A 19-Month-Old Girl With Acute Choledocholithiasis: A Case Report

Abstract

Cholelithiasis, or gallstone(s), is a leading cause of healthcare utilization in the United States. It is more common in adults but can occur in the pediatric population as well. The following is a case report of choledocholithiasis in a 19-month-old girl. A 19-month-old girl with abdominal pain presented to the emergency department (ED) after being found to have cholelithiasis on an outpatient abdominal ultrasound (US). Three days prior to presentation, the patient was seen by her pediatrician for fussiness, decreased oral intake, and non-bloody, non-bilious emesis. She was diagnosed with a suspected urinary tract infection (UTI) and prescribed amoxicillin-clavulanate for empiric treatment. The following day, the patient returned to her pediatrician for worsening abdominal pain; she was given one dose of intramuscular ceftriaxone and scheduled for outpatient abdominal US. Her past medical history is significant for omphalocele status post-surgical correction, several congenital cardiac defects, bilateral small kidneys, and poor weight gain. The patient has a normal chromosomal microarray and no family history of hepatobiliary/pancreatic disease. In the ED, the patient was afebrile and hemodynamically stable. Physical examination was significant for mild hepatomegaly, mild abdominal tenderness without peritoneal signs, and the presence of a well-healed surgical scar on the abdomen with an underlying abdominal hernia. Laboratory tests were significant for leukocytosis of 14.5×10³/microliter (mcL), elevated gamma-glutamyl transferase (GGT) of 305 unit/L (U/L), aspartate aminotransferase (AST) of 86 U/L, alanine aminotransferase (ALT) of 343 U/L, total bilirubin of 2.3 milligram/deciliter (mg/dL), direct bilirubin of 1.6 mg/dL, and lipase of 1,726 U/L. Abdominal US revealed several gallstones and mild to moderate intra- and extrahepatic biliary ductal dilatation likely due to a stone in the distal common bile duct (CBD). Pediatric surgery and gastroenterology recommended admission for pain management and magnetic resonance cholangiopancreatography (MRCP). After admission, the patient was started on ursodiol and piperacillin/tazobactam. MRCP showed a common hepatic duct measuring 13 mm and a 9×5 mm stone in the distal common bile duct. Due to a lack of available outside facilities with the capability to perform endoscopic retrograde cholangiopancreatography (ERCP) in a pediatric patient, medical management was pursued. Throughout her admission, the patient improved clinically, laboratory studies became normal, and pain was controlled. Repeat US showed persistent biliary dilation with cholelithiasis. The patient was cleared for discharge on ursodiol and amoxicillin-clavulanate and close follow-up with pediatrician, pediatric surgeon, and pediatric gastroenterologist. Follow-up US performed two weeks after discharge showed interval resolution of intra- and extrahepatic biliary duct dilatation and cholelithiasis without evidence of cholecystitis. Abdominal pain accounts for 5%-10% of all pediatric ED visits, and although cholelithiasis and choledocholithiasis are rare in the pediatric population, as this case demonstrates, it is an important differential diagnosis. Observation is the recommended management for asymptomatic patients as most cases spontaneously resolve. Patients with clinical signs or laboratory abnormalities can be treated medically, with ERCP, or with cholecystectomy.

Keywords: abdominal pain; cholecystitis; choledocholithiasis; cholelithiasis; gallstone pancreatitis; omphalocele.

Figure 1. Initial abdominal ultrasound

Abdominal ultrasound (pancreas transverse view) showing several stones within the gallbladder without gallbladder wall thickening, mild to moderate intra- and extrahepatic biliary ductal dilatation with the common bile duct measuring 9 mm and an ovoid lesion measuring 1.5×0.6 cm in the distal common bile duct. Red arrows point to intrahepatic biliary ductal dilatation. White arrows point to dilated gallbladder and extrahepatic biliary ductal dilatation.

Figure 2. MRCP

MRCP showing the gallbladder distended with multiple gallstones, trace amount of free fluid adjacent to the liver, and moderate intra- and extrahepatic biliary ductal dilatation with the common hepatic duct measuring 13 mm in diameter and an ovoid filling defect measuring 9×5 mm in the distal common bile duct (white arrow). MRCP: magnetic resonance cholangiopancreatography

Figure 3. Repeat abdominal ultrasound

Repeat abdominal ultrasound (A: liver sagittal view, B: pancreas view) showing the intrahepatic ducts and CBD remaining dilated with multiple gallstones, the largest of which measuring 9 mm. No gallbladder wall thickening. CBD: common bile duct

Figure 4. Follow-up abdominal ultrasound

Follow-up abdominal ultrasound (gallbladder view) showing interval resolution of previously seen intra- and extrahepatic biliary duct dilatation and cholelithiasis without cholecystitis, including a 6 mm gallstone in the neck of the gallbladder.