Cholecystitis in Overweight Mexican American Children

Myths and FactsFrancisco J Cervantes MD

Laredo Pediatrics & Neonatology PAAncestral Health Symposium, Atlanta GA.

August 2013

www.LaredoPediatrics.com

A Rational Approach During 2001 we recommended the SAD Diet

(Standard American Diabetes Association) low fat, high Carbs. It didn't work

August 2002: Modified Diet, basically: lower sugar intake, more protein and vegetables, diet drinks or water. Blood work and diet recommended at school to Overweight kids and close f/u

September 2003: Results of First 1000 classified patients

April 2004: Update to 3000 patients

Patient Distribution by Age and BMI

BMI scale for Adult Population

Screening

• CMP, GGT, Lipid profile, Liver Function Test: Alkaline phosphatase, ALT, AST, Bilirubin,

• HbA1c, Insulin, THS and T4• Biometric information; Weight, Height, BMI,

Waist and hip circumference and Percentage of body fat

• Blood pressure• Ultrasound of the liver if altered liver enzymes,

or complaining of RUQ pain or discomfort

Facts About Diabetes 80% in our children has at least 1 close relative

with diabetes10% has one of the parents with diabetes1% has both parents with diabetesMexican American have poor tolerance to

carbohydratesAs the intake of carbohydrates increases so are

the levels of insulin, visceral fat and acanthosis.

THE GOOD NEWS: IT IS REVERSIBLE!!

MAXIMUM DAILY TOLERANCE OF CARBOHYDRATESIN MEXICAN AMERICAN CHILDREN

50 – 100 GRAMS OF CARBOHYDRATES

3 Fruits (10X 3 = 30 grams) a banana accounts for 30 to 40 grams1 cup plain cereal = 30 grams2 to 3 glasses of 8 oz of regular milk = 30 grams ( Regular = 10; 2% 11; Skim 15 grams)

Criteria for screening for liver disease

• Persistent Overweight BMI 85 to 90 %tile

• BMI above 95 %tile

• Rapid Increase in BMI no matter where it starts • Family history of Lipid disorder, liver or gallbladder disease and Diabetes

• RUQ or epigastric discomfort

Local Experience•2555 patients, about equally divided, boys (1230, 48.1%) and girls (1325, 51.9%)•First generation American-born children of Hispanic descend.•Patients were followed because of changes in BMI then the discovery of the fatty liver and subsequently Gallbladder disease.• All patients have at least one metabolic screen.•BMI groups normal BMI 75, 85, 95,97 and ≥99

WWW.Laredopediatrics.com

Liver Enzymes and BMI in Boys

Liver Enzymes in Children with Normal BMI

Causes of GB disease in ChildrenHistory of cardiac or abdominal surgery

Prolonged parenteral nutrition Hemolytic disease

Hepatobiliary obstructive disease Obesity

Rapid decreases in weightSystemic InfectionAcute renal failure Prolonged fasting Low calorie diet

Certain medications Organ transplant

women—especially pregnant, use of hormone replacement therapy, or birth control pills (decrease gallbladder movement)people over age 60 (As people age, the body tends to secrete more cholesterol into bile)American Indians (Pima Indians of Arizona, 70% of women have gallstones by age 30)Mexican Americans overweight or obese ( Bile salts Cholesterol GB emptyingpeople who fast or lose a lot of weight quickly people with a family history of gallstones (possible genetic link)people with diabetes (high levels of fatty acids called triglycerides)people who take cholesterol-lowering drugs

Who is at risk for gallstones?

The Classic 4 F’s still apply: Female, Fertile, Forty, Fat

Signs and Symptoms

• Typical symptoms of RUQ pain, nausea, vomiting.• Tenderness to palpation or mass at RUQ• Leukocytosis and jaundice • The pain and tenderness are less localized in younger

children• Epigastric pain mimic RUQ pain• Epigastric pain or discomfort postprandial• Atypical presentation: Sleep apnea and sleep

disturbance

Fact about GB polypsResembling growth in the gall bladder wall

True polyps are abnormal accumulation of mucous membrane tissues that would normally be shed by the body

Main types of polypsCholesterol Polyp/Cholesterosis

Cholesterosis with fibrous dysplasiaAdenomyomatosis

Hyperplastic cholecystosis Adenocarcinoma

It affects 5% of adult, the causes uncertain, but there is a correlation between increase age, and presence of Gall stone.

The polyps are detected by abdominal ultrasound performed for another reason

Cholesterosis might contribute to the formation of the GB polyps

Figure 1.  Focal hepatic steatosis.

Prasad S R et al. Radiographics 2005;25:321-331

©2005 by Radiological Society of North America

Screening Criteria for Gallbladder Disease in Children

•Acute or persistent epigastric or non-specific abdominal pain, postprandial•Rapid decline in BMI•Family history of Gall bladder disease•persistently elevated GGT or Total Bilirrubin

Normal Findings of HB Scan

• Hepatocytes take up the radiopharmaceutical in minutes after injection

• Hepatic ducts seen in fifteen minutes• Gallbladder seen within 45 to 60 minutes• GB Ejection Fraction >40• Small intestine seen by 30 minutes

Liver Size in Children

Liver Size by BMI Groups

Hepatomegaly and Fatty Liver

NL

Fatty Liver

Ultrasound

Surgical Gallbladder Cases

• 404 in 4,000,000 in 4 years = 1 in 40,000 per year at Texas Children’s Houston (2005-2008) 73% women

• 11 in 2000 in 1 yr = 1 in 200 per year at Laredo Pediatrics (2010 -2011) 63% women

• 8 other reported at local pediatric meetings

Conclusion •Incidence of Gallbladder disease is on the rise on overweight children. •Gallbladder disease should be in the differential diagnosis of any pediatric patient who presents with localized pain in the epigastric, RUQ or ill-defined, Jaundice or dyspepsia and asymptomatic patients with BMI of ≥85•Consider Liver ultrasound as primary tool over more expensive and invasive procedures •HB Scan helps identify adequate GB function