Bile is normally made in the liver and flows through the bile ducts into the gallbladder and duodenum (duodenum). When stones are formed in the bile ducts for any reason, they are generally called cholelithiasis because they are more commonly formed in the gallbladder. Anatomically, the liver and gallbladder are located in the upper right part of the abdomen.

As bile flows from the liver into the duodenum, which is the continuation of the stomach, it stops by the gall bladder on its way and accumulates there. Its density increases even more by absorbing water. After consuming certain foods, especially fatty foods, the gallbladder contracts and sends the concentrated bile into the duodenum.

What is the gallbladder and where is it located?

The gallbladder is a pear-shaped organ located just below the liver in the upper right region of the abdomen. It makes an important contribution to the body's digestive functions with the yellow-green colored bile it secretes into the intestines.

What does the gallbladder do?

Located in the upper right abdomen, just below the liver, the gallbladder is responsible for storing and releasing bile fluid produced by the liver, which helps digest fats in the food consumed. While the stomach and intestines are responsible for digesting food, the gallbladder secretes bile through a tube called the bile duct, making it an important part of the digestive system.

What are Gallstones?

Gallstones are formed when bile, which aids digestion, solidifies and forms a precipitate as a result of very high levels of cholesterol or bilirubin in the bile. Gallstones can be as small as a grain of sand or as large as several centimeters. Some people develop only one while others develop many stones at the same time.

Why do gallstones form in children?

Patients under 15 years of age account for 12% of all Cholecystectomy (removal of the gallbladder) cases. In the past, almost all gallstones in children were thought to develop due to blood diseases (such as Hereditary Spherostosis, Sickle Cell Anemia, Beta Thalassemia), but today this rate has decreased to below 20%. Today, an underlying cause cannot be explained in most cases.

The underlying causes that need to be investigated are obesity, pregnancy, dietary habits, total parenteral nutrition, biliary tract anomalies, large small intestine removal, use of certain drugs (some antibiotics and diuretics).

Among the causes of gallstones, 3 types of formation pathways come to the fore:

1. Excessive presence of cholesterol in bile;

Under normal conditions, the chemical content of bile in the gallbladder is sufficient to dissolve the cholesterol excreted from the liver. Sometimes an amount of cholesterol above the level that can be dissolved in bile can be excreted from the liver and this excess cholesterol can crystallize and cause stone formation over time.

2. Excess Bilirubin in bile;

Bilirubin is formed as a result of the breakdown of the hemoglobin molecule that enables red cells carrying oxygen in the blood to fulfill this task. In some diseases where destruction increases, bilirubin also increases and stones may form. Cirrhosis of the liver, bile duct infections and various blood diseases are examples of this situation.

3. Failure to Fully Empty the Bile; In various situations that adversely affect the functioning of the gallbladder, the fluid in the gallbladder can become quite dense and cause stone formation.

Are Gallstones in Children Familial?

There is no evidence yet that it is genetic or familial. In adults, if stones are detected in one person in the family, the incidence is higher in 1st degree relatives. In adults, it is more common in women, but in children, boys and girls are approximately equal. In adults, it is more common in those who are fed with fiber-free foods. In our study in children, it was found to be more common in overweight patients.

What are the Clinical Symptoms of Gallstones in Children?

Most cases in children are asymptomatic. They usually have insidious and recurrent abdominal pain. Abdominal pain may be accompanied by vomiting, fever and jaundice, which are signs of an infection called colnagitis. If the stone falls from the sac into the bile ducts and causes obstruction, signs of obstruction occur; sudden and rapidly intensifying pain in the upper right part of the abdomen, vomiting, chills, fever and pain in the right shoulder. It is also more common in some geographical regions.

When the stones in the gallbladder, which move under the influence of gravity, block the outlet of the gallbladder and prevent its normal emptying, various symptoms begin to occur. If the stone falls into the main bile duct during the course of gallstone disease, a much more problematic process is entered. In this process called obstructive jaundice, the patient may experience symptoms such as abdominal pain, jaundice, red or brown urine color, nausea, vomiting and sometimes fever.

