Gallbladder contraction in familial dysautonomia

The impaired function of the autonomic nervous system in patients with familial dysautonomia (FD) is frequently associated with gastrointestinal dysfunction. This study sought to determine whether gallbladder contraction is also affected in these patients. Nine consecutive patients with FD were assessed by real-time ultrasonography for gallbladder volume and calculated percentage of gallbladder contraction before and 45-60 min after a 50 g fatty meal, and compared with nine healthy control patients, matched for age and gender. Gallbladder volume before the fatty meal was found to be larger in healthy controls than in FD patients (25.4 ± 9.5 and 15.4 ± 7.4 ml³, respectively; p = 0.024). No significant difference was demonstrated between the groups after the fatty meal (controls: 12.1 ± 6.0; FD: 9.0 ± 6.6 ml, respectively) and the calculated percentage of gallbladder contraction was similar in both groups (controls: 53.4 ± 16.6; FD: 44.8 ± 18.8%). These results indicate that gallbladder function in FD patients does not differ from the general population and preventive measures for gallstone formation are not required.     

Stimulation with fatty meal (Lipomul) to assess gallbladder emptying in children with chronic acalculous cholecystitis

OBJECTIVE: Chronic acalculous cholecystitis previously has been diagnosed by hepatobiliary scan stimulated with intravenous octapeptide of cholecystokinin. This compound may soon be unavailable in the United States. The goal of this study was to describe the characteristics of children with chronic acalculous cholecystitis diagnosed by hepatobiliary scintigraphy with oral Lipomul challenge, and to evaluate their clinical response to cholecystectomy. METHODS: Retrospective chart review of patients with no gall stones detected by abdominal ultrasound or computed tomography with gallbladder ejection fraction (GBEF) <35% after Lipomul challenge who subsequently underwent cholecystectomy. Fifteen patients with a mean age of 14.9 +/- 0.9 years were included. The mean duration of symptoms before evaluation was 8.2 +/- 2.5 months. RESULTS: The mean GBEF after Lipomul challenge was 16.7% +/- 2.7%. All patients had abdominal pain. Ninety percent had right upper quadrant pain and 86% had typical biliary colic. Pain was precipitated by fatty meals in 73.3%. Histopathologic analysis of the gallbladder demonstrated chronic cholecystitis in 80% of cases. The mean postoperative follow-up was 20 +/- 5 months. Six months after the surgery, nine patients (60%) were asymptomatic, five (33%) had marked improvement of symptoms, and one (6%) was unchanged. At the time of latest follow-up, symptoms had reappeared in two patients who had been asymptomatic at the 6-month visit (13%). Seven patients (46%) remained asymptomatic, five (33%) had marked improvement but continued to have some persistent symptoms, and one (6%) was unchanged. CONCLUSIONS: Chronic acalculous cholecystitis may be responsible for right upper quadrant pain in children without gallstones. A GBEF <35% at 30 minutes after Lipomul challenge may be useful in identifying patients who could benefit from cholecystectomy. Lipomul may be a good alternative to cholecystokinin for gallbladder stimulation during scintigraphy.     

Gallbladder hypocontractility in infantile colic

We evaluated gallbladder contractility in 58 colicky infants and 57 age-matched controls. Gallbladder size was measured before and 1 h after feeding and the contraction index of the gallbladder was calculated. The results showed decreased contractility of the gallbladder in colicky infants: mean contraction index in colicky infants was 56% (95% confidence interval, 49–63%) and in controls 67% (61–73%). No difference was found in the fasting size of the gallbladder. Postprandial contraction was decreased in colicky infants examined in the evening (n = 14) compared with those examined in the morning (n = 44). Decreased contraction of the gallbladder was found in those colicky infants who presented colicky cry compared with colicky infants without symptoms at the time of examination. No structural abnormalities were found in the general abdominal survey. In conclusion, infants with colic have hypocontractility of the gallbladder. This indicates abnormal biliary tract physiology in association with infantile colic.     

