Gallbladder Disease in Children and Adolescents Richard J. Andrassy, MD, Lackland Air Force Base, Texas Terry A. Treadwell, MD, Temple, Texas Irving A. Ratner, MD, FACS, FACP, San Antonio, Texas Clifford J. Buckley, MD, Lackland Air Force Base, Texas
Gallbladder disease in children and adolescents is fortunately an uncommon cause of abdominal pain [l-4]. The relative incidence of this disease in persons twenty years old and younger, houtever, appears to be increasing. In 1924, Blalock [5] reviewed 883 cases of biliary tract disease at Johns Hopkins and found only eleven cases in patients younger than twenty years, an incidence of only 1.2 per cent. In 1954, Glenn and Hill [S] reviewed a twenty year experience with 3,222 cases of biliary tract disease and found only seven cases of gallbladder disease in children fifteen years of age or younger, an incidence of only 0.22 per cent. Interest in gallbladder disease in children was stimulated by the early work of Potter [4,7,8], and an increasing number of reports on this entity have been published in the past several years [9-121. From 1970 through 1974,1,803 primary cholecystectomies were performed for biliary disease at the Santa Rosa Medical Center. Of this-group, seventy-nine patients were twenty years old or younger, an incidence of 4.3 per cent. Thirteen patients were fifteen years old or younger, an incidence of 0.72 per cent. A review of this material is presented with special reference to duration of symptoms, etiology, and associated illness in this age group. Clinical Data and Results
There were sixty-nine females and ten males (12.6 per cent) in this group of seventy-nine patients twenty years or younger. Sixty patients (75.9 per cent) were MexicanAmericans, five were black, and fourteen were white. The average age of the males was 12.5 years (range, 2 to 20 years). The age of the females averaged 17.8 years (range, 3 months to 20 years). Forty-one patients (51.9 per cent) were markedly overweight at the time of admission. Thirty-eight of the sixty-nine females (55 per cent) were parous. Duration of symptoms attributable to biliary disease ranged from 12 hours to seven years. Thirteen patients
From the Department of Surgery, Santa Rosa Children’s Hospital, San Anto&o. Texas. Reprint requests should be addressed to Richard J. Andras~y. MD, Department of Surgery. Wilford Hall USAF Medical Center. Lackland Air Force Base. Texas 76236.
Valumo 132, July 1976
(16.5 per cent) had had symptoms far longer than twenty-four months. Sixty-eight patients presented with the chief complaint of epigastric pain or pain in the right upper quadrant. Intolerance to fatty food, nausea and vomiting, and bloating were other frequent symptoms. Intermittent jaundice was the presenting symptom in several patients. Physical examination revealed tenderness in the right upper quadrant in the majority of patients, but only rarely could a mass be palpated. All five black patients were found to have hemoglobinopathies. Four had sickle cell trait, and one had glucoseg-phosphate dehydrogenase deficiency. No hemolytic diseases were found in the remaining seventy-four patients. Oral cholecystography utilizing iopanoic acid (Telepaquea) was performed in sixty-nine patients. Stones were found in forty-one patients, nonvisualization on double doses occurred in twenty-six, and results, were normal in two. Pathologic features correlated well with findings on oral cholecystography. A preoperative intravenous cholangiogram was made in six patients and correlated with intraoperative findings in all six. Sixty-nine patients (87.3 per cent) were found to have stones at surgery. In the ten patients without stones, two were found to have cholesterosis, cultures revealed Salmonella typhosa in two, and two had subacute cholecystitis without stones. Perforation of the common duct at the junction of the cystic duct, a choledochal cyst, pancreatitis, and a positive culture for coagulase-negative staphylococcus were found in one patient each. In the twenty-one patients seventeen years of age or younger, there were fourteen females and seven males (33.3 per cent). The average age in this group was 11.6 years (males, 9.6 years; females, 12.6 years). The average duration of symptoms was 9.7 months. Sixteen of twenty-one patients (76 per cent) were found to have stones. Laboratory findings, including results of complete blood cell count, liver function tests, and serum amylase determinations, were not of particular aid in this series. Elevated bilirubin levels did not correlate with the presence of common duct stones or with the severity of findings. Management consisted of cholecystectomy with drainage in all cases, and the average hospital stay was 11.2 days. There were fifteen complications (18.8 per cent) and no mortality in this series. Complications included four urinary tract infections, two upper gastrointestinal bleeding episodes, two wound infections, one case of phlebitis, one subhepatic abscess, three instances of atelectasis and fever, and two cases of unexplained fever.
