A 4-year-old child with gallstones? Dr. Kremena Grozdeva in front of FACTS

Gallstone disease is an extremely rare condition in children. But what a challenge it is when it is diagnosed… Dr. Kremena Grozdeva in front of FACTS.

- Dr. Grozdeva, you are a pediatric gastroenterologist, and you recently had a rather interesting medical case with a 4-year-old girl. You found significant dilation of the bile ducts and what next?
- In a child with severe abdominal pain, increased liver tests, in the presence or absence of jaundice, an ultrasound of the abdominal organs is always performed in order to visualize the liver, gallbladder, bile ducts and spleen. In this particular clinical case, there were ultrasound data for dilation of the bile ducts, incl. the common bile duct, which flows into the duodenum. In order to visualize the biliary tree in more detail, we performed an additional MRI with contrast of the bile ducts, which proved that the cause of their dilation was stones in the common bile duct. We discussed the clinical case with Prof. Petko Karagyozov, Head of the Gastroenterology Clinic at ASK UMBAL Tokuda, and decided to proceed with endoscopic retrograde cholangiopancreatography. The procedure is routinely performed in adult patients, since the indications for them are much more numerous compared to the indications in childhood.

In Bulgaria, there is no pediatric gastroenterologist who can perform it, and in most places in the world, these procedures in children are performed by adult gastroenterologists.

The procedure is highly specialized and requires many years of experience and exceptional precision in its implementation. It is both diagnostic and therapeutic. During the procedure, papillotomy and removal of stones from the common bile duct were performed. In childhood, given the small diameter of the bile ducts, this procedure is an extremely professional challenge and carries a high risk of complications. Both I and the child's parents are extremely grateful to Prof. Petko Karagyozov, who performed it, because otherwise the child would have had to be referred for surgical treatment.

- Why is this condition extremely rare in children, especially at this early age?
- To make it easier to remember the risk factors for gallstone formation, the English literature uses the five F rule (5Frule), namely:
-- fair (more common in whites)
-- fat (in obese patients)
-- female (more common in women)
-- fertile (usually after 1-2 births)
-- forty (over 40 years of age)
In children, most of these risk factors are absent and therefore the condition is rarer. In recent years, with the increase in obesity among children, many teenagers have been diagnosed with gallstone disease.

- Gallstones in an adult are one thing, but what is the challenge in a child?
- Gallstones are often seen during an ultrasound examination of the abdominal organs for another reason. In most cases, the condition requires observation and conservative treatment. However, when obstruction (blockage) of the common bile duct occurs, it must be quickly diagnosed and intervened.

- How many similar cases with children have you had?
- In the last 10 years, we have had about 30 patients who required endoscopic retrograde cholangiopancreatography as a therapeutic procedure. We help these children thanks to the extremely good collaboration we have with Prof. Petko Karagyozov.

- What is the reason for the appearance of gallstones at such an early age?
- The causes of gallstone disease at all ages can be very different, such as family history, obesity, hemolytic anemia, genetic disorder in the ratio between the components in the composition of bile juice, the use of certain antibiotics, etc.

- What are the risks of performing such a procedure?
- Complications after endoscopic retrograde cholangiopancreatography can be serious and even life-threatening, such as pancreatitis (inflammation of the pancreas), cholangitis (inflammation of the bile ducts), bleeding, perforation of the common bile duct and biliary peritonitis, etc. The complication rate is lower when the procedure is performed by an experienced endoscopist and all recommendations for complication prevention are followed.
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Dr. Grozdeva graduated from MU-Sofia in 1996. She has had a specialty in “Pediatrics” since 2004. After graduation, she worked at the 3rd DCC in Sofia. Then she entered the Multi-profile Hospital for Active Treatment of Children's Diseases. In 2012, she acquired her second specialty “Pediatric Gastroenterology”. She has been part of the team of the pediatric clinic of the “Tokuda Hospital Sofia” since the opening of the hospital. She participated in the experience exchange program in the “Tokushukai” hospitals in Japan.