Gallbladder volume and contractility in term and preterm neonates: normal values and clinical applications in ultrasonography

The aim of this study was to establish the normal values and evaluate associated factors of gallbladder volume and contractility in term and preterm neonates by using ultrasonography. Sonographic measurement of gallbladder volume was performed by using the ellipsoid method in 50 preterm and 46 term infants. We collected data soon after delivery and at 6-h fasting, and at 3-h and 6-h fasting following regular milk feeding. Serial postprandial changes of gallbladder volume and contractility were collected at 15-min intervals for one hour. Gallbladder contraction index (C.I.) was determined as percentage decrement of postprandial size from initial size. Fasting gallbladder volume was larger in term group ( p < 0:05). Term neonates more readily showed significant contraction (C.I. > 50%; p < 0:05). In preterm infants significant contraction was clearly observed at postconceptional age > 31 weeks or body weight > 1300 g. The presence of hepatobiliary diseases might be detected by evaluating serial changes of gallbladder volume and contractility under ultrasonography in the neonatal stage.     

Value of sonography in prolonged neonatal jaundice. Findings in 13 cases]

BACKGROUND: Different conditions are associated with a prolonged cholestatic jaundice in the neonatal period: viral hepatitis, biliary atresia and choledocal cyst are the most frequent causes. Laboratory findings are necessary, although they do not permit an etiologic diagnosis in all cases. Serial ultrasonographic study could be proposed for the evaluation of biliary excretion before and after feeding, in order to differentiate between these three conditions. PATIENTS AND METHODS: Between February 1993 and January 1997, 13 newborns (seven girls and six boys) aged from 30 to 186 days, presented with jaundice and conjugated hyperbilirubinemia. They were evaluated by laboratory tests; serial ultrasonographic examinations were performed after 4 hours fasting then 1 and 2 hours after meal. RESULTS: The gallbladder (GB) was visualized in nine patients. In five of these patients, it contracted after feeding suggesting the diagnosis of neonatal hepatitis, that was confirmed by the clinical evolution. In three patients, the GB did not change in size and the diagnosis of biliary atresia was surgically proven. In one patient, a choledocal cyst was visualized and confirmed by surgery. The GB was not identified after 4 hours of fasting in four patients; biliary atresia was suspected and confirmed by surgery. CONCLUSION: Serial ultrasound of the GB is an easy and non-invasive method. It was useful in identifying those conditions requiring surgery in eight patients. We recommend its use as the initial method in the evaluation of neonatal jaundice before the other invasive methods.     

Left ventricular function in isolated rheumatic mitral stenosis in children

A total of 18 patients with pure rheumatic mitral stenosis between the ages of eight and 14 years (average 11.8 years) were studied. Left ventricular angiograms in the right anterior oblique view were obtained in each. Moderate to severe pulmonary arterial hypertension was present in all but one. The mean left ventricular end-systolic volume index was 25.4 +/- 8.5 ml/m2; it was increased in five patients. The mean left ventricular end-diastolic volume index was 64 +/- 13.5 ml/m2. It was normal in all except one patient, in whom it was increased to 91 ml/m2. The left ventricular stroke volume index, 39.6 +/- 8.8 ml/m2, was within the normal range. The left ventricular stroke volume index, 39.6 +/- 8.8 ml/m2, was within the normal range. The mean left ventricular ejection fraction was 0.61 +/- 0.09 ml, with a range of 0.44-0.72. The mean left ventricular ejection fraction was lower than normal (P less than 0.05). The ejection fraction was low in five of the 18 patients. Four of the five patients with an ejection fraction below 0.60 had severe pulmonary arterial hypertension. There was no correlation between the ejection fraction and left atrial pressure or the mitral valve area. Segmental contraction analysis in the five patients with a low ejection fraction showed global hypokinesia in four and segmental hypokinesia, involving predominantly the posterobasal segment, in one patient. Our study suggests that even children with pure mitral stenosis may have left ventricular dysfunction in the absence of active carditis.     