19
Andrassy et al
Comments
Although cholecystitis is generally considered a disease of the adult population, the incidence in children and adolescents appears to be increasing. This is substantiated by the incidence of 4.3 per cent during the past five years as presented in this series. This may represent several factors: (1) increased cognizance of this disease entity in the younger population; (2) increased availability of diagnostic aids; (3) influence of diet and obesity on the general population, with earlier occurrence of cholelithiasis and cholecystitis; and, perhaps, (4) the specific prevalence of this disease in the racial population under review, in which sixty of seventy-nine patients (75.9 per cent) were Mexican-Americans. It has been our clinical impression that there is a disproportionately high incidence of gallbladder disease in the Mexican-American population, and this was reflected in the incidence of 75.9 per cent in this study (Mexican-American persons comprise only 46.9 per cent of the population in Bexar County). The possibility that diet or other factors contribute to the lithogenic qualities of the bile in these patients warrants further study. Obesity and dietary habits are frequently suggested in association with cholelithiasis [5,8-201. We considered 51.9 per cent of our patients markedly overweight, and almost 90 per cent were above their ideal weight. The majority of our patients were females (87.4 per cent), and thirty-eight (55 per cent of the females) were parous. Estrogen (specifically, estriol) appears to exert a lithogenic effect on bile [13], hence the increased incidence of this disease in females. It is of interest that many of our patients presented with signs and symptoms of cholecystitis one to three months after their first pregnancy. This association, however, was reported as early as 1912 by Mayo [14,15]. It has been reported that the incidence of gallbladder disease in blacks is lower than that in other racial groups in this country [16]. There was no instance of cholelithiasis or cholecystitis in our black patients in the absence of a hemolytic disorder. Sickle cell trait was present in four patients, and glucose6-phosphate dehydrogenase deficiency in one. There were, however, no associated hemolytic disorders in the nonblack patients, and hence this study does not support the view that the most common cause of cholelithiasis in children is related to hemoglobinopathies [3,17]. Congenital anomalies of the biliary tree have been implicated as a frequent cause of cholecystitis in the younger age group [18,19]. Stenosis or splitting of the
20
distal cystic duct was the most common finding in the series of Forshall and Rickham [19]. Only two patients were found to have a specific anatomic abnormality in our series. One patient, three months of age, was found to have a small perforation of the common duct at the junction with the cystic duct. Early in the twentieth century typhoid fever apparently was associated with gallbladder disease in children, and Potter [S] had considered enteric infections such as typhoid to be a possible etiology of acalculous cholecystitis. Gravier, Dorman, and Vatteler 1201, Natar [IO], and others have reported scattered instances of Salmonella paratyphi and S typhosa as etiologic factors in their patients. Sears, Golden, and Horsley [9], however, believe that S typhosa infections are an uncommon cause of this disease today. In two of the patients in our series who presented with acute acalculous cholecystitis, bile cultures subsequently revealed typhosa. Cultures of bile from an additional patient in our series grew coagulase-negative staphylococcus after an attack of acalculous cholecystitis. .Bloom and Swain [21] suggested transient inflammation of the cystic duct associated with mesenteric lymphadenitis caused by the virus of infectious hepatitis as another possible etiology of acalculous cholecystitis. We did not document this in our series. Glenn and Hill [6] emphasized that many children with acute cholecystitis had acute systemic disease, such as hemolytic streptococcal