After the stone blocks the bile duct for a few hours, inflammatory changes occur in this area and this condition is called cholecystitis. If infection is added to this picture, care should be taken as it can cause very serious life-threatening problems. This disease is called cholangitis. Apart from cholangitis, a gallstone that falls into the common bile duct can also cause acute pancreatitis, an inflammatory disease of the pancreas. This disease can be life-threatening.

In summary, the following clinical findings can be seen:

• Sudden and rapidly worsening pain in the right upper abdomen
• Back pain
• Pain in the right shoulder
• Nausea, vomiting
• Darkening of urine color
• Light-colored stools
• Excessive gas and other digestive problems
• Diarrhea

What are the Complications of Gallstones in Children?

Gallstones can cause many serious diseases such as inflammation of the gallbladder, obstructive jaundice that develops when a stone falls into the bile duct, inflammation of all bile ducts and pancreas.

Patients usually complain of pain in the right-upper part of the abdomen, radiating to the right and being felt on the right side of the back, nausea and sometimes vomiting attacks.

If there is inflammation, fever is added to the picture. These painful attacks usually start after a heavy fatty meal and can last for 1-5 hours.

The other disease caused by gallstones is less common, in which a large stone in the gallbladder penetrates the wall of the gallbladder over a long period of time, passes into the intestine and causes a mechanical obstruction in a narrow part of the small intestine. Gallstones, which gradually grow and increase in number during their natural course, constantly irritate the inner lining of the gallbladder and can increase the risk of the chronic inflammatory process progressing into cancer. This risk is considered particularly high in cases of stones exceeding 2-3 cm in size.

Complications may include the following conditions:

• Gallbladder inflammation. A stone lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever.
• Blockage of the common bile duct. Stones can block the tubes (ducts) through which bile flows from the gallbladder or liver into the small intestine. This can cause jaundice and bile duct infection.
• Blockage of the pancreatic duct. The pancreatic duct runs from the pancreas to the common bile duct. Pancreatic fluids that help digestion flow through the pancreatic duct. A stone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense and persistent abdominal pain and usually requires hospitalization.
• Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer. However, gallbladder cancer is very rare, so although the risk of cancer is increased, the chance of getting gallbladder cancer is still very low.

Are There Risk Factors for Gallstones?

Gallstones are more common in women than in men in adults. However, there is no significant difference between the two sexes in children.

• Overweight or obesity
• Sedentary life
• Nutrition with products rich in fat content
• Consuming high cholesterol foods
• Fiber-poor diet
• Having a family history of gallstones
• Diabetes
• Blood diseases such as sickle cell anemia and leukemia
• Rapid weight loss
• Using oral contraceptives containing estrogen (birth control drugs) or receiving hormone therapy
• Liver diseases

In addition to these factors, prolonged fasting, bariatric surgery and Crohn's disease can also lead to an increased risk of gallstone formation.

Gallstones tend to form when bile flow and emptying of the gallbladder are slowed down. The most common cause of stone formation is the concentration of cholesterol in bile with high cholesterol content. The second most common stone form is pigmented stones.

Cholesterol stones are usually yellow in color and consist of undissolved cholesterol. Pigmented stones are dark brown or black in color and are caused by excess bilirubin in the bile.

Sometimes mixed stones, which are formed by the combination of various substances, can be detected. Mix type stones rank 3rd in the frequency of detection. These stones may contain calcium carbonate, calcium phosphate, cholesterol and bile.

The 4th type of gallbladder stones are calcium stones. They occur in people with high levels of calcium in the bloodstream and in these people, kidney stones can often be detected in addition to gallstones.

How are Gallstones Diagnosed in Children?

As in all diseases, the diagnosis is made by History and Physical Examination and confirmed by laboratory and imaging studies. History and Physical Examination findings are described above.

