Pediatric cholelithiasis, once considered extremely rare, is now being increasingly recognized. Epidemiological studies suggest that the incidence of gallstones in children is between 0.13% and 0.3%.[1] Gallstones in infants are commonly pigment stones, often associated with hemolytic diseases, infections, total parenteral nutrition, and congenital biliary anomalies. Hemoglobin E trait, although usually benign, may result in intermittent hemolysis that predisposes to pigment stone formation. Early recognition and timely management are critical to avoid complications.[2]

Patient Profile:

• Age: 7-month-old male
• Birth History: Full-term normal vaginal delivery, uneventful antenatal period, birth weight 3.2 kg
• Neonatal History: Developed neonatal hyperbilirubinemia due to ABO incompatibility; managed with 24-hour phototherapy

Clinical Presentation:

• Recurrent, non-bilious, non-projectile vomiting containing food particles for one month
• Irritability and inconsolable crying post-feeding
• Previous similar episodes since 3 months of age, temporarily relieved with OTC medications

Examination Findings:

• General: Pale, mildly dehydrated, afebrile, anicteric
• Systemic: Normal vitals; abdomen soft, non-tender, non-distended; no hepatosplenomegaly or palpable mass; normal bowel sounds

Investigations:

• Hemoglobin: 8.5 g/dL (later improved to 10 g/dL)
• Hemoglobin Electrophoresis: Hb E trait (heterozygous)
• Abdominal Ultrasound: Distended gallbladder with normal wall thickness and a 0.4 cm hyperechoic lesion in the neck with posterior acoustic shadowing
• X-ray Abdomen, Chest X-ray, ECG: Within normal limits
• Liver function tests and other blood parameters: Normal

Management:

Initial (Conservative) Management:

• Kept nil per os (NPO)
• Intravenous fluids for hydration
• IV Cefotaxime and IV Ondansetron
• Symptoms improved by day 2; oral feeds resumed
• IV fluids stopped by day 3, antibiotics stopped by day 5
• Discharged on day 5 in stable condition

Follow-Up and Surgical Management:

• At 2 months follow-up: Repeat ultrasound confirmed persistent gallstone
• Hemoglobin improved to 10 g/dL
• At 11 months of age: Elective open cholecystectomy performed via right subcostal incision
• Intraoperative findings: Three pigmented gallstones (each ~0.5 × 0.5 cm)
• Drain removed on POD 3; oral liquids started on POD 2, solids on POD 3

• Discharged on POD 12 after suture removal in stable condition
• Follow-up: Child remained asymptomatic with no recurrence

TREATMENT-

• The baby was admitted and managed conservatively. Baby was kept NPO, started on maintenance IV fluids, IV cefotaxime and IV ondensatron. After 24 h of hospitalization, irritability reduced and gradually started feeding, IV fluid was tappered and stopped in 3 days. IV cefotaxime was discontinued on 5th day and discharged well after 5 days. The baby was regularly followed up in the OPD and repeat abdominal ultrasonography after 2 months was also suggestive of hyperechoic lesion with posterior acoustic shadow measuring approx 0.4cm in gall bladder neck. Repeat Hb was 10g/dl.
• Patient was taken up for elective cholecystectomy for symptomatic cholelithiasis at 11-month of age. Right subcostal incision was made and 3 pigmented stone of approximately 0.5x0.5cm was removed from gall bladder following which cholecystectomy was done. Abdomen was closed in layers after placing a right subcostal drain. Patient was shifted to postoperative ward. On post-operative day 2, he was allowed to take liquid diet and on day 3 solid diet was started. Drain was removed on post-operative day 3. Patient was discharged on post-operative day 12 after removal of stitches in stable condition. The patient was reviewed in the OPD after 1 week of discharge with no complaint.

Cholelithiasis in infants poses a diagnostic challenge due to nonspecific symptoms and low clinical suspicion. The increasing use of ultrasonography in pediatric evaluation has improved early detection. In this case, the presence of Hb E trait, a mild hemoglobinopathy, likely contributed to pigment gallstone formation due to low-grade hemolysis.[3]

Key Points:

• Risk Factors in Infants: Hemolytic disorders, prolonged fasting, TPN, infections, congenital anomalies
• Clinical Variability: Ranges from asymptomatic to colicky pain, vomiting, irritability, or complications like cholecystitis or pancreatitis
• Diagnosis: Ultrasonography is the modality of choice for detection; MRCP and HIDA scan may be needed in complicated or unclear cases

Management Guidelines:

• Asymptomatic stones: Often observed, especially in neonates
• Symptomatic stones: Require cholecystectomy, especially with hemolytic background
• Open approach preferred in small infants; laparoscopy may be considered in older children

This case underscores the need to maintain a high index of suspicion for cholelithiasis in infants presenting with persistent vomiting and irritability, especially with hemolytic disorders like Hb E trait. Timely diagnosis, appropriate conservative management, and elective cholecystectomy led to a complete recovery in this case. Pediatric surgeons and pediatricians must remain vigilant for atypical presentations of gallstones in infants.

1. Zdanowicz K, Daniluk J, Lebensztejn DM, Daniluk U. The etiology of cholelithiasis in children and adolescents—a literature review. International journal of molecular sciences. 2022 Nov 2;23(21):13376.
2. Gupta A. Decision Making Through Problem Based Learning in Hematology. 2024.
3. Karami H, Kianifar HR, Karami S. Cholelithiasis in children: a diagnostic and therapeutic approach. Journal of Pediatrics Review. 2017 Jan 10;5(1):45-50.