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RUQ Ultrasound Normal, Recommend Clinical Correlation

Sohail R. Shah, MD, MSHA, FACS, FAAP Texas Children’s Hosptial

Background •  Incidence of pediatric gallbladder disease continues to rise

U.S. Pediatric Data 1997: 5500 cholecystectomies 2013: 8500 cholecystectomies HCUPnet, 2013

TCH Data 1960 – 1980: 36 cholecystectomies 1980 – 1997: 128 cholecystectomies Jan 2005 – Oct 2008: 455 cholecystectomies Mehta et al, Pediatrics 2012

•  Increasing incidence correlates with change in most common etiologies and risk factors in children Mehta et al, Pediatrics 2012

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Common Scenarios

16-year-old male with recurrent postprandial RUQ and epigastric pain

•  Associated nausea •  Worse after high fat meals

Physical Exam: •  No abdominal tenderness

Diagnostic Studies to Order: RUQ ultrasound and labs

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1.  Presence of stones/sludge 2.  Gallbladder wall thickness 3.  Pericholecystic fluid 4.  Common bile duct diameter

Labs WBC: 10.5k Amylase: 68 Lipase: 19 Total bilirubin: 0.1

Alk phos: 97 AST: 14 ALT: 7

15-year-old female with 24 hours of worsening RUQ pain •  Associated nausea •  Prior postprandial pain episodes

Physical Exam: •  RUQ tenderness •  + Murphy’s sign

Diagnostic Studies to Order: RUQ ultrasound and labs

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1.  Presence of stones/sludge 2.  Gallbladder wall thickness 3.  Pericholecystic fluid 4.  Common bile duct diameter

Labs WBC: 16k Amylase: 68 Lipase: 19 Total bilirubin: 0.5

Alk phos: 103 AST: 60 ALT: 54

13-year-old female with 5 day history of intermittent RUQ and epigastric pain

•  Associated nausea, occasional vomiting •  Prior postprandial pain episodes

Physical Exam: •  Minimal epigastric tenderness

Diagnostic Studies to Order: RUQ ultrasound and labs

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1.  Presence of stones/sludge 2.  Gallbladder wall thickness 3.  Pericholecystic fluid 4.  Common bile duct diameter

Labs WBC: 9.7k Amylase: 74 Lipase: 36

Total bilirubin: 2.4 Alk phos: 145 AST: 58 ALT: 97

16-year-old female with 48 hour history of epigastric pain •  Associated nausea and vomiting •  Decreased appetite •  Prior postprandial pain episodes

Physical Exam: •  Significant epigastric tenderness

Diagnostic Studies to Order: RUQ ultrasound and labs

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1.  Presence of stones/sludge 2.  Gallbladder wall thickness 3.  Pericholecystic fluid 4.  Common bile duct diameter

Labs WBC: 24k Amylase: 1843 Lipase: 4128 Total bilirubin: 1.7

Alk phos: 176 AST: 167 ALT: 227

Now that we’ve covered the basics…

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14-year-old female with several week history of recurrent postprandial RUQ pain

•  Associated nausea •  Worse after high fat meals •  Lasts 1-2 hours after most meals

Physical Exam: •  No abdominal tenderness

Diagnostic Studies to Order: RUQ ultrasound and labs

1.  Presence of stones/sludge 2.  Gallbladder wall thickness 3.  Pericholecystic fluid 4.  Common bile duct diameter

Labs WBC: 6.5k Amylase: 34 Lipase: 23 Total bilirubin: 0.1

Alk phos: 73 AST: 24 ALT: 28

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Hydroxy Iminodiacetic (HIDA) Scan

Hydroxy Iminodiacetic (HIDA) Scan

Gallbladder Ejection Fraction: 17%

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What is the diagnosis?

Biliary Dyskinesia

What is your plan?

Refer for outpatient surgical evaluation

Biliary Dyskinesia •  Defined as a gallbladder ejection fraction <35%

•  Ejection fraction is determined by HIDA scan with cholecystokinin (CCK) analog infusion

•  Poor gallbladder contractility leads to bile stasis, microscopic bile crystallization, and mucosal irritation

•  Majority of gallbladder specimens after cholecystectomy demonstrate histopathologic evidence of chronic cholecystitis

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Biliary Dyskinesia Cont’d

•  Increasingly common diagnosis in children

•  TCH Review (1/2005 – 10/2008) – Third leading indication for cholecystectomy (16%) – 78% female – 51% overweight (30% severely obese) – Percent of cholecystectomies for biliary dyskinesia compared to

historical cohort (1980 – 1996): 16% vs 0%, p < 0.0001

Treatment Success for Biliary Dyskinesia

•  Meta-analysis in adults demonstrated that patients with RUQ pain, absence of gallstones, and low gallbladder EF on HIDA scan demonstrated that cholecystectomy was more effective (96%) than medical treatment (4%) in improvement of symptoms Mahid SS et al, Arch Surg 2009

•  Pediatric data is less clear (smaller studies) –  70 – 98% reported symptom relief with cholecystectomy

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Other Acalculous Conditions Gallbladder Hydrops:

•  Acute distention and edema of the wall of the gallbladder without evidence of gallstones or congenital anomalies

•  Most often associated with severe sepsis or shock •  Most resolve with conservative management

Gallbladder Polyps: •  Rare in children •  Current recommendations are to proceed with laparoscopic

cholecystectomy for symptomatic patients or for polyps ≥ 1 cm

Summary •  The incidence of gallbladder disease in children is rising

•  Initial diagnostic studies for suspected gallbladder disease should include a RUQ ultrasound and labs

•  The most common reasons for laparoscopic cholecystectomy are symptomatic cholelithiasis and complications from gallstone obstruction; however, biliary dyskinesia is increasingly more common

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Summary Cont’d •  A normal RUQ ultrasound and labs does not eliminate

gallbladder disease from the differential

•  A HIDA scan and clinical correlation are important in the diagnosis of biliary dyskinesia

•  Patient / family counseling are important in setting expectations for treatment success with laparoscopic cholecystectomy for biliary dyskinesia

Questions?

Sohail R. Shah, MD, MSHA, FACS, FAAP Division of Pediatric Surgery Office Phone: 832-822-3135 srshah2@texaschildrens.org