East and Central African jozirnal of Su?gey Val. 5, NO. 2 Acute acalculous cholecystitis in children J M Rijcken MD Pro~~incialSurgeon Gn~eruI'rovincial Hospital Gweru, Zimbabwe Key words: acalculous cholecystitis, children Acute acalculous cholecystitis (AAC)is a rare because of the high incidence of necrosis of the disease in African children and usually occurs gallbladder wall. as a complication of some other diseases, such as systemic infections. AAC can, however, be Introduction the primary pathology but, because of its low Acute cholecystitis is most commonly associated with incidence, it is difficult to establish definite gallstones. Acute acalculous cholecystitis in adults mechanisms and causes. has been described after shock, extensive burns, in sepsis, as a postoperative complication and after The case histories of six children (mean age receiving long-term parenteral feeding and this seven years) with AAC are presented. They suggests a different pathogenesis. were treated in Queen Elizabeth Central Hospital, Blantyre, Malawi and in Gweru AAC also has been described in children, although Provincial Hospital in Zimbabwe between 1985 it is considered to be a rare condition. Ternberg'.l3,in and 1996. In four children, pre-operative 1977, described 74 cases in children, of which 60 % ultrasonography showed the typical signs of occurred as a complication of other illnesses, such AAC. as gastro-enteritis and pneumonia. Cholecystectomy was performed on all seven Gallbladder disease is, however, rare in Africans. children. One child died postoperatively from Onuigbo2, in Nigeria, found only 26 patients with generalised sepsis and in two children a wound gall bladder disease among 7,500 surgical specimens. infection occurred. In Uganda, Kawooya3 found an incidence of 0.28% as detected by sonography and also Garrido4 in In the tropics, where many children are seen Mozambique found a very low incidence of gall with gastro-enteritis and other infectious bladder disease in postmortem specimens in Maputo. diseases, the possibiLity of AAC must be borne in mind when a child is admitted with right Biliary symptoms in the black child are often upper abdominal tenderness and fever. attributed to Ascaris lumbricoides, which may The role of ultrasonography is emphasised. It migrate into the common bile duct and cause is a reliable, non-invasive and quick transient obstructive jaundice. This will only occur investigation, which helps to establish the in massive infestation of the small bowel with diagnosis before surgery. migration of the worms into the duodenum and common bile duct. Cholecystitis without jaundice Cholecystectomy is the treatment of choice, and palpable masses in the bowel can not be Adclress for correspondence: Schurenbergsweg 70, 4432 PC, Hoensbroek, the Netherlands E-mail: [email protected] 32 J M Rijcken attributed to Ascaris infestations5. Investigations: Hb 10.9g/dl, WBC 29.5 x 10" a raised bilirubin, negative Widal but positive In the tropics, the incidence of gastro-enteritis and malarial parasites. Ultrasonography showed a other infectious diseases in children is very high distended and thick-walled gallbladder. and more cases of AAC would be expected, yet there are few published reports9J0. He underwent cholecystectomy and histology showed non-specific cholecystitis. His recovery The possibility of AAC must be borne in mind was complicated by a wound infection. whenever a child is admitted with right upper abdominal tenderness and fever. Delay in 4 An 11-year-old girl was admitted with establishing the diagnosis contributes to the high gastroenteritis complicated by fever, right upper morbidity and mortalityR~"J4. quadrant abdominal pain and sepsis. Investigations: Hb 10.3g/cll, WBC 6.8 x lo9, Patients and methods normal bilirubin and negative Widal and malarial Six cases of AAC in black children were seen in parasites. Ultrasonography showed gross Queen Elizabeth Central Hospital in Blantyre, distension of the gallbladder. Malawi and in Gweru Provincial Hospital, Gweru, Zimbabwe between 1985 and 1996. There were She was treated by cholecystectomy and four boys and two girls, with a mean age of seven histology showed non-specific cholecystitis. years (range 3 to 11 years). Recovery was uneventful. Case histories 5 A five-year-old girl suffering from pneumonia, 1 A malnourished girl aged seven years presented developed fever and abdominal pain with a with fever, abdominal pain, ascites, jaundice and palpable liver. vomiting. Investigations: Hb 8.7g/dl, WBC 7.0 x lo9, Investigations: Hb 11.4g/dl, WBC 14.0 x lo9. normal bilin~binand both negative Widal and Raised bilirubin but Widal negative. malaria parasites. Ultrasonography showecl a Ultrasonography not done. thick-walled gallbladder. She was treated by cholecystjejunostomy and Histology of the excised gallbladder showecl histology showed a generalised Schistosoma necrotising cholecystitis. The patient died of mansoni infestation of the liver and gallbladder. generalised sepsis. Recovery was uneventful. 