
His neonatal course had been smooth; his birth weight at term was
approximately 3 kg. There were two hospital admissions in early childhood
for unrelated minor surgical procedures. There was no family history of
jaundice, haemolysis, gallbladder disease or dyslipidemia. He was not
receiving any medications and had no history of allergy or adverse drug
reactions.
On examination he was pyrexial. There was no anaemia or jaundice,
clubbing or dysmorphic features. He weighed 57.0 kg and was 162.0 cm tall
(BMI 21.7, 75th centile for age). The cardiovascular and respiratory systems
were normal. There was guarding in the right upper quadrant with a positive
Murphy sign and no rebound tenderness. A rectal examination was not
carried out. There was no abdominal distension, no palpable masses and
bowel sounds were normal. The skin and mucosae were healthy, his hair and
nails unremarkable.
1
2
St Matthews University, Florida, USA.
Department of Paediatrics, Ealing Hospital NHS Trust
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THE WEST LONDON MEDICAL JOURNAL 2010
2, 2
An abdominal CT scan showed a mildly distended gallbladder with a
thickened wall measuring 6 mm, consistent with cholecystitis. There was no
bile duct dilation and the pancreas and kidneys were normal. Abdominal
ultrasound scan confirmed these findings; no gallstones were identified. Blood
results for this patient showed an elevated C-reactive protein throughout
admission ranging from 176 mg/L on admission to a peak on day three at 384
mg/L. The white cell count was raised at 15 x10^9 on admission, 20.5 x10^9
on day 3 (a neutrophilia), and blood cultures remained negative. Routine
electrolytes, bilirubin, alkaline phosphatase, and liver transaminases were all
normal. Haemolysis was excluded by the normal hemoglobin, red blood cell
indices and blood film.
A diagnosis of acalculous cholecystitis (AC) was made; treatment with
intravenous cefuroxime and metronidazole was initiated. Gentamicin was
substituted on day three because of the persistent high white count and CRP.
Following this change in antibiotics the patient improved rapidly; he was
discharged on day seven for outpatient follow-up. He has received an elective
laparoscopic cholecystectomy. A year after surgery he remains well with no
further episodes of abdominal pain; his routine blood investigations remain
within the normal range.
DISCUSSION
Cholecystitis or inflammation of the gallbladder is most commonly
secondary to a gallstone that obstructs the outflow of bile into the common
bile duct and gives rise to distention of the gallbladder (1). Resultant decrease
in blood flow and lymphatic drainage is thought to cause ischemia and
inflammation in the gall bladder, both of which further distend the
gallbladder. Bile stasis from outflow obstruction can also lead to ascending
bacterial infection, most frequently from Escherichia coli. Gallstones form
following supersaturation of the bile with cholesterol. This situation may
arise in conditions of high cholesterol intake, obesity, hypo-secretion of bile
acids or phospholipids, decreased gall bladder motility or a combination or
these (4,5,6). Pathologies of red cells leading to increased fragility and
turnover are associated with the development of pigment gallstones. Crohn’s
disease patients have an increased prevalence of gallstones due to terminal
ileum disease and changes in enterohepatic circulation (7). A combination of a
decreased bile acid pool, multiple surgical procedures and chronic illness may
predispose patients to gallstone formation.
Cholecystitis may also occur in the absence of stones, as first described in
adults in 1844 and in some detail in children in 1966 (3). Some 6-17% of
cholecystectomies show no gallstones on examination. Acute acalculous
cholecystitis (ACC) carries a higher mortality rate as it is oftern follows a
sepsis syndrome, burns, trauma, ventilation or prolonged use of narcotic pain
medication. Total parenteral nutrition, dehydration, infections including
hepatitis, Salmonella typhi, threadworm infections and malaria have been
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ACALCULOUS CHOLECYSTITIS IN 14-YEAR OLD BOY WITH NO PREDISPOSING
FACTORS
specifically documented as a cause of acalculous cholecystitis. Mesenteric
lymphadentitis leading to possible reactive hyperplasia of the cystic duct may
initiate cholecystitis leading to initiate obstruction of bile flow. Chronic AC
may result from a functional defect of the gall bladder causing bile stasis (69).
Congenital malformations of the gallbladder must also be considered in
the diagnosis of abdominal pain at any age. The gallbladder develops from a
bud of the duodenum that gives rise to the gallbladder and cystic duct (10).
Disruption of this process causes malformed gallbladders. Anomalies include
double gallbladders, multiseptate gallbladders, vestigial or absent gallbladder.
Multiseptate gallbladders are thought to occur from an arrest in the solid stage
of development; these in particular may be related to non-specific abdominal
pain (11). The majority of such anomalies show no syndromic association.
Abdominal ultrasound and abdominal computed tomography may both be
employed to evaluate adolescents with abdominal pain. Other imaging
techniques such as oral cholecystography, cholescintigraphy, and magnetic
resonance cholangioraphy are used prior to surgery to identify or exclude
speicfic gallbladder anomalies (11). Scintigraphy is considered positive for
cholecystitis when the gallbladder is not visualized one hour after injection of
technitium-99; this suggests there is an obstruction of flow preventing bile
entering or leaving the gallbladder. Regardless of age or cause, the mainstay
of current treatment remains percutaneous cholecystectomy, together with
systemic parenteral antibiotics.
CONCLUSION
The great majority of acalculous cholecystitis in children is related to
acute or chronic illness. The case reported here is unusual in that no such
association was identified. Gallbladder disorders should always be carefully
excluded in adolescents suffering abdominal pain.
Acknowledgements
The authors would like to thank Dr. Donald Bentley for his helpful review
of the script.
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