Tests and procedures used to diagnose these stones include Blood tests and imaging. Ultrasonography is performed on every patient and is diagnostic. In some patients, depending on the clinical condition of the patient, the following tests may be performed; Computed Tomography (CT) scans may be recommended. These images are analyzed to look for findings. The tests check for stones in the bile ducts. A test that uses a special dye to highlight the bile ducts in images can help determine if a stone is causing a blockage. Tests may include a hepatobiliary iminodiacetic acid (HIDA) scan, Magnetic Resonance imaging (MRI) or Endoscopic Retrograde Cholangiopancreatography (ERCP). During the procedure, gallstones discovered using ERCP can be removed.

In summary, after the history and physical examination, the following tests are performed. Blood tests and ultrasound are done for every patient, while other tests are determined according to the patient.

• Blood test
• Ultrasound
• CT Scan
• Magnetic Resonance cholangiopancreatography (MRCP)
• Cholescintigraphy (HIDA scan)
• Endoscopic ultrasound

What is recommended to prevent gallstones in children?

The following recommended lifestyles have been shown to reduce your risk of gallstones.

Not skipping meals.

Eating regularly at your daily meals.

Skipping meals or continuous fasting can increase the risk of gallstones. Lose weight slowly. If you need to lose weight, go slowly.

Rapid weight loss can increase the risk of gallstones. Aim to lose 1 or 2 kilograms (about 0.5-1 kilo) per week.

Maintain a healthy weight.

Obesity and being overweight increase the risk of gallstones.

Try to maintain a healthy weight by reducing the calories in your food intake and increasing physical activity.

Once you reach a healthy weight, try to maintain it by continuing your diet and exercise.

How are Gallstones Treated in Children?

A child whose gallstones do not cause symptoms may not need treatment. Your doctor will determine gallstone treatment based on your symptoms and diagnostic test results.

Are medicines used to dissolve gallstones?

Medicines you take by mouth can help dissolve gallbladder sludge. However, it is often not possible to dissolve gallstones in this way, and even if the stone dissolves, the gallstones will probably form again if treatment is stopped.

How is Gallbladder Surgery Performed?

Today, the gold standard method for removal of the gallbladder (cholecystectomy) is usually the laparoscopic method. If this cannot be done for technical or other reasons, it is performed open. The gallbladder is completely removed.

What kind of problems can be encountered after gallbladder stone surgery in children?

Anesthesia and laparoscopy may have general complications. Respiratory distress, abdominal and shoulder pain, vomiting and delayed bowel function.

Surgically; obstruction due to stones escaping into the bile ducts (this may require endoscopic and surgical procedure), bleeding, intra-abdominal abscess, bile leakage due to the opening of the clips, which may heal spontaneously or may require a second surgical intervention.

Injury to the main vessels supplying the liver, especially in inexperienced hands, which can cause serious morbidity and mortality.

Since the anatomy of the liver and bile ducts may include many variations, the surgery should be performed by people with sufficient experience and knowledge in this field.

What should be considered after gallbladder surgery?

After removal of the gallbladder, bile flows directly through your bile duct into your small intestine rather than being stored there. The bile stored in the sac flows into the duodenum when needed (especially after fatty foods) and facilitates the digestion of food. If this is not possible after cholecystectomy, excessively fatty and spicy foods should be avoided for life to avoid digestive problems.

What is done before laparoscopic cholecystectomy surgery?

First of all, a good history should be taken and a general physical examination should be performed. Then, the family (mother and father) should be well informed about the process, i.e. before, during and after the operation. If the child is older, the child is also included. A number of tests are performed, these tests are not general but are determined according to the patient. The patient is also seen by the anesthesiologist and the family and child are informed about the anesthesia process. The patient is fasted for 4 hours before surgery.

What is the Recovery Process After Laparoscopic Cholecystectomy?

4-6 hours after surgery, the patient is fed according to the doctor and/or nurse's instructions. The patient may need to be hospitalized for 1-2 days. After the surgery, the patient takes only painkillers and antibiotics in line with the doctor's recommendations. The patient is seen by the doctor after 48-72 hours, during which time there is no need for dressing, the stitches dissolve spontaneously and do not need to be removed. The patient continues his/her normal active life after the operation in accordance with the doctor's recommendations.

*** The information provided here, the content of the website is organized for the purpose of informing the visitor, especially the families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her knowledge.