6 A 10-year-old girl without previous history of 2 A five-year-old boy suffering from illness developed fever, abdominal pain and gastroenteritis was admitted with fever, pain in vomiting. the right upper quadrant of his abdomen and Investigations: Hb 13.8g/dl, WBC 8.7 x 10"ith ascites. normal bilin~binand negative malarial parasites. Investigations: Hb 9.4g/dl, WBC 10.5 x lo9.Widal Ultrasonography was not done. and malaria parasites negative. Ultrasonography confirmed a distended gallbladder with oedema Cholecystectomy was done and histology of the gallbladder wall. showed necrotising cholecystitis. She recovered without complication. He underwent cholecystectomy and histology showed necrosis of the gallbladder wall. Results Recovery was complicated by wound infection. Mild fever, nausea, vomiting and abdominal pains were the common symptoms. Sometimes a mass 3 A three-year-old boy with gastroenteritis and was palpable in the right upper quadrant of the worm infestation was admitted with fever, abdomen. Jaundice was not a consistent feature jaundice, right upper quadrant pain and a and was found in only two of the six patients. In palpable liver. general the symptoms were those of an infection ancl the abdominal symptoms were often have been found in these cases and are believed to overshadowed by the concomitant illness. have contributed. In all the cases of AAC ciescribecl by Goris, positive cultures were made from the bile7. Laboratory tests were not really helpful and only Iudin16 also found organic disorders (strangulation, showed that an infection was present. The Widal long cystic duct and poor evacuation) in all 18 test is not specific. The diagnosis was reached pre- reported cases of acalculous cholecystitis in operatively in four cases from ultrasonography. children . Five of our patients underwent conventional In this group of six children, no obvious cholecystectomy and, in three, necrosis of the gallbladder disorders were found in five cases but, gallbladder wall was found. In the child with in the child with schistosomiasis, there were many extensive Schistosomiasis, it was technically adhesions which may have contributed to the impossible to remove the gallbladder, so a cholecystitis. None of the children had worm cholecystojejunostomy was performed . infestations or haemolytic anaemia. In one child, a bile culture was positive. Three children were The average hospital stay was 18.7 days. The admitted with gastro-enteritis and subsequently average pre-operative illness was 6 days and the developed AAC, while one child had severe pre-operative delay was three days. pneumonia on admission. These children could fit either causal hypothesis but the numbers are too One child died due to generalised sepsis and two small to reach conclusions. Most likely a children had wound infections necessitating combination of events causes AAC. drainage and a prolonged hospital stay. Ultrasonography has proved to be a very valuable Discussion and reliable non-invasive diagnostic tool in AAC in children is a recognised but rare cholecystitis. It permits a rapid and accurate diseasel~8~11~12~13~14~15~1G.Ternberg and Keating evaluation of the right upper abdomen. described 74 cases of AAC in children and found Particularly in children, this non-invasive method that, in 60 %, the AAC occurred as a complication has great advantages. Greenberg et a16 recognisecl of other illnesses, most frequently upper three important signs of gallbladder disease: respiratory tract infections and gastro-enteritisI3. They conclude that biliary stasis and superimposed 1 a marked thickened sonolucent gallbladder wall infection caused by dehydration, fever, prolonged or, Elsting and/or prolonged ileus are the mechanisms 2 a thickened hyper-reflective irregular wall causing AAC. 3 cholelithiasis ding to Glenn and Becker, however, it is not Ultrasonography is particularly reliable in detecting stasis but vascular change in the gallbladder calculi with an accuracy of over 90%. In AAC, no wall which is the main mechanism14. Severe trauma, calculi are found but the thickened wall is a very sepsis and massive blood transfusions are typical and persistent sign and this was found conditions in which a clotting cascade may occur. consistently in our patients, who had Activation of the Hageman factor (factor Xll) in the ultrasonography. clotting cascade may lead to thrombosis of the blood vessels in the gallbladder wall. Most authors recommend cholecystectomy because, in many series, necrosis