septicemia, erysipelas, and typhoid. Perhaps, as previously suggested [5,11], the etiology of acute acalculous cholecystitis is not entirely bacterial, but the result of associated dehydration and stagnation of bile. This dehydration and stagnation may, however, predispose to infection. Very few bile cultures actually were obtained in our series, except in the patients with acalculous cholecystitis. We are now trying to obtain cultures of the bile in all instances regardless of etiology. There is a high correlation between organisms cultured from the bile obtained at surgery, and the organisms cultured from postoperative wound infections [22]. Appropriate antibiotic coverage may be instituted earlier in these instances. It appears that systemic illnesses and, in particular, typhosa may be etiologic factors in acalculous cholecystitis and should be considered in the child found to have cholecystitis without stones at laparotomy. Oral cholecystograms remain the best means of diagnosing gallbladder disease. Pathologic findings correlated well with such studies even when they were obtained during an acute attack in the presence of mildly abnormal liver enzyme levels. Of interest
The Am&can
Journal ol Surgery
Pediatric Gallbladder Disease
is the 100 per cent correlation between preoperative intravenous cholangiograms and operative findings in the six patients so studied. Further evaluation of this diagnostic modality seems justly warranted. Although elevated alkaline phosphatase levels were seen in a substantial number of patients, laboratory tests including liver function test results were rarely of particular value in assessing the operative findings. The disease presentation in our adolescent age group most frequently occurred in females, obese patients, and those with previous pregnancy. Although this is very similar to the disease presentation in the adult population, there continues to be considerable delay in diagnosis (7 years in one 20 year old patient). Most likely this delay has been related to the hesitancy of most practitioners to consider this entity in the adolescent population. In fact, despite a rather typical history and the presence of tenderness in the right upper quadrant, several of these patients underwent explorltion with the preoperative diagnosis of acute appendicitis. Kirtley and Holcomb [11] reported that 15 per cent of their patients underwent operation with the preoperative diagnosis of acute appendicitis. Gallbladder disease in infants and young children differs, however, from the disease in adolescents and adults. Many of the patients younger than ten years of age were found to have cholecystitis in the absence of cholelithiasis. It is in this younger age group that an extra effort must be made to obtain appropriate cultures and rule out associated congenital anomalies, Cholecystectomy proved to be a safe procedure in this age group with no mortality and only one complication requiring reoperation. Summary
Seventy-nine patients, twenty years old or younger, with cholecystitis underwent cholecystectomy during a five year period at Santa Rosa Medical Center. There was a considerable delay in diagnosis in many cases. Etiologic factors differed with race and age; however, the disease appears to be quite similar in adolescents and adults. Hemolytic disease was present in all five blacks but in none of the re-
Vokrme 132. July 1978
maining seventy-four patients. Patients younger than ten years of age are more likely to have congenital anomalies or infectious etiologies for the gallbladder disease. Cholecystectomy was associated with minimal morbidity and no mortality in this series. Cholecystitis should be considered early in the child or adolescent with unexplained abdominal pain, and oral cholecystograms proved to be a safe and reliable method of diagnosis. References 1. Swenson 0: Pediatric Surgery. New York, Appleton-CenturyCrofts, 1969, p 780. 2. Hawkins PE, Graham FB, Hallkfay P: Gallbladder disease in children. Am J Surg 111: 741. 1966. 3. Gross RC: The Surgery of Infancy and Chikfhood. Philadelphia, WB Saunders, 1953. 