Real-time sonography for screening of gallbladder dysfunction in children with type 1 diabetes mellitus

The aim of this study was to evaluate the occurrence of gallbladder dysfunction in children with type 1 diabetes mellitus using real-time ultrasonography. The study population consisted of 20 diabetic children (11 male, 9 female; age 11.7+/-2.8 years; diabetes duration 0.5-7 years) with clinically negative neuropathy findings and 15 healthy controls (11 male, 4 female; age 10.5+/-3.7 years). Three-dimensional measurements of the gallbladder were made before and 15, 30, 45, 60 min after intake of diet chocolate. Gallbladder volumes were calculated by the ellipsoid formula. Fasting gallbladder volume of diabetic children (16.9+/-9.5 ml) was significantly greater than that of the controls (10.6+/-5.3 ml; p=0.017). Ejection fraction and maximal contraction showed no significant difference between the two groups. Diabetic patients with multiple microvascular complications had diminished gallbladder motility. There was a negative correlation between BMI and maximal contraction (p<0.05). Nerve conduction velocity was diminished in 45% of the diabetic patients. In conclusion, gallbladder function is preserved in pediatric type 1 diabetic patients with a disease duration less then 10 years, but dilated gallbladder at rest may be an early sign of gastrointestinal autonomic neuropathy and a risk factor for gallstone formation.     

Biliary dyskinesia in children

Biliary dyskinesia (BD) is a well-recognized cause of chronic abdominal pain in adults, but is less common in children. We reviewed our experience with the diagnosis, treatment, and follow-up in a group of children treated with cholecystectomy from March 1995 to October 2000. We identified children with chronic upper abdominal pain, normal ultrasonography (US), and delayed cholecystokinin (CCK)-stimulated gallbladder emptying (<35%). All other diagnostic tests for their abdominal pain were reviewed. Their treatment, surgical intervention, and outcome were recorded. During the study period, 74 cholecystectomies were performed in our institution, 10 (13.5%) of them for BD. The duration of symptoms ranged between 1 and 60 months (mean 22). All patients had a normal plain abdominal radiograph, normal US, and delayed gallbladder ejection fraction (EF). All were treated by elective laparoscopic cholecystectomy. Symptoms were completely relieved in all patients during the follow-up period, which ranged between 9 and 24 months (mean 12.8). Cholecystectom should be considered in children with chronic upper-abdominal pain and delayed EF on CCK-HIDA scintigraphy. Laparoscopic cholecystectomy is the procedure of choice in these patients.     

Biliary dyskinesia: is the problem with Oddi?

We report our experience of cholecystectomy for treating symptoms suggestive of biliary disease in association with a decreased gallbladder ejection fraction (GBEF) but without evidence of cholelithiasis. Five children with normal biliary ultrasounds were evaluated between January 1990 and December 2000 for recurrent upper abdominal pain. Based on a cholecystokinin (CCK)-provoked GBEF of less than 50% and the absence of any other gastrointestinal pathology, patients underwent cholecystectomy with operative cholangiography for presumed biliary dyskinesia. Pathological examination demonstrated chronic inflammation in all cases. Two patients had complete resolution of their symptoms, but three had persistent pain following surgery. Biliary dyskinesia seems an uncommon cause of persistent abdominal pain in childhood. Cholecystectomy was not always effective in relieving symptoms. Biliary scintigraphy with CCK provocation should not be used as the sole criterion for cholecystectomy. Sphincteric manometry may be valuable in the assessment of this small group of patients to avoid inappropriate intervention. The future perhaps lies in better understanding of the physiological action and pharmacological control of the sphincter of Oddi.     

