Case report
A 5-year-old male was admitted to Namazi hospital (Shiraz, Iran), suffering from a persistent colicky abdominal pain for the last 30 days. Except for his premature birth, he had no history or family history of the following conditions; previous medical problems, taking any medications, past surgeries, abdominal trauma, weight loss, obesity, metabolic syndrome, hemolytic diseases, severe skin itching (Bayler disease), recurrent icterus, anemia, splenectomy, symptoms of chronic liver disease or liver dysfunction, liver disorders (e.g., Wilson’s disease), steatorrhea, chronic diarrhea, as well as any underlying causes of gallstone formation. The pain was localized in the epigastric and periumbilical areas exacerbating after consuming dairy and high-fat foods. The pain was accompanied by fever, vomiting, and constipation. The patient was born with GA = 28W and a weight of 900 g. His current body weight and height were 16 kg (10–25th percentile) and 112 cm (50–75th percentile), respectively. Vital signs were stable; blood pressure 100/70 mm Hg, heart rate 104 beats/min, respiratory rate 28 breaths/min, and body temperature of 36.5°C. He had hepatomegaly and abdominal tenderness in the epigastric and periumbilical areas in the physical examination.
The hemoglobin, white blood cell, and platelet counts were 12.9 g/dL, 3700/mm3, and 192×106/mm3, respectively. Hemoglobin electrophoresis was normal. Hemolysis was not noted. Blood chemistries were as following: cholesterol 98 mg/dL (reference range, 120–200 mg/dL), total protein 6 mg/dL (6.1–7.9 mg/dL), albumin 4 mg/dL (3.5–5.6 mg/dL), alkaline phosphatase 962 U/L , AST 104 U/L (15–40 U/L), ALT 180 U/L (5–45 U/L), GGT 160U/L (5–32 U/L), total bilirubin 1.7 mg/dL (<2.0 mg/dL), amylase 44 U/L (16–91 U/L), and lipase 90 mg/dL (4–29 mg/dL) (Table 1).
Abdominal ultrasound imaging revealed a distended gallbladder by diffuse wall thickening with a maximum thickness of 3.5 mm, a CBD 10.8 mm in diameter, and an 8.5-mm-sized stone in the distal CBD, suggestive of acute cholecystitis.
Non per oral diet, intravenous hydration, and administration of analgesics and antibiotics (cefotaxime and metronidazole) were started after the patients’ admission. The medical care team decided to perform MRCP and ERCP to evaluate and manage the CBD stone. In MRCP evaluation, mild dilation of central intrahepatic bile ducts and CBD (6 mm) was apparent, associated with a dark signal of a 5 mm stone within the pancreatic portion of CBD located at a 15 mm distance to the major papilla. The gall bladder’s position was on the left side of the subhepatic area, concurrent with portal vein abnormality. The main portal vein was trifurcated, and ascending portion (umbilical portion) of the left portal vein was hypoplastic. Additionally, small teres ligament differentiation of segment IV was suboptimal (Figure 1).
Since our center is well-equipped, ERCP was performed under general anesthesia. During the procedure, dilatation of CBD with a stone in the middle was investigated (Figure 2). After sphincterotomy, a 10*15 mm pigmented stone was removed using a stone retrieval balloon (Figure 3). After the stone removal, all signs and symptoms were alleviated. There were neither any complications during ERCP nor after discharge. The patient was discharged, and Ursodeoxycholic acid (10 mg/kg/dose) and Polyethyenglycol syrup (PEG) (1 cc/kg/day) were prescribed for 20 days. No complications, signs, or symptoms were observed in the follow-up visit, and all lab results and abdominal sonography were within the normal range. Finally, the patient was referred for elective cholecystectomy.
Table 1: Laboratory data during hospitalization