4. Mustard WT: Pediatric Surgery. Chicago, Year Book Medical, 1972, p 745. 5. Blalrxk A: A statistical study of eight hundred eighty-eight cases of biliary tract disease. Bull Johns Hopkins Hosp 35: 391, 1924. 6. Glenn F, Hill MR: Primary gallbladder disease in children. Ann Surg 139: 302, 1954. 7. Potter AH: Gallbladder disease in young subjects. Sung GyrrecoI Obstet 46: 795, 1926. 6. Potter AH: Biliary disease in young subjects. Surg Gynecol Obstet 66: 604, 1936. 9. Sears HF, Golden GT. Horsley S: Cholecystitis in childhood and adolescence. Arch Surg 106: 651, 1973. 10. Natar Gz Gallbladder disease in childhood. Aust Paediatr J 6: 147, 1972. 11. Kirtley JA, Holcomb GW: Surgical management of disease in the gallbladder and comon duct in children and adolescents. Am J Surg 111: 39,1966. 12. Crichlow RW, Seltzer Ml-l, Jannetta PJ: Cholecystitis in adolescents. Am J Dig Dis 17: 68, 1972. 13. Lynn J, Williams L, O’Brien JW, Hensburg J, Egdahl RH: Effects of estrogen upon bile. Implications with respect to gallstone formation. Ann Surg 178: 514, 1973. 14. Deaver JB, Ashhurst APC: Surgery of the Upper Abdomen. Philadelphia, P. Blakiston’s Son, 1914. 15. Mayo WJ: Collected Papers, 19 11. Philadelphia, P. Blakiston’s Son, 1911, p 141. 16. Pieretti R, Auldest AW, Stephens CA: Acute cholecystitis in children. Surg Gynecol O&t& 140: 16, 1975. 17. Seiler I: Gallbladder disease in’children. Am J Dis ChiM99: 662, 1960. 18. Walker CHM: Etiology of cholelithiasis in childhood. Arch Dis Child32: 161, 1955. 19. Forshall I, Rickham PO: Gallbladder disease in childhood. Br JSurg42: 161, 1955. 20. Gravier L, Dorman GW, Vatteler Tp: Gallbladder disease in infants and children. Surgery 63: 690, 1968. 21. Bloom RA, Swain VAJ: Noncalculous distention of the gallbladder in childhood. Arch Dis Child41: 503, 1966. 22. Chetlin SH, Elliott DW: Preoperative antibiotics in biliaty surgery. Arch Surg 107: 319, 1973.
21
Gallbladder disease in children and adolescents is fortunately an uncommon cause of abdominal pain [l-4]. The relative incidence of this disease in persons twenty years old and younger, houtever, appears to be increasing. In 1924, Blalock [5] reviewed 883 cases of biliary tract disease at Johns Hopkins and found only eleven cases in patients younger than twenty years, an incidence of only 1.2 per cent. In 1954, Glenn and Hill [S] reviewed a twenty year experience with 3,222 cases of biliary tract disease and found only seven cases of gallbladder disease in children fifteen years of age or younger, an incidence of only 0.22 per cent. Interest in gallbladder disease in children was stimulated by the early work of Potter [4,7,8], and an increasing number of reports on this entity have been published in the past several years [9-121. From 1970 through 1974,1,803 primary cholecystectomies were performed for biliary disease at the Santa Rosa Medical Center. Of this-group, seventy-nine patients were twenty years old or younger, an incidence of 4.3 per cent. Thirteen patients were fifteen years old or younger, an incidence of 0.72 per cent. A review of this material is presented with special reference to duration of symptoms, etiology, and associated illness in this age group. Clinical Data and Results
There were sixty-nine females and ten males (12.6 per cent) in this group of seventy-nine patients twenty years or younger. Sixty patients (75.9 per cent) were MexicanAmericans, five were black, and fourteen were white. The average age of the males was 12.5 years (range, 2 to 20 years). The age of the females averaged 17.8 years (range, 3 months to 20 years). Forty-one patients (51.9 per cent) were markedly overweight at the time of admission. Thirty-eight of the sixty-nine females (55 per cent) were parous. Duration of symptoms attributable to biliary disease ranged from 12 hours to seven years. Thirteen patients
From the Department of Surgery, Santa Rosa Children’s Hospital, San Anto&o. Texas. Reprint requests should be addressed to Richard J. Andras~y. MD, Department of Surgery. Wilford Hall USAF Medical Center. Lackland Air Force Base. Texas 76236.
