| disease | Infection of the Biliary Tract in Children |
| alias | Cholangitis, Acute Cholecystitis |
Acute cholecystitis and cholangitis are relatively rare in children, with occasional cases complicated by cholelithiasis (even rarer in children). Among the 66 cases treated at Beijing Children's Hospital over 25 years, only one involved a 13-year-old girl with acute suppurative cholangitis accompanied by stones. In this group of cases, there were 49 males and 17 females.
bubble_chart Etiology
The main causes of acute cholecystitis and cholangitis are gallstone retention and bacterial infection. Gallstone retention is often caused by bile duct obstruction, with common obstructive factors including congenital or inflammatory strictures of the bile duct, anastomotic stricture and reflux after biliary-enteric anastomosis, and spasms of the choledochal sphincter caused by Chinese Taxillus Herb worms. Bacteria can invade the gallbladder and bile ducts through the blood, lymph, intestines, or adjacent organs. The primary bacteria causing inflammation are Escherichia coli, accounting for about 70%, while others include staphylococci, hemolytic streptococci, Proteus, etc., and mixed infections may also occur.
bubble_chart Pathological Changes
At the onset of acute cholecystitis or cholangitis, the mucous membrane becomes congested and edematous, subsequently affecting all layers of the gallbladder or bile duct wall, leading to thickening of the wall and the presence of fibrinous exudate on the surface. In severe cases of infection, the gallbladder wall may develop suppurative foci, resulting in suppurative cholecystitis or/and cholangitis. The younger the patient, the more rapidly the disease progresses. Due to concurrent spasms of the sphincter at the cystic duct or common bile duct orifice, the gallbladder or common bile duct may expand, leading to localized ischemia and necrosis, which can cause perforation and gall bladder-induced peritonitis. At this stage, the child may exhibit symptoms such as confusion and toxic shock.
bubble_chart Clinical ManifestationsThe onset is often abrupt, with most patients seeking medical attention within 1 day of onset. The main symptoms include abdominal pain, high fever with chills, and occasionally jaundice. The upper abdominal pain may present as persistent or intermittent dull pain, distending pain, or severe colicky pain. It is often accompanied by nausea and vomiting. High fever may lead to convulsions, or symptoms such as lethargy, delirium, and unconsciousness. Jaundice is mild and short-lived.
Physical examination reveals an acutely ill appearance, with body temperature persistently above 38.5°C, potentially reaching up to 41°C. There is marked tenderness and muscle rigidity in the right upper abdomen, and sometimes an enlarged gallbladder may be palpable. In some severe cases, the primary manifestation is toxic shock, and only after treatment do symptoms such as abdominal distension and fullness, generalized abdominal rigidity, and tenderness—signs of peritonitis—emerge.
Peripheral blood tests show an elevated white blood cell count, with possible neutrophilia, left shift, and toxic granulation.
Generally, the diagnosis is not difficult based on the history of upper abdominal pain and signs of tenderness in the right upper quadrant. For children presenting with toxic shock, the possibility of this condition should also be considered. A diagnosis can be made by combining symptoms, signs, and the rapid progression of the disease, along with symptoms such as lethargy, delirium, confusion, or unconsciousness. If there is peritoneal effusion, a peritoneal puncture can be performed. The presence of green effusion confirms the diagnosis of biliary peritonitis.
Acute cholecystitis can be treated with non-surgical therapy, including antispasmodics, analgesics, and anti-infection treatment. Broad-spectrum antibiotics such as ampicillin, gentamicin, cephalosporins, and metronidazole are commonly used antimicrobial agents. Since most patients cannot eat, intravenous fluids are also required to maintain nutrition and hydration.
1. Chinese medicine therapy primarily focuses on clearing and draining damp-heat and soothing the liver to regulate qi.
Example prescription: Bupleurum 3g, Skullcap Root 9g, Aucklandia Root 3g, Submature Bitter Orange 9g, Curcuma Root 9g, Dandelion 15g, Rhubarb Rhizoma 6g, Virgate Wormwood 15g, Gentian Root 6g. For severe abdominal pain, add Corydalis Tuber 9g and Chinaberry Fruit 9g.
2. Surgical therapy: Indications for surgery: ① After confirmed diagnosis of biliary peritonitis, early surgery should be pursued as soon as possible; ② High fever, toxic shock, with no significant improvement or worsening condition after short-term correction; ③ Complications such as liver abscess, pancreatitis, gallbladder necrosis, or perforation during treatment; ④ Bile duct stones. Scar stenosis that cannot be relieved without surgery. The principle of surgery is to relieve biliary obstruction and provide adequate drainage to reduce intra-biliary pressure. Preoperative preparation should be active, including blood transfusion, fluid replacement, intravenous antibiotics, and shock correction. If symptoms do not improve after 3–6 hours of active treatment, emergency surgery should be performed to avoid missing the rescue opportunity.
The surgical approach can be determined based on the child's general condition and local circumstances. For suppurative, perforated, or gangrenous cholecystitis, cholecystectomy is performed. If the lesion is confined to the gallbladder and the child's general condition is poor, cholecystostomy may also be performed. If accompanied by common bile duct inflammation or perforation, bile duct drainage is required, along with seasonal epidemic peritoneal drainage.
Generally, acute cholecystitis can subside and heal on its own with non-surgical treatment, but cases complicated by peritonitis require surgical intervention after active preparation. Among the 66 cases mentioned, 3 resulted in death, with the ages of the deceased being 2 months (1 case) and under 1 year (2 cases). All were children with advanced-stage gallstone-induced peritonitis.
Cholecystitis should be differentiated from pestilential hepatitis, which is characterized by liver enlargement, possibly normal white blood cell count, and impaired liver function. Acute cholecystitis and cholangitis complicated by peritonitis must be distinguished from other causes of peritonitis such as appendicitis, pancreatitis, and gastrointestinal perforation (e.g., intestinal perforation due to cold-damage disease). In addition to general medical history, signs, and X-ray examination, ultrasound can assess gallbladder size and wall thickening, while peritoneal puncture examination also aids in diagnosis.
