What Causes Gallstones in Children?
Gallstones are hardened accumulations of chemicals in the gallbladder. They form through a process called cholelithiasis, and generally range from a few millimeters to a few centimeters in diameter, notes the University of Maryland Medical Center, or UMMC. While the exact causes of gallstones are unknown, there are risk factors associated with their development. Gallstones are not uncommon in adults, affecting about 25 million in the United States annually, but they are fairly rare in children.
Types
Most gallstones are made up predominantly of cholesterol, calcium carbonate or pigment called calcium bilirubinate. The rates of occurrence are different in children than in adults, as the study “Calcium Carbonate Gallstones in Children” found. While cholesterol stones make up around 75 percent of adult stones, they account for less than 25 percent in children. Pigment stones, the second most-common type in adults and children, account for around 15 and 20 percent, respectively. Calcium carbonate stones are rare in adults, accounting for only about 4 percent of stones. This type is significantly more common in children, accounting for about 25 percent of childhood gallstones. Around 5 percent of children have protein gallstones.
Risk Factors
Although adult women are far more likely to develop gallstones than adult men, occurrence in children is about equal, notes UMMC. Obesity, congenital blood disorders such as spherocytosis or sickle cell disease and a family history of gallstones put a child at increased risk of developing the condition, according to Seattle Children’s Hospital, or SCH. A high-fat, high-cholesterol or low-fiber diet increases risk as well, explains MayoClinic.com.
The gallbladder is a small organ that stores bile until the body is ready to use it for digestion. When bile is needed, the gallbladder releases it into the intestine. Bile is produced by the liver and helps with fat digestion. It is made up of water, fats, salts, proteins, bilirubin and cholesterol. Gallstones generally form when the cholesterol hardens, but gallstones can also form from hardened bilirubin. Gallstones are more common in adults, but children also sometimes get gallstones. Usually, children who develop gallstones have no specific reason or underlying condition responsible for the gallstone formations; however, several factors and conditions increase the risk of gallstone formations in children. In addition, those children who have parents who have had gallstones are more likely to develop gallstones themselves.
Symptoms
Some gallstones produce no symptoms, but when they do, symptoms are usually sudden, says SCH. Pain in the upper right or middle right section of a child’s abdomen or back is a primary symptom of gallstones, according to Children’s Hospital Boston. The pain, which also sometimes manifests between the shoulder blades or in the right shoulder, usually lasts about half an hour, and often presents after eating, especially following fatty or greasy meals. Gallstones that obstruct a child’s bile duct may also cause nausea, vomiting, fever and jaundice, adds SCH.
Physical Conditions
Obese children are more likely to develop gallstones. Also, children who have had multiple abdominal surgeries or a spinal injury may be more prone to develop gallstones.
Intravenous Nutrition
Children who have been on a feeding tube for a long period of time are at a higher risk of developing gallstones. Intravenous feedings affect the flow of bile by slowing it down, which can promote the formation of gallstones. According to the University of Maryland, about 40 percent of individuals who have received intravenous feedings develop gallstones.
Symptoms
A child who has gallstones may experience intense pain in the upper right side of the abdomen and back. The pain may be felt at any time, but it often follows meals containing greasy food items. Children with gallstones may also experience nausea and/or vomiting.
Diagnosis and Treatment
Gallstones can be detected via ultrasound. The only effective treatment for gallstones is to completely remove the gallbladder (cholecystectomy). The gallbladder is removed laparoscopically under general anesthesia. Since the gallbladder’s only function is to store bile, it is not a vital part of the digestive system. Without a gallbladder, the bile will simply move directly from the liver to the intestines.
Diagnosis
A child’s pediatrician may suspect gallstones based on the location, frequency, severity and duration of pain, and if it has notable triggers such as high-fat meals. The pediatrician may recommend the child see a gastroenterologist. An abdominal ultrasound or a CT scan can provide images of the gallbladder that reveal stones. Further testing, such as an MRI or HIDA scan, may be necessary to determine whether there is any obstruction in a child’s bile ducts. Blood tests can check for other gallstone complications, such as an infection, jaundice or pancreatitis.
The study found that girls who are obese and extremely obese are six and eight times more likely, respectively, to have gallstones than girls who are underweight or of normal weight. Obese and severely obese boys are more than twice and three times as likely to have gallstones compared to their peers, according to the findings published in the Journal of Pediatric Gastroenterology & Nutrition.
Gallstones affect nearly 20 million adults in the US. Symptoms of gallstones include recurrent abdominal pain, fever and nausea.
“The high rate of gallstones in obese children and adolescents may surprise paediatricians because gallstone disease is generally regarded as an adult disorder. Since obesity is so common, paediatricians must learn to recognise the characteristic symptoms of gallstones,” said George Longstreth, gastroenterologist from Kaiser Permanente San Diego Medical Centre.
Treatment
If a child’s gallstones produce no symptoms, and if no complications or duct blockages are detected, the stones require no treatment, according to SCH. In other instances, the only treatment for a child’s gallstones is removal of the gallbladder with a procedure called a cholecystectomy. The procedure is performed under general anesthesia, usually laproscopically, with four incisions in the abdomen. It typically has no permanent effect on a child’s quality of life, as a gallbladder is unnecessary. Painkillers may be prescribed to treat symptoms until the operation is performed.
Is Gallstone Disease caused by Obesity or by Dieting?
The effects of dieting and obesity on the risk of acute gallstone disease were evaluated in a case-control study in Maastricht, The Netherlands, during 1983–1986. The study comprised 151 cases with acutely symptomatic gallstone disease and 451 population controls. The effects of dieting and obesity as measured by body mass index (weight (kg)/height (m)2) were disentangled in a multivariate logistic regression analysis. Both dieting and body mass index were positively associated with the rate of gallstone disease. The association with dieting largely disappeared when initial body mass index was controlled for (rate ratio = 1.4, 95% confidence interval 0.8–2.4). Conversely, controlling for dieting did not affect the association between body mass index and gallstone disease. Analysis by risk period (year 1 and 2–5, 6–10, and 11–15 years prior to interview) did not show consistent risk period-specific effects when initial body mass index was controlled for. The authors conclude that dieting does not account for the association between obesity and gallstone disease. In obese persons, dieting does not increase the risk of acute gallstone disease over the long term. Am J Epidemiol 1992:135:274–80.
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Carel Thijs, Paul Knipschild and Pieter Leffers
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Dr. Mehmet Oz