A tubulopapillary adenoma of the gallbladder in a child of 3 years

Adenoma is the most frequent type of gallbladder (GB) neoplasm; however, GB neoplasms are unusual and unsuspected diagnoses in childhood. The average patient age is 50.5±16.3 years. We present a case of tubulopapillary adenoma of the gallbladder in a 3-year-old girl. She was admitted to the hospital with a 6-month history of abdominal pain and nausea and vomiting. Ultrasonography (USG) revealed an echogenic soft tissue lesion in the lumen of the GB. She underwent cholecystectomy. A tubulopapillary adenoma and adenomatous hyperplasia of the GB were diagnosed histologically. According to the literature, this is the youngest patient found to have gallbladder adenoma.     

Prospective study on changes in the donor gallbladder contraction function after left lateral lobe hepatectomy

This study aimed to evaluate the feasibility of donor gallbladder preservation in liver transplantation. Conventional removal of the donor gallbladder is applied in a majority of pediatric liver transplantation. A total of 42 donors who underwent gallbladder preservation in liver transplantation from October 2013 to December 2015 at the Beijing Friendship Hospital, China, were enrolled for the study. The changes in gallbladder volume and the gallbladder EF of donors before and after surgery were measured through ultrasound, and the changes in the donor gallbladder contraction function before and after surgery were evaluated to help verify the feasibility of gallbladder preservation in living donor left lateral lobe hepatectomy. The gallbladder emptying index dropped to 42.67% in 2 weeks after surgery and gradually increased with the length of recovery time, which could reach 69.14% in 3 months after surgery. At that time, 97.6% of the donors were considered to have recovered their gallbladder contraction function. The gallbladder contraction function at an early stage after gallbladder preservation in liver transplantation is not obviously improved, but it can recover to a normal level in 1 month after surgery, indicating that the gallbladder preservation in hepatectomy of living donor can effectively guarantee the gallbladder contraction function.     

Incidence of ceftriaxone-associated gallbladder pseudolithiasis

We prospectively evaluated the incidence of gallbladder pseudolithiasis in children treated with high doses of ceftriaxone for a variety of serious infections. We also monitored the time interval needed for this phenomenon to develop and resolve completely after initiation and cessation of treatment, respectively. Included in this study are 44 children treated with ceftriaxone 100 mg/kg/d divided into 2 equal intravenous doses and followed by serial abdominal sonography. Eleven children developed pseudolithiasis of gallbladder 2-9 d after initiation of ceftriaxone therapy. Six children (54.5%) developed this complication within the first 3 d. Lithiasis completely resolved 8-23 d after the end of treatment. In conclusion, pseudolithiasis of the gallbladder developed in 25% of sick children and completely resolved in all patients. Early development of this complication was not exceptional. It occurred in more than half of these children.     

Cholelithiasis in thalassemic children

A prospective, case-controlled study was performed in 49 thalassemic children with severe hemolysis using real-time ultrasonographic (US) examination of the gallbladder and biliary system to detect gallstones, Seven children showed the presence of gallstones; 3 had undergone splenectomy before this study. Gallstones were found in 3 patients while admitted for elective splenectomy. The 14.3% incidence of gallstones in this group was significantly higher than in the control group. The children with gallstones also had significantly higher mean serum bilirubin levels, but their mean hemoglobin levels and mean intervals of blood transfusion were not significantly different from those thalassemic children with severe hemolysis who did not have gallstones. The proportion of gallstones also increased with age. US examination of the biliary tract is a simple, noninvasive technique and is practicable in children. This study indicates the need to screen for gallstones in high-risk groups of thalassemic children. Early detection of gallstones leads to correct management and better outcome, especially in splenectomized patients, who are more susceptible to infection.Supported by a Rachadapisek Sompoj Research Fund, Faculty of Medicine, Chulalongkorn University Offprint requests to: S. Chittmittrapap     

Making the diagnosis of biliary atresia using the triangular cord sign and gallbladder length

