This is a 10-year old with an acute onset of sharp 
constant epigastric pain without radiation.  The pain is 
worse when lying down and when ambulating.  He is 
unable to jump.  He has had three loose stools without 
blood, mucus, or foul odor.  He has some nausea, but 
no vomiting, dysuria, fever, or cold symptoms.
     Exam:  VS T36.7 (TM), P80, R18, BP 134/84, 
oxygen saturation 100% in room air.  He is in moderate 
distress due to pain.  He does not appear to be toxic.  
Eyes normal.  Ears normal.  There is bilateral maxillary 
sinus tenderness.  Pharynx red with enlarged tonsils 
(no exudates).  Neck supple without adenopathy.  Heart 
regular without murmurs.  Lungs clear.  Abdomen flat, 
guarding, moderate non-localized tenderness and 
rebound.  A Murphy's sign cannot be reliably elicited.  
Bowel sounds are active.  No masses.  No hernias.  
Testes are normal.  No CVA tenderness.  Extremities 
with good pulses and perfusion.  Strength good.
     An abdominal series and laboratory studies are 
ordered.  He is given a dose of oral antacids.

View abdominal series [Supine view]



[Upright view]

     Laboratory studies:  CBC WBC 7,000 with 24% 
lymphs, 5% monos, and 71% segs.  Hgb 13, Hct 34, 
platelet count 329,000.  Amylase 66.  UA normal.
     The abdominal series shows some dilated bowel.  
The gas pattern is not distributed well.  Most of the gas 
is in the central abdomen.  The flat view shows a small 
opacification in the right upper quadrant.  There may be 
other small densities overlying the bowel gas inferiorly, 
but this is not certain.  The upright view shows a small 
opacification on the right but it is located lower than the 
opacity seen on the supine film.  Either this is a different 
lesion, or the opacification is mobile, and it moves 
inferiorly with gravity.
     Since this is not likely to be a vascular calcification in 
a 10-year old, the differential includes urolithiasis, 
cholelithiasis, or a high appendicolith.

View a close-up of the calcifications.

     Following the antacid and a period of observation, 
his abdominal pain subsides without other analgesics.  
He does not have CVA tenderness and there is no 
hematuria making urolithiasis unlikely.  His exam is now 
only positive for mild right upper quadrant tenderness 
without rebound.  His bowel sounds are active.  He can 
ambulate well and he tells the staff that he wants to go 
home.  He is given discharge instructions regarding 
abdominal pain.  He is instructed to see his physician in 
the morning.

     In a follow-up visit with his physician, he has 
continued to improve.  However, as a follow-up to 
identify the cause of the right upper quadrant 
opacifications, an abdominal ultrasound is performed.

View ultrasound.

     This ultrasound transducer is over the anterior 
abdomen in the right upper quadrant.  The liver is 
shown here.  The "S" is the spine.  The black arrow 
points to the gall bladder.  A stone is seen in the gall 
bladder in this view.  Note the echo "shadow" cast by 
the stone.  Other views reveal other stones in the gall 
bladder.  There are no stones in the common duct.

Discussion
     Gallstones in children are not felt to be common.  
However, many of them are asymptomatic.  While most 
gallstones in children are classically associated with 
hemolytic disease and hemoglobinopathies (hereditary 
spherocytosis, sickle cell anemia, thalassemia, etc.), an 
increasing incidence of cholesterol stones have been 
noted.  It is now felt that cholesterol stones are more 
common than pigment stones in children.  Cholecystitis 
and cholelithiasis are more common in childhood than is 
generally appreciated.  Other children at increased risk 
include premature infants on furosemide and children 
receiving parenteral nutrition.
     The usual clinical presentation of cholecystitis and 
cholelithiasis is often not present in children.  Most 
children present with non-specific abdominal pain.  Liver 
function studies may be normal.  Plain film abdominal 
radiographs may reveal calcifications, however, they 
are often normal.  Ultrasound is the easiest means of 
making a definitive diagnosis of cholelithiasis.  Acute 
cholecystitis may require a bile duct flow study such as 
a nuclear medicine excretion study.  Cholecystitis may 
sometimes occur without cholelithiasis (acalculous 
cholecystitis).
     Pediatric experience with newer therapeutic 
approaches such as lithotripsy and bile acid stone 
dissolution are lacking.  Treatment has been 
traditionally surgical, however, this may be evolving.  

References
     Holcomb GW.  Gallbladder Disease.  In:  Welch KJ, 
Randolph JG, Ravitch MM, etal (eds).  Pediatric 
Surgery, fourth edition.  Year Book Medical Publishers, 
Inc., Chicago, 1986, pp. 1060-1067.
     Karrer FM, Lilly JR, Hall RJ.  Biliary Tract Disorders 
and Portal Hypertension.  In:  Ashcraft 
KW, Holder TM.  Pediatric Surgery, second edition.  
W.B. Saunders Company, Philadelphia, 1993, pp. 
493-494.
     Swischuk LE.  The Abdomen.  In:  Swischuk LE.  
Emergency Imaging of the Acutely Ill or Injured Child, 
third edition.  Williams & Wilkins, Baltimore, 1994, pp. 
254-258.