Valumo 132, July 1976
(16.5 per cent) had had symptoms far longer than twenty-four months. Sixty-eight patients presented with the chief complaint of epigastric pain or pain in the right upper quadrant. Intolerance to fatty food, nausea and vomiting, and bloating were other frequent symptoms. Intermittent jaundice was the presenting symptom in several patients. Physical examination revealed tenderness in the right upper quadrant in the majority of patients, but only rarely could a mass be palpated. All five black patients were found to have hemoglobinopathies. Four had sickle cell trait, and one had glucoseg-phosphate dehydrogenase deficiency. No hemolytic diseases were found in the remaining seventy-four patients. Oral cholecystography utilizing iopanoic acid (Telepaquea) was performed in sixty-nine patients. Stones were found in forty-one patients, nonvisualization on double doses occurred in twenty-six, and results, were normal in two. Pathologic features correlated well with findings on oral cholecystography. A preoperative intravenous cholangiogram was made in six patients and correlated with intraoperative findings in all six. Sixty-nine patients (87.3 per cent) were found to have stones at surgery. In the ten patients without stones, two were found to have cholesterosis, cultures revealed Salmonella typhosa in two, and two had subacute cholecystitis without stones. Perforation of the common duct at the junction of the cystic duct, a choledochal cyst, pancreatitis, and a positive culture for coagulase-negative staphylococcus were found in one patient each. In the twenty-one patients seventeen years of age or younger, there were fourteen females and seven males (33.3 per cent). The average age in this group was 11.6 years (males, 9.6 years; females, 12.6 years). The average duration of symptoms was 9.7 months. Sixteen of twenty-one patients (76 per cent) were found to have stones. Laboratory findings, including results of complete blood cell count, liver function tests, and serum amylase determinations, were not of particular aid in this series. Elevated bilirubin levels did not correlate with the presence of common duct stones or with the severity of findings. Management consisted of cholecystectomy with drainage in all cases, and the average hospital stay was 11.2 days. There were fifteen complications (18.8 per cent) and no mortality in this series. Complications included four urinary tract infections, two upper gastrointestinal bleeding episodes, two wound infections, one case of phlebitis, one subhepatic abscess, three instances of atelectasis and fever, and two cases of unexplained fever.
19
Andrassy et al
Comments
Although cholecystitis is generally considered a disease of the adult population, the incidence in children and adolescents appears to be increasing. This is substantiated by the incidence of 4.3 per cent during the past five years as presented in this series. This may represent several factors: (1) increased cognizance of this disease entity in the younger population; (2) increased availability of diagnostic aids; (3) influence of diet and obesity on the general population, with earlier occurrence of cholelithiasis and cholecystitis; and, perhaps, (4) the specific prevalence of this disease in the racial population under review, in which sixty of seventy-nine patients (75.9 per cent) were Mexican-Americans. It has been our clinical impression that there is a disproportionately high incidence of gallbladder disease in the Mexican-American population, and this was reflected in the incidence of 75.9 per cent in this study (Mexican-American persons comprise only 46.9 per cent of the population in Bexar County). The possibility that diet or other factors contribute to the lithogenic qualities of the bile in these patients warrants further study. Obesity and dietary habits are frequently suggested in association with cholelithiasis [5,8-201. We considered 51.9 per cent of our patients markedly overweight, and almost 90 per cent were above their ideal weight. The majority of our patients were females (87.4 per cent), and thirty-eight (55 per cent of the females) were parous. Estrogen (specifically, estriol) appears to exert a lithogenic effect on bile [13], hence the increased