Common bile duct stones in infancy: A medical approach

Abstract

Symptomatic choledocholithiasis in infancy is not common. It usually presents with jaundice and acholic stools and is diagnosed on abdominal ultrasonography. Favourable outcome of conservative management has been reported, but specific management guidelines are not well defined in the literature. We describe three cases using a combination of ursodeoxycholic acid and antibiotics as a treatment paradigm, which could potentially negate more invasive treatment. All three patients had ultrasonography proven choledocholithiasis with concomitant obstructive liver function test. They were treated with a combination of ursodeoxycolic acid and antibiotics. Patient 1 had an Escherichia coli urinary tract infection and was treated with oral bactrim. Intravenous amoxicillin, gentamicin and metronidazole were used for the other two patients. All three patients responded with a return to normal-coloured stools within 48 h of combination treatment. Repeat ultrasonography done within 11 days after the first study for all three patients confirmed complete resolution of choledocholithiasis. It is postulated that this improvement is as a result of a reduction in inflammation and oedema, associated with a low-grade cholangitis, following antibiotic treatment. This is coupled with improved bile flow with ursodeoxycholic acid therapy. The findings suggest the potential application of this safe, non-invasive therapeutic strategy as initial management in infants with this condition. A follow-up prospective randomised controlled trial may be an answer to prove the validity of this observation but due to the rarity of this problem, it would be a challenge to recruit sufficient number of patients.

An Uncommon Case in a Healthy Infant: A Case of Infantile Cholelithiasis

“…The infantile cholelithiasis can resolve spontaneously or progress to choledocholithiasis or cholecystitis. A variety of treatment options were antibiotics or ursodeoxycholic acid [29], elective cholecystectomy, and even emergent operative exploration [26]. Ultrasonography has a sensitivity and specificity of about 95% for gallbladder cholelithiasis, but only 50–75% for choledocholithiasis.…”

Rolling stones: an instructive case of neonatal cholestasis

“…Medical management with ursodeoxycholic acid is recommended in neonates with choledocholithiasis if they are asymptomatic or with mild symptoms. Antibiotics can aid in the resolution of stones in neonates who have signs of infection [ 5 , 11 , 12 ]. In a study of 13 infants with gallstones, 10 remained asymptomatic without surgical management, and stones resolved on their own in 5 of them, with the other 5 either lost to follow-up or with persistent calcified gallstones [ 6 ].…”

“…In a study of 13 infants with gallstones, 10 remained asymptomatic without surgical management, and stones resolved on their own in 5 of them, with the other 5 either lost to follow-up or with persistent calcified gallstones [ 6 ]. In another study, 3 infants with choledocholithiasis treated with antibiotics and ursodeoxycholic acid had resolution of gallstones and CBD dilation [ 11 ]. It has been reported that choledocholithiasis resolves spontaneously in up to 35–60% of cases seen in neonates and infants [ 5 ].…”

Management of Pediatric Patients Presenting with Acute Abdomen Accompanying Dilatation of the Common Bile Duct

“…Although choledocholithiasis is rare in children, we must consider the possibility of CBD dilatation caused by CBD stones. The underlying pathophysiology of choledocholithiasis in children is unclear and has been commonly related to hemolytic conditions, prematurity, gastrointestinal surgery, Crohn's disease, parenteral nutrition, cystic fibrosis, and diuretic or antibiotic therapy [ 12 ]. None of our patients had any of these risk factors.…”

“…One-stage laparoscopic CBD stone clearance is currently as effective as both preoperative and postoperative two-stage ERCP CBD clearance with similar morbidity and mortality outcomes [ 15 ]. However, there are many reports that CBD stones in children can pass spontaneously without any significant complications [ 8 12 ]. In the present study, 2 patients underwent preoperative stone removal with ERCP and an operation.…”