Background. To evaluate the accuracy and utility of the triangular cord sign and gallbladder length in diagnosing biliary atresia by sonography.?Materials and methods. Sixty fasted infants with cholestatic jaundice aged 2–12 weeks were examined sonographically using a 5–10 MHz linear array transducer, focusing on the triangular cord sign (as described by Choi et al. [1]), the gallbladder, and ducts. The triangular cord is defined as a triangular or tubular echogenic density seen immediately cranial to the portal vein bifurcation; it represents the fibrotic remnant of the obliterated cord in biliary atresia. The findings were blinded to blood chemistry, ^{99 m}Tc-DISIDA hepatobiliary scintigraphy, and liver biopsy. Diagnosis of biliary atresia was confirmed at surgery and histology. Non-biliary atresia infants resolved medically. Comparative charges of the various investigations was made.?Results. Twelve infants had biliary atresia, and ten demonstrated a definite triangular cord. The two false-negatives had small or nonvisualized gallbladders. No false-positives were recorded. Gallbladder length ranged from 0–1.45 cm with a mean of 0.52 cm in biliary atresia compared to a mean of 2.39 cm in nonbiliary atresia infants. ^{99 m}Tc-DISIDA hepatobiliary scintigraphy showed no excretion (false-positive) in 23 % of nonbiliary atresia cases. Scintigraphy and liver biopsy charges were 2 and 6 times that of sonography, respectively.?Conclusion. The triangular cord sign and gallbladder length together are noninvasive, inexpensive, and very useful markers for biliary atresia. Received: 26 May 1999/Accepted: 28 July 1999     

Use of colonic manometry to differentiate causes of intractable constipation in children.

We evaluated colon manometry as a means of differentiating causes of intractable constipation in children. We studied pressure changes in the transverse, descending, and rectosigmoid colons of 23 children with intractable constipation. All patients had a history of less than one bowel movement per week for longer than 2 years without resolution after conventional medical management. The possibility of Hirschsprung disease was excluded in all. On the basis of pathologic and manometric studies of the upper gastrointestinal tract, 10 patients had a diagnosis of gastrointestinal neuropathy and two had a diagnosis of myopathy. The other 11 patients had functional fecal retention; this diagnosis was based on history and outcome of therapy. On the day of study we used endoscopy to place a manometry catheter into the transverse colon and recorded intraluminal pressure for longer than 4 hours. After obtaining a baseline recording, we gave the patient a meal to assess gastrocolonic response. Colonic contractions were recorded in 21 of 23 children. Children with functional fecal retention could be differentiated from those with neuropathy by examination of the postprandial record. After a meal children with functional fecal retention had (1) an increase in motility index (3.4 +/- 0.5 while fasting vs 9.1 +/- 1.3 postprandially; p less than 0.001), and (2) at least one high-amplitude propagated contraction (in 10 of 11 children). The patients with neuropathy had no high-amplitude propagated contractions (p less than 0.001 vs group with functional fecal retention) and motility index in these children did not increase significantly after a meal (2.7 +/- 1.0 while fasting vs 2.9 +/- 1.3 postprandially). The two children with hollow visceral myopathy had no contractions. We conclude that in children with severe chronic constipation the colonic results of manometry differentiate patients with functional fecal retention from those with neuropathy or myopathy of the colon.     

Gallbladder dyskinesia: a cause of chronic abdominal pain in children.

PURPOSE: Gallbladder dyskinesia (GD) is a well-established disorder in adults, but it is not clearly defined in the paediatric population. Therefore, the aim of this study was to review our experience in a group of children with chronic abdominal pain associated with impaired gallbladder emptying in the absence of cholelithiasis. METHODS: The records of sixteen patients who underwent cholecystectomy with the diagnosis of GD were evaluated retrospectively. Clinical presentation, symptoms, diagnostic studies, and the effect of cholecystectomy in alleviating abdominal complaints were investigated. RESULTS: All patients had symptoms of upper abdominal pain in the absence of other attributable causes associated with low gallbladder ejection fractions (GEF) < 35 %, during cholecystokinin-stimulated hepatobiliary scan (CCK-HBS), and free of gallstones on ultrasound (USG). Abdominal pain and nausea were the most common presenting symptoms. Mean GEF was 15.3 %. All patients underwent cholecystectomy. The histopathological diagnoses of all operated patients were consistent with chronic cholecystitis. Symptoms were completely relieved in all except two patients. CONCLUSION: GD should be considered in the differential diagnosis of recurrent abdominal pain in children. Patients with this condition present with biliary-type pain and investigations show no evidence of gallstones in the gallbladder. Performing a CCK-HBS establishes the diagnosis. Patients with an abnormal GEF (< 35 %) should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 80 % of patients. To avoid late diagnosis, CCK-HBS should be employed early in the evaluation of biliary colic with negative sonographic findings.     

