Cholelithiasis and Perforation of the Gallbladder in an Infant, With Recovery

Abstract

Cholecystitis with cholelithiasis is an unusual finding in infancy, but the condition has been reported several times in the literature of the last 200 years; however, it has always been an autopsy finding, and no case could be found that had been diagnosed during life and treated, with subsequent recovery, in an infant under 1 year of age. REPORT OF A CASEA 6-weeks-old female infant was admitted to the Los Angeles Childrens Hospital with a diagnosis of intestinal obstruction. At 2 weeks of age the baby began to be constipated. The scanty stools were described as white, yellow, green, and slimy. At 5 weeks of age, the abdomen began getting larger and became especially noticeable four days prior to admission. Bowel movements were now obtained only by enema. The appetite had been fair, but there had been intermittent vomiting for a week prior to admission. This vomitus contained only curdled milk.On admission the baby appeared to be well developed, fairly well nourished, and acutely and chronically ill, with a markedly distended tight abdomen. The temperature was 100.6 F, and the blood pressure was 100/60 mm. Hg. Peristalsis was present but not remarkable. There was a suggestion of shifting dulness. The hemoglobin was 62% (colorimetric method), the white blood cell count 7,300, and the urine negative. A tentative diagnosis of abdominal malignancy with ascites was made and further studies were instituted.Course.-Roentgenograms of the abdomen showed a moderately dilated small bowel with evidence of intraperitoneal fluid. A possible malrotation with chronic volvulus was considered, and a paracentesis was performed with removal of 400 cc. of yellow brown, slightly cloudy fluid. The possibility of a choledochus cyst was seriously considered. A barium enema revealed a normally placed cecum. Intravenous pyelograms were negative. The icteric index was 16, and cholesterol 118 mg. per 100 cc. of blood serum. A second tap allowed removal of 500 cc. of cloudy green fluid. The child took her formula quite well and vomited only occasionally. The temperature rose to 101 F, and on the sixth day after admission, surgery was performed. (Van den Bergh reactions were: direct, 2.3 mg. per 100 cc. of blood serum; indirect, 2.4 mg. per 100 cc.) Surgery.\p=m-\Under ether anesthesia, an upper abdominal right rectus incision was made. Blood was administered. Exploration revealed several hundred cubic centimeters of free bile-stained fluid between the coils of intestine. In some areas there were filmy adhesions with some pocketing. In the right upper quadrant was a perforated bile abscess cavity ( fig. 2). The liver and loops of intestine had partly walled off this area. The liver itself appeared normal. At the base of the abscess was a perforation of the gallbladder at its junction with the cystic duct. The gallbladder contained one small stone, and there were numerous siones in the common duct. The duct was opened. A tiny probe could not be passed into the duodenum because of stones; some of these were washed out and an attempt made to pas...

Japanese clinical practice guidelines for congenital biliary dilatation

“…Various surgical procedures have been reported as follows: (1) intraperitoneal drainage only , (2) biliary drainage through a perforation site , (3) construction of a tube biliary fistula, (4) suture closure of the perforation site , (5) closure by placing a gallbladder patch on the perforation site, (6) sewing a caulescent gallbladder wall as a patch on the perforation site , T tube insertion into the common bile duct, (7) cholecystoduodenostomy or cholecystojejunostomy , (8) if the perforation site is the gallbladder, cholecystectomy; if the perforation site is the bile duct, choledochojejunostomy (choledochoduodenostomy), (9) choledochojejunostomy (choledochoduodenostomy), (10) T tube biliary fistula, (11) extrahepatic biliary resection after several months , (12) extrahepatic biliary resection according to the general physical condition of the patient , etc.…”

Ischemic gallbladder perforation in a premature infant

“…The etiology for gallbladder perforation during infancy is unknown except for cholelithiasis [3,5]. Gull et al [2] suggested that perinatal asphyxia and sepsis with resulting splanchnic ischemia might be a possible cause for neonatal gallbladder perforation.…”

“…To our knowledge, there have been only 4 cases of gallbladder perforation reported in infants or neonates [2][3][4][5]. The etiologies for gallbladder perforation during infancy remain idiopathic except for cholelithiasis [3,5]. Fundus is the most common site of the perforation.…”

Focal Bacterial Infections

“…The literature has documented about 25 cases, of which 9 were seen in association with an epidemic of neonatal enteritis caused by Salmonella enteritidis [111]. Of the remaining infants, 16 were the subjects of isolated case reports [24,103,[112][113][114][115][116][117][118][119][120][121][122][123], and 3 died of other causes with inflammatory changes in the gallbladder described as an incidental finding at autopsy [81,95,124]. A tissue diagnosis of "chronic cholecystitis" was established in an infant whose biliary disease apparently began at 6 days of age [125].…”

“…The pathogenesis of this condition is uncertain; all but three cases [99,118,122] of cholecystitis in the newborn period have been acalculous. It is postulated that sepsis, dehydration, prolonged fasting (e.g., total parenteral nutrition), congenital obstruction, or a stone impacted in the cystic duct leads to biliary stasis and acute distention of the gallbladder.…”