Cholelithiasis in Down's syndrome

The Etiology of Cholelithiasis in Children and Adolescents-A Literature Review

The incidence of gallstone disease has increased in recent years. The pathogenesis of cholelithiasis is not fully understood. The occurrence of the disease is influenced by both genetic and environmental factors. This article reviews the literature on cholelithiasis in children, with the exception of articles on hematological causes of cholelithiasis and cholelithiasis surgery. The aim of this review is to present the latest research on the pathogenesis of gallstone disease in children. The paper discusses the influence of all factors known so far, such as genetic predisposition, age, infections, medications used, parenteral nutrition, and comorbidities, on the development of gallstone disease. The course of cholelithiasis in the pediatric population is complex, ranging from asymptomatic to life-threatening. Understanding the course of the disease and predisposing factors can result in a faster diagnosis of the disease and administration of appropriate treatment.

Neonatal cholelithiasis in Down syndrome: Is hypothyroidism involved? A case-report

We report a 3-month-old male with Down syndrome (DS), prolonged jaundice and poor weight gain, that showed biliary lithiasis and undiagnosed congenital hypothyroidism (CH).CH should be considered in DS, especially in presence of gastrointestinal symptoms or malformations. Clinicians should be aware of the increased risk of gallstones in hypothyroid children with DS, even in neonatal age.

Cholelithiasis in children with CHD: is it a problem?

BACKGROUND

An association of heart disease and its treatment with biliary calculi is popularly accepted. We sought determine the prevalence and risk factors of paediatric gallstone disease in the presence of CHD and analyse the treatment options. We evaluated the role of open-heart surgery in the development of gallstones in patients with CHD. Patients and methods In a 10-year, retrospective, chart review (2005-2014), patients with CHD and cholelithiasis were identified and reviewed.

RESULTS

In all, 19 of 4729 children with CHD had cholelithiasis (0.4%); eight patients underwent cardiac surgery before diagnosis of cholelithiasis (group 1), whereas 11 of them had not (group 2). The prevalence was 0.3% in group 1 and 0.5% in group 2. In nine asymptomatic patients, gallstones were found incidentally. Children with cholecystolithiasis (n=17) received ursodeoxycholic acid. A resolution of gallstones was found in four cases; two patients underwent biliary surgery, and the others (15/17) were successfully managed non-operatively.

CONCLUSION

Despite an accumulation of risk factors, prevalence of gallstones is not as high as expected in children with CHD. Open-heart surgery with a heart-lung machine plays a minor role as an aetiological factor. In about half of the cases, cholelithiasis is an incidental finding and patients stay asymptomatic. Prophylactic administration of ursodeoxycholic acid is not indicated in children undergoing open-heart surgery for CHDs. Biliary surgery is reserved for patients with recurrent symptoms or cholestasis. In children with CHD, cholelithiasis is a minor and manageable co-morbid condition.

Prevalence, clinical investigation, and management of gallbladder disease in Rett syndrome

AIM

This study determined the prevalence of cholelithiasis and/or cholecystectomy in Rett syndrome, described gallbladder function in a clinical cohort, and identified recommendations for assessment and management of gallbladder disease.

METHOD

The incidence of cholelithiasis/cholecystectomy was estimated from data describing 270 and 681 individuals with a pathogenic MECP2 mutation in the Australian Rett Syndrome Database and the International Rett Syndrome Phenotype Database respectively. Gallbladder function in 25 females (mean age 16y 5mo, SD 20y 7mo, range 3y 5mo-47y 10mo) with Rett syndrome (RTT) was evaluated with clinical assessment and ultrasound of the gallbladder. The Delphi technique was used to develop assessment and treatment recommendations.

RESULTS

The incidence rate for cholelithiasis and/or cholecystectomy was 2.3 (95% confidence interval [CI] 1.1-4.2) and 1.8 (95% CI 1.0-3.0) per 1000 person-years in the Australian and International Databases respectively. The mean contractility index of the gallbladder for the clinical sample was 46.5% (SD 38.3%), smaller than for healthy individuals but similar to children with Down syndrome, despite no clinical symptoms. After excluding gastroesophageal reflux, gallbladder disease should be considered as a cause of abdominal pain in RTT and cholecystectomy recommended if symptomatic.