Frequency of urinary tract infection in pediatric liver transplantation candidates

An increased frequency of infections has been reported in patients with chronic liver disease. The tendency of patients in this population to acquire UTI is not completely understood. We aimed at investigating the incidence of UTI in children with cirrhosis, before liver transplantation. Twenty-six children (9 girls, 17 boys; mean age, 7.66 +/- 5.73 yr) with chronic liver disease who had undergone liver transplantation between 2002 and 2004 were included. On admission for liver transplantation, patients were examined for presence of UTI. Serum biochemistry, complete blood cell count, urinalysis and culture, glomerular filtration rate, and abdominal ultrasonography were performed prior to liver transplantation. Ten of 26 patients (38.5%) were found to have symptomatic UTI. Urine cultures revealed E. coli in five (50%), Klebsiella pneumoniae in three (30%), Enterococcus faecalis in one (10%), and Enterobacter aeruginosa in one (10%) patient(s), respectively, as etiologic factors. The etiologies of chronic liver disease in our patients with UTI were BA in five, PFIC in three, Wilson's disease in one, and alpha-1 antitrypsin deficiency in one patient. We found a significantly greater number of UTIs in patients with biliary atresia than in those without biliary atresia (p < 0.05). The mean age of the patients with UTI was 2.75 +/- 3.49 yr, which was significantly lower than in those without UTI (9.75 +/- 4.86 yr, p < 0.05). Levels for white blood cells, thrombocytes, ALT, and alkaline phosphatase were significantly higher in patients with UTI than in those without UTI. There were no significant differences between the groups with regard to serum albumin, bilirubin, AST, GGT, BUN, or creatinine levels, glomerular filtration rate, duration of disease, and PELD scores. In patients with bacteriuria, renal USG revealed normal findings in all, but except one patient who had pelvicalyceal dilatation. Scintigraphic findings demonstrated acute pyelonephritis in six (60%) patients with UTI. VCUG demonstrated vesicoureteral reflux in two patients. In conclusion, symptomatic UTI is common in children with cirrhosis. It occurs more frequently in patients with biliary atresia than it does in patients with other types of chronic liver disease. In febrile children with chronic liver disease, UTI should be considered in the differential diagnosis.     

Myocardial performance index combining systolic and diastolic myocardial performance in doxorubicin-treated patients and its correlation to conventional echo/Doppler indices

This study was designed to evaluate the utility of myocardial performance index (MPI) in anthracycline cardiotoxicity. The MPI measures the ratio of total time spent in isovolumic activity (isovolumetric contraction time and isovolumetric relaxation time) to the ejection time, thus giving a global index combining systolic and diastolic myocardial performance. In this study, MPI was measured in 35 doxorubicin-treated children (aged 108.5+/-55.31 months, 23 males and 12 females) in sinus rhythm and 32 age-matched controls, and it was compared with conventional Doppler echocardiographic parameters. The isovolumetric contraction time was prolonged (38.37+/-24.43 vs 26.37+/-15.53, p <0.02) and ejection time was shortened (231.91 +/- 28.87 vs 256.21+/-19.55, p<0.001) in doxorubicin-treated patients compared to that in normal children. The isovolumetric relaxation time did not show significant difference between patients and control group (60.11+/-10.92 vs 61.06+/-12.12, p>0.05). MPI was significantly increased in doxorubicin-treated patients compared with that in control groups (0.42+/-0.07 vs 0.34+/-0.06, p<0.001), and significant correlation was observed between MPI and fractional shortening, ejection fraction, and left ventricular end diastolic and end systolic diameters (respectively, r = -0.508, p <0.002; r = -0.532, p<0.001; r = 0.467 p<0.005; r=0.606, p<0.001). Also, a weak correlation was found between MPI and duration of the disease and patient ages (r = 0.393, p < 0.02; r = 0.379; p < 0.02). However, there was no correlation between MPI and cumulative doxorubicin dose (r = 0.311, p > 0.05) and diastolic Doppler parameters in doxorubicin-treated patients. We think that MPI may be a useful parameter in monitoring left ventricular dysfunction in anthracyline-treated patients.     