incidence of this disease in females. It is of interest that many of our patients presented with signs and symptoms of cholecystitis one to three months after their first pregnancy. This association, however, was reported as early as 1912 by Mayo [14,15]. It has been reported that the incidence of gallbladder disease in blacks is lower than that in other racial groups in this country [16]. There was no instance of cholelithiasis or cholecystitis in our black patients in the absence of a hemolytic disorder. Sickle cell trait was present in four patients, and glucose6-phosphate dehydrogenase deficiency in one. There were, however, no associated hemolytic disorders in the nonblack patients, and hence this study does not support the view that the most common cause of cholelithiasis in children is related to hemoglobinopathies [3,17]. Congenital anomalies of the biliary tree have been implicated as a frequent cause of cholecystitis in the younger age group [18,19]. Stenosis or splitting of the
20
distal cystic duct was the most common finding in the series of Forshall and Rickham [19]. Only two patients were found to have a specific anatomic abnormality in our series. One patient, three months of age, was found to have a small perforation of the common duct at the junction with the cystic duct. Early in the twentieth century typhoid fever apparently was associated with gallbladder disease in children, and Potter [S] had considered enteric infections such as typhoid to be a possible etiology of acalculous cholecystitis. Gravier, Dorman, and Vatteler 1201, Natar [IO], and others have reported scattered instances of Salmonella paratyphi and S typhosa as etiologic factors in their patients. Sears, Golden, and Horsley [9], however, believe that S typhosa infections are an uncommon cause of this disease today. In two of the patients in our series who presented with acute acalculous cholecystitis, bile cultures subsequently revealed typhosa. Cultures of bile from an additional patient in our series grew coagulase-negative staphylococcus after an attack of acalculous cholecystitis. .Bloom and Swain [21] suggested transient inflammation of the cystic duct associated with mesenteric lymphadenitis caused by the virus of infectious hepatitis as another possible etiology of acalculous cholecystitis. We did not document this in our series. Glenn and Hill [6] emphasized that many children with acute cholecystitis had acute systemic disease, such as hemolytic streptococcal septicemia, erysipelas, and typhoid. Perhaps, as previously suggested [5,11], the etiology of acute acalculous cholecystitis is not entirely bacterial, but the result of associated dehydration and stagnation of bile. This dehydration and stagnation may, however, predispose to infection. Very few bile cultures actually were obtained in our series, except in the patients with acalculous cholecystitis. We are now trying to obtain cultures of the bile in all instances regardless of etiology. There is a high correlation between organisms cultured from the bile obtained at surgery, and the organisms cultured from postoperative wound infections [22]. Appropriate antibiotic coverage may be instituted earlier in these instances. It appears that systemic illnesses and, in particular, typhosa may be etiologic factors in acalculous cholecystitis and should be considered in the child found to have cholecystitis without stones at laparotomy. Oral cholecystograms remain the best means of diagnosing gallbladder disease. Pathologic findings correlated well with such studies even when they were obtained during an acute attack in the presence of mildly abnormal liver enzyme levels. Of interest
The Am&can
Journal ol Surgery
Pediatric Gallbladder Disease