INTERPRETATION

Gallbladder disease is relatively common in RTT and should be considered in the differential diagnosis of abdominal pain in RTT.

Population-based study of incidence and clinical outcome of neonatal cholestasis in patients with Down syndrome

OBJECTIVE

To study the incidence and outcome of Down syndrome-associated neonatal cholestasis in a population-based cohort.

STUDY DESIGN

This retrospective study included all neonates diagnosed with Down syndrome born between January 2005 and September 2011 in the County of Stockholm, Sweden. Clinical and biochemical data related to cholestasis, early gastrointestinal (GI) involvement, congenital heart defects (CHD), and bone marrow disease were obtained from the computer-based hospital chart system.

RESULTS

A total of 206 newborns with Down syndrome were identified, for an incidence of 1 in 880 newborns. Prevalences of other diseases in these newborns included 47% for CHD, 11.2% for GI involvement, 3.9% for neonatal cholestasis, and 3.4% for bone marrow disease. Neonatal cholestasis was more common in the newborns with GI involvement (3 of 23 vs 5 of 183 of those without GI involvement; P = .047), CHD (8 of 96 vs 0 of 110 of those without CHD; P = .0019), and bone marrow disease (3 of 7 vs 5 of 199 of those without bone marrow disease; P = .0013). Cholestasis was severe in 3 patients (all of whom had bone marrow disease, with liver failure and early death in 2), and transient in 5 patients.

CONCLUSION

Neonatal cholestasis occurs in a significant percentage of patients with Down syndrome and is always associated with involvement of other organs. The outcome is variable, being most severe in newborns with the combination of neonatal cholestasis and bone marrow disease.

The prevalence and risk factors for gallstone disease

Gallstone disease is one of the most prevalent gastrointestinal disorders. In addition, the costs associated with the diagnosis and treatment of gallstone disease have been rapidly increasing. The etiology and pathogenesis of gallstone disease remains incompletely understood. Gallstone formation may result from a complex interaction of genetic and environmental factors. This article reviews the prevalence and risk factors associated with gallstone disease. Understanding the pathogenesis of gallstone disease could lead to the development of better therapeutic and preventive strategies for dealing with this disease.

Cholelithiasis and biliary sludge in Downs syndrome patients

CONTEXT AND OBJECTIVE

Although studies have demonstrated increased frequency of gallbladder abnormalities among Downs syndrome (DS) patients in some countries, there is only one paper on this subject in the Brazilian literature. The aim of this study was to demonstrate the prevalence, clinical characteristics and evolution of lithiasis and biliary sludge among DS patients in a maternity and childrens hospital in Rio de Janeiro.

DESIGN AND SETTING

This was a cross-sectional study followed by a retrospective cohort study on all individuals with an ultrasound diagnosis of gallbladder abnormalities.

METHODS

547 DS patients (53.2% male, 46.8% female) attending the Instituto Fernandes Figueira in 2001 underwent abdominal ultrasound examination at ages of between one day and three years (mean: five months). Clinical and ultrasound data were analyzed.

RESULTS

In 50 patients (9.1%), the ultrasound demonstrated gallbladder abnormalities (6.9% lithiasis and 2.1% biliary sludge). Spontaneous resolution was observed in 66.7% of the patients with biliary sludge and 28.9% with lithiasis. Cholecystectomy was carried out on 26.3% of the patients with gallstones.

CONCLUSION

The results from this study and comparison with the literature suggest that DS patients are at risk of developing lithiasis and biliary sludge and should be monitored throughout the neonatal period, even if there are no known risk factors for gallstone formation. Most frequently, these gallbladder abnormalities occur without symptoms and spontaneously resolve in most non-symptomatic patients. DS patients should be monitored with serial abdominal ultrasound, and cholecystectomy is indicated for symptomatic cases or when cholecystitis is present.