Biliary dyskinesia: a potentially unrecognized cause of abdominal pain in children

Biliary dyskinesia is defined as symptomatic biliary colic without cholelithiasis, and is diagnosed during cholescintigraphy by assessing gallbladder emptying with cholecystokinin (CCK) stimulation. Unfortunately, gallbladder emptying is not routinely assessed during cholescintigraphy in pediatric patients. The purpose of this review is to assess the effectiveness of cholecystectomy in patients with chronic abdominal pain and delayed gallbladder emptying and to assess whether these findings correlate with the histologic evidence of chronic cholecystitis. We retrospectively reviewed the medical records of all patients (n=16) at our institution from October 1997 to August 2001 who underwent quantitative cholescintigraphy with CCK stimulation that demonstrated delayed gallbladder emptying (<35% at 60 min) and who subsequently underwent cholecystectomy. Laparoscopic cholecystectomy was performed in 16 patients with chronic abdominal pain. All 16 patients had delayed gallbladder emptying (mean ejection fraction: 15±8%, range: 3–32%). The mean age was 12±2 years (range: 8–17 years). Presenting symptoms included abdominal pain (86%), fatty food intolerance (27%), emesis (13%), and diarrhea (13%). Mean duration of abdominal pain before operation was 11±19 months (range: 2 weeks–6 years). One patients symptoms persisted postoperatively, but abdominal pain resolved in all other patients. Histologic evidence of chronic cholecystitis was demonstrated in 86% of surgical specimens. Five patients underwent concurrent appendectomy, and all had normal appendiceal histology. Our experience suggests that children with chronic abdominal pain and delayed gallbladder emptying on CCK-stimulated cholescintigraphy are likely to benefit from cholecystectomy and to have histologic evidence of chronic cholecystitis.     

Hepatobiliary scintigraphy and the string test in the evaluation of neonatal cholestasis

We evaluated [99mTc]diisopropylphenyl-carbamoylmethylimidodiacetic acid ([99mTc]DISIDA) cholescintigraphy with measurement of duodenal fluid radioactivity collected by the string test in patients with neonatal cholestasis. Twenty-six infants with prolonged jaundice and acholic stools were studied prospectively. Twelve patients had neonatal hepatitis, 12 biliary atresia, and one each Alagille syndrome and alpha 1-antitrypsin deficiency liver disease. All infants except the biliary atresia patients and four of the neonatal hepatitis patients revealed bowel activity on scan 6 h after tracer administration. At 24 h, three of these latter patients with neonatal hepatitis and two of the patients with biliary atresia revealed bowel activity. String radioactive counts for neonatal hepatitis ranged from 99,574 to 967,205 cpm (374,504 +/- 232,210 cpm; mean +/- SD) and for biliary atresia from 8,342 to 370,346 cpm (117,149 +/- 98,698 cpm; mean +/- SD). While neither test alone was capable of correctly differentiating among all patients, those patients with biliary atresia had either a negative hepatobiliary scan at 24 h or string radioactive count below 197,007 cpm. Disparity between the hepatobiliary scan and the string radioactive counts mandates further diagnostic investigation. These data suggest that simultaneous administration of the string test with hepatobiliary scintigraphy is advantageous in the evaluation of infants with cholestatic jaundice.