The reported incidence of gallstones and bile sludge in children is 1.9% and 1.46%, respectively [1]. In symptomatic patients, a cholecystectomy is performed. Ursodeoxy-cholic acid (UDCA) treatment dissolves gallstones in 19–37% of pediatric cases [2]. There is no consensus on the most appropriate medical or surgical treatment of pediatric gallstones.

This study investigated the demographic characteristics and symptoms of children with gallstones, underlying etiology, UDCA treatment response and cholecystectomy rates in two hospitals in Turkey.

Data were collected on demographic characteristics, personal and family histories, underlying disease that might lead to stones, symptoms and laboratory findings. All the patients received UDCA treatment at a dose of 20 mg/kg per day at admission. The UDCA treatment was stopped in case of no treatment response after six months and in cases of failure to achieve complete dissolution by one year [4]. Treatment was continued in cases where gallstones were partially dissolved after six months [4]. A treatment response was considered complete dissolution of gallstones, as determined by USG. The patients underwent USG and laboratory examinations every three months. Ethical approval for the study was obtained from the ethics committee.

Chi square test, Student’s t test and Mann–Whitney U tests were conducted for comparisons of variables using SPSS 19.0. Statistical significance was set at 0.05 in all tests.

There were 74 children (33 males, aged 2 mo-17 y) with mean (SD) age of 7.5 (4.3) y. Clinical findings on admission included abdominal pain (38, 51.4%), nausea (25, 33.8%), vomiting (21, 28.4%), lack of appetite (15, 20.3%), cholestasis (3, 4.1%), and acholic stool (1, 1.4%). Dehydration, acute pancreatitis and elevated transaminase levels were observed in 4 (5.4%), 2 (2.7%) and 10 (13.5%) cases, respectively. Asymptomatic gallstones were present in 29 (32.2%).

Risk factors and underlying diseases are shown in Table I. The mean (SD) follow-up duration was 17 (17.1) months, and duration of UDCA treatment was 9.7 (7.2) months (2–24 months). Gallstones disappeared within six months after treatment in 22 (29.7%) cases, and in 7 more by the end of 1.5 years. No change was observed in 45 (60.8%) cases. The average time to the resolution of gallstones was 4.9 (3.3) months. Adverse reactions (vomiting and abdominal pain) occurred in only one patient (1.4%).

TABLE I 	Risk Factors in Turkish Children With Gallstones (N=74)

A cholecystectomy was performed in 21 (28.4%) cases, mostly laparoscopically, except for patients with choledochal cysts. Thirteen of the patients were asymptomatic. Of these, eight patients had a >1 cm gallstone, and five had multiple stones. Details of response to treatment are shown in Table II.

TABLE II Treatment Response in Turkish Children with Cholelithiasis (N=74) 

Hematological diseases are reported to be the most frequent risk factor for gallstones, with a reported incidence of 8.9-50% [5,6]. In this study, a cholecystectomy was performed in 21 (28.4%) cases, most of whom were asymptomatic and had gallstones larger than 1 cm. These findings are similar to that in the literature [7].

Some previous studies reported that UDCA had no effect on gallstones, whereas others reported that it had some effect [8]. Bogue, et al. [9] reported that an asymptomatic child could be treated safely without surgical interventions. Interestingly, in the present study, the gallstones were resolved in 20% of patients with larger stones (>1 cm). Although no stone analysis was conducted, these were most likely cholesterol stones, as these are the most common stones found in children without haematological diseases [10]. The lack of treatment response among the children with hemolytic diseases shows that black pigment stones are resistant to UDCA treatment.

There is no consensus on the indications for a cholecystectomy in asymptomatic pediatric patients [11]. A previous study reported longer operative times and post-operative stays, in addition to higher morbidity rates, among symptomatic patients who underwent a cholecystectomy than among asymptomatic patients [12]. Thus, as reported earlier, pediatric patients with gallstones who fail to respond to medical treatment should undergo a cholecystectomy, performed laparoscopically [13].

The present study has limitations common to retrospective studies. A controlled prospective study with larger numbers of patients is needed to provide additional evidence on the use of UDCA treatment for gallstones in children.

In conclusion, whether medical or surgical treatment should be recommended for gallstones remains a matter of debate, especially in pediatric patients. UDCA can be recommended before surgery, especially in asymptomatic patients without hemolytic diseases.

Contributors: All authors have contributed, designed and approved the study.

Funding: None. Competing interest: None stated.