is the 100 per cent correlation between preoperative intravenous cholangiograms and operative findings in the six patients so studied. Further evaluation of this diagnostic modality seems justly warranted. Although elevated alkaline phosphatase levels were seen in a substantial number of patients, laboratory tests including liver function test results were rarely of particular value in assessing the operative findings. The disease presentation in our adolescent age group most frequently occurred in females, obese patients, and those with previous pregnancy. Although this is very similar to the disease presentation in the adult population, there continues to be considerable delay in diagnosis (7 years in one 20 year old patient). Most likely this delay has been related to the hesitancy of most practitioners to consider this entity in the adolescent population. In fact, despite a rather typical history and the presence of tenderness in the right upper quadrant, several of these patients underwent explorltion with the preoperative diagnosis of acute appendicitis. Kirtley and Holcomb [11] reported that 15 per cent of their patients underwent operation with the preoperative diagnosis of acute appendicitis. Gallbladder disease in infants and young children differs, however, from the disease in adolescents and adults. Many of the patients younger than ten years of age were found to have cholecystitis in the absence of cholelithiasis. It is in this younger age group that an extra effort must be made to obtain appropriate cultures and rule out associated congenital anomalies, Cholecystectomy proved to be a safe procedure in this age group with no mortality and only one complication requiring reoperation. Summary
Seventy-nine patients, twenty years old or younger, with cholecystitis underwent cholecystectomy during a five year period at Santa Rosa Medical Center. There was a considerable delay in diagnosis in many cases. Etiologic factors differed with race and age; however, the disease appears to be quite similar in adolescents and adults. Hemolytic disease was present in all five blacks but in none of the re-
Vokrme 132. July 1978
maining seventy-four patients. Patients younger than ten years of age are more likely to have congenital anomalies or infectious etiologies for the gallbladder disease. Cholecystectomy was associated with minimal morbidity and no mortality in this series. Cholecystitis should be considered early in the child or adolescent with unexplained abdominal pain, and oral cholecystograms proved to be a safe and reliable method of diagnosis. References 1. Swenson 0: Pediatric Surgery. New York, Appleton-CenturyCrofts, 1969, p 780. 2. Hawkins PE, Graham FB, Hallkfay P: Gallbladder disease in children. Am J Surg 111: 741. 1966. 3. Gross RC: The Surgery of Infancy and Chikfhood. Philadelphia, WB Saunders, 1953. 4. Mustard WT: Pediatric Surgery. Chicago, Year Book Medical, 1972, p 745. 5. Blalrxk A: A statistical study of eight hundred eighty-eight cases of biliary tract disease. Bull Johns Hopkins Hosp 35: 391, 1924. 6. Glenn F, Hill MR: Primary gallbladder disease in children. Ann Surg 139: 302, 1954. 7. Potter AH: Gallbladder disease in young subjects. Sung GyrrecoI Obstet 46: 795, 1926. 6. Potter AH: Biliary disease in young subjects. Surg Gynecol Obstet 66: 604, 1936. 9. Sears HF, Golden GT. Horsley S: Cholecystitis in childhood and adolescence. Arch Surg 106: 651, 1973. 10. Natar Gz Gallbladder disease in childhood. Aust Paediatr J 6: 147, 1972. 11. Kirtley JA, Holcomb GW: Surgical management of disease in the gallbladder and comon duct in children and adolescents. Am J Surg 111: 39,1966. 12. Crichlow RW, Seltzer Ml-l, Jannetta PJ: Cholecystitis in adolescents. Am J Dig Dis 17: 68, 1972. 13. Lynn J, Williams L, O’Brien JW, Hensburg J, Egdahl RH: Effects of estrogen upon bile. Implications with respect to gallstone formation. Ann Surg 178: 514, 1973. 14. Deaver JB, Ashhurst APC: Surgery of the Upper Abdomen. Philadelphia, P. Blakiston’s Son, 1914. 15. Mayo WJ: Collected Papers, 19 11. Philadelphia, P. Blakiston’s Son, 1911, p 141. 16. Pieretti R, Auldest AW, Stephens CA: Acute cholecystitis in children. Surg Gynecol O&t& 140: 16, 1975. 17. Seiler I: Gallbladder disease in’children. Am J Dis ChiM99: 662, 1960. 18. Walker CHM: Etiology of cholelithiasis in childhood. Arch Dis Child32: 161, 1955. 19. Forshall I, Rickham PO: Gallbladder disease in childhood. Br JSurg42: 161, 1955. 20. Gravier L, Dorman GW, Vatteler Tp: Gallbladder disease in infants and children. Surgery 63: 690, 1968. 21. Bloom RA, Swain VAJ: Noncalculous distention of the gallbladder in childhood. Arch Dis Child41: 503, 1966. 22. Chetlin SH, Elliott DW: Preoperative antibiotics in biliaty surgery. Arch Surg 107: 319, 1973.
21
