Introduction
Biliary obstruction is defined as the blockage of the extrahepatic biliary system (1). The etiology of the benign or malignant extrahepatic biliary system blockage involves various reasons, including gall stones in the cystic duct causing pressure on the bile duct (Mirizzi syndrome), choledochal cysts, and choledocholithiasis. Benign blockage of the extrahepatic biliary system can be due to stricture diseases such as fibrotic strictures from gall stone passage, PSC, and iatrogenic strictures from bile duct cannulation. Neoplastic cases are presented with stricture diseases causing biliary obstruction, including pancreatic head cancer (causing distal CBD stricture), ampullary carcinoma or adenoma, and cholangiocarcinoma (2). The most common cause of biliary obstruction in developed countries is choledocholithiasis due to cholesterol stones. Pigmented stones due to hemolysis and infectious diseases, recurrent pyogenic cholangiohepatitis with increased risk for cholangiocarcinoma, and calculi in intrahepatic bile ducts are common etiologies in the Asian population which are rare in western countries. Recurrent pyogenic cholangiohepatitis is characterized by recurrent bacterial cholangitis, stricture, and dilatation of the biliary system. Gallbladder malignancy is more common in East Asia, Central and South America, Central and Eastern Europe, and the north of India (2, 3).
In general, choledocholithiasis is uncommon in children. Since the extrahepatic biliary obstruction in children is very rare, most reports describe the condition’s etiology in adult patients. The prevalence of cholelithiasis in pediatrics has been reported to be 0.13% - 0.3%. However, the incidence is higher in obese children and adolescents and is estimated at 2% - 6.1% (4).
More than 80% to 90% of all patients with CBD stones can be treated by non-surgical methods through sphincterotomy and stone extraction in combination with Dormia baskets or balloon catheters. In case of non-extractable stones >1 cm, additional procedures such as mechanical lithotripsy, including balloon dilatation, extracorporeal shock-wave lithotripsy, electrohydraulic probe lithotripsy, laser lithotripsy, stenting for immediate and definitive stone treatment are applied (4). Endoscopic retrograde cholangiopancreatography is a diagnostic and therapeutic technique routinely used for adults (5). Relative to the published studies regarding adult ERCP, the articles on pediatric ERCP remain limited for several reasons (6). Firstly, it is technically more challenging to be used for children. Secondly, pancreaticobiliary pathology in the pediatric population is rare, so the study cannot have an adequate sample size. Additionally, in children weighing more than 10 kg, pediatric ERCP duodenoscopes and accessories have limited application (8). Moreover, the advancement of MRCP has limited the use of ERCP for diagnosis.
This case report presents a CBD stone case with a left-sided gall bladder treated with ERCP in an otherwise healthy 5-year-old male.
Left-sided gallbladder refers to a gallbladder located on the left side of the ligamentum teres. It is a rare anomaly usually related to the absence of segment Ⅳ, portal vein anomalies, or biliary system anomalies. Diagnosis of the associated anomalies is essential for managing liver transplantation, liver resection, and complicated hepatolithiasis. Preoperative diagnosis of the left-sided gallbladder with associated anomalies is required to reduce the risks of operative complications (7).