Aspects of digestive tract tumors in Down syndrome: a literature review

The purpose of this study was to describe the digestive neoplasms found in persons with Down syndrome. Due to intellectual disability, persons with Down syndrome do not convey their symptoms and pain, leading to delayed diagnosis and potentially worse outcome. It is thus important to know which organs are at risk for tumors and possible tumor risk factors. In a review of the literature, we found 13 benign tumors and 127 cancers in 1 fetus, 8 children, and 131 adults with Down syndrome. The review suggests a decreased incidence of digestive cancer, however, with a possible increased incidence of neoplasms of the pancreas and gallbladder. The distribution of cancers is distinct from that in the general population and that in persons with other intellectual disabilities who share the same life conditions, suggesting that constitutional protective factors exist. This review may allow a more specific, adapted medical follow-up for persons with Down syndrome and could help to elucidate the oncogenesis of digestive neoplasms.

Gallbladder motility in children with Down syndrome

OBJECTIVE

The aim of this study was to investigate gallbladder motility in children with Down syndrome by measuring gall-bladder volume and contraction index.

METHODS

This study, performed between January 2001 and December 2002 at the Ondokuz Mayis University, School of Medicine, Department of Paediatric Neurology, Samsun, Turkey, included 21 patients with Down syndrome (study group) and 22 healthy children (control group). After an 8-hour fast, gallbladder diameters in both groups were measured in length, width, and height by ultrasonography before and 30 minutes after a test meal. The volume of gallbladder before and after a test meal was determined, and the contraction index was calculated. Blood triglyceride and cholesterol levels were measured, and 5-hydroxyindoleacetic acid (5-HIAA) levels in urine were determined.

RESULTS

Mean gallbladder volume before test meal in the study group and controls was 8,412.4 +/- 5,174 mm and 16,516.8 +/- 6,796.1 mm (P < 0.001), respectively. The mean contraction index of the study group was 41.2% +/- 19.4% and of controls, 75.0% +/- 12.3% (P < 0.001). The mean triglyceride level of the study group was significantly higher than controls (P < 0.05). The mean urine 5-HIAA level of the study group was lower than controls (P < 0.05).

CONCLUSION

CI was lower in patients with Down syndrome, suggesting gallbladder hypomotility. Hypomotility may be a feature associated with the high prevalence of gallstones in Down syndrome.

Increased risk of symptomatic gallbladder disease in adults with Down syndrome

Previous reports have documented an increased prevalence of asymptomatic cholelithiasis among children with Down syndrome. Whether this predisposes adults with Down syndrome to symptomatic gallbladder disease has not been studied. A case control study compared the rate of symptomatic gallbladder disease in 28 index cases of adults with Down syndrome and that of sex-matched controls. The rate of gallbladder disease was 25% among the Down syndrome group, compared to 4.5% among the control group (P = 0.002). Patients with Down syndrome were also more likely to have a family medical history of gallbladder disease. Utilizing logistic regression analysis, the adjusted relative risk for gallbladder disease among individuals with Down syndrome was 3.52.

Gallstone composition: are children different?

During a 5-year period (1997-2002) 20 consecutive children (11 boys; median age, 8 years; range, 0.3-13.9 years) underwent cholecystectomy for cholelithiasis at a regional pediatric surgical center. Multiple stones were present in 16 patients (80%). All stones were collected prospectively. Composition studies were performed after grinding an aliquot of stone and examining a layer of crushed powder by Fourier transform infrared microspectroscopy. The relative proportions of each major stone component were assessed: cholesterol, protein and calcium salts of bilirubin, fatty acids, carbonate, and hydroxyapatite. Of the 20 children, 10 had black pigment stones, 2 had cholesterol stones, 1 had brown pigment stones, and 7 had calcium carbonate stones; the latter are exceptionally rare in adults. The composition of pediatric gallstones in this series differs from that found in adults.

Genetic background of cholesterol gallstone disease

Cholesterol gallstone formation is a multifactorial process involving a multitude of metabolic pathways. The primary pathogenic factor is hypersecretion of free cholesterol into bile. For people living in the Western Hemisphere, this is almost a normal condition, certainly in the elderly, which explains the very high incidence of gallstone disease. It is probably because the multifactorial background genes responsible for the high incidence have not yet been identified, despite the fact that genetic factors clearly play a role. Analysis of the many pathways involved in biliary cholesterol secretion reveals many potential candidates and considering the progress in unraveling the regulatory mechanisms of the responsible genes, identification of the primary gallstone genes will be successful in the near future.