Biliary Pseudolithiasis in Children: To Avoid Unnecessary Surgical Procedure / 소아외과

Gallbladder stones in children are not common without underlying hemolytic diseases or other risk factors like obesity. Ceftriaxone, a third generation cephalosporin, is known to make biliary precipitations that can be mistaken for biliary stones. We here report two children with biliary pseudolithiasis with different treatment modalities. One child was mistaken for symptomatic gallbladder stones and underwent elective laparoscopic cholecystectomy, while the other child, after thorough history taking on the ceftriaxone medication, was suspected of biliary pseudolithiasis and was treated conservatively. Both children had the history of usage of ceftriaxone in previous hospitals for infectious diseases. The ceftriaxone history of the first child was missed before the surgery. When gallbladder stones are found in children without any underlying diseases, specific history taking of the usage of ceftriaxone seems to be absolutely required. In this case, immediate interruption of the antibiotic could resolve the episode and avoid unnecessary surgical procedure.

Litiasis biliar asociada a ceftriaxona en pediatría: reporte de dos casos y revisión de la literatura / Biliary lithiasis due to ceftriaxone treatment in pediatric: report of two cases and literature review

Introducción: La ceftriaxona es una cefalosporina de tercera generación, bactericida, de amplio espectro de acción y de una vida media larga, por lo que es utilizada ampliamente en pediatría. Un efecto colateral poco conocido de este fármaco es la formación de precipitaciones biliares. Objetivo: Presentar 2 casos clínicos de pacientes de 9 y 14 años que cursaron con litiasis vesicular asintomática durante el tratamiento con ceftriaxona, y que tuvieron una resolución espontánea antes de 30 días. La revisión de la literatura muestra que la detección de precipitaciones biliares ocurre en un 14-47 por ciento de los pacientes tratados con ceftriaxona, los factores de riesgo de desarrollarlas es una mayor edad, tratamiento prolongado y dosis alta. Su resolución es espontánea y precoz. Conclusión: La formación de precipitaciones biliares si bien es frecuente, la mayoría de las veces es asintomática y de resolución espontánea, por lo que ceftriaxona sigue siendo un antibiótico seguro.

Introduction: Ceftriaxone is a third-generation cephalosporin, with a wide spectrum of action and a prolonged half-life time. These properties have contributed to its widespread use in pediatric patients.An infrequent collateral effect is the development of biliary pseudolithiasis. The aim is to present two cases of 9 and 14 years old, with asymptomatic gallstones during treatment with ceftriaxone, andresolved spontaneously before 30 days. Material and methods: Literature review shows that biliary pseudolithiasis occurs between 14 percent to 47 percent of patients treated with ceftriaxone. Risk factors are older age, long treatment, and high doses. Its resolution is early and spontaneous. Conclusion: Formation of biliary pseudolithiasis although frequent, most of the times is asymptomatic and resolves spontaneously, therefore ceftriaxone remains as safe antibiotic.

A Prospective Study on Ceftriaxone-associated Biliary Pseudolithiasis: A Dose-related Comparison

PURPOSE: Ceftriaxone, a parenteral third-generation cephalosporine, is widely used in the treatment of various bacterial infections. It possesses high calcium-binding affinity, forming complexes with calcium in bile salts to develop precipitate that mimics gallstone on ultrasonography. Biliary pseudolithiasis resolves completely with cessation of therapy, but several symptomatic patients have undergone cholesystectomy. We prospectively evaluated the incidence, risk factors and dose- related comparison with ultrasonography. METHODS: Between November 1998 and August 1999, 81 cases of inpatients on ceftriaxone treatment in Dongguk University Pohang Hospital were enrolled for this study. They were divided according to dose of ceftriaxone, high-dose and low-dose groups. Repeated sonography was performed on 1, 3, 5 and 7 days after initiation of ceftriaxone treatrnent and then weekly until pseudolithiasis were resolved. RESULTS: Thirty-eight percent of the subjects acquired pseudolithiasis. Sonographic abnormalities appeared from 1 to 10 days after ceftriaxone therapy and completely resolved from 1 to 24 days after cessation of ceftriaxone therapy. The incidence of pseudolithiasis was significantly higher in the high-dose group(P<0.001). In the high-dose group, fasting over a day was a significant risk factor of pseudolithiasis(P<0.01). Sex, age, duration of ceftriaxone therapy, laboratory findings, type of infection or chief complaint were not significant risk factors for pseudolithiasis. CONCLUSION: We suggest that abdominal ultrasonography should be considered in all children who receive high dose ceftriaxone with fasting over a day. If pseudolithiasis was developed, we can detect the most of resolution after 30 days of cessation of therapy.

Ceftriaxone Associated Biliary Pseudolithiasis / 대한소아소화기영양학회지

PURPOSE: Ceftriaxone, a potent parenteral third-generation semisynthetic cephalosporin is widely used for the treatment of a variety of bacterial infections in both children and adult. Review of recent data indicates that ceftriaxone treatment has been associated with the development of reversible biliary pseudolithiasis and that is thought by many to be a benign process. Despite, several reports describe patients with ceftriaxone pseudolithiasis who required cholecystectomy for presumed acute cholecystitis. In this study we evaluated the incidence, risk factors, and prognosis of gallbladder pseudolithiasis after ceftriaxone treatment. METHODS: Between march, 1997 and January, 1998, any child admitted to the Children's hospital of National University of Seoul and prescribed ceftriaxone for probable or definite bacterial infection were eligible for the study. 21 of them had ultrasound examination on the 2~12 days later after the start of ceftriaxone treatment, 8 of whom documented gallbladder precipitates or pseudolithiasis during treatment by serial abdominal ultrasound. Repeat abdominal ultrasound was performed 10~80 days later after the end of ceftriaxone treatment. The children with underlying liver disease or decreased renal function were excluded in this study. RESULTS: 1) 21 children had ultrasound examinations of gallbladder during ceftriaxone treatment and 8 (38%) of them acquired pseudolithiasis. 2) The patients who developed gallbladder pseudolithiasis were significantly older (6.3+/-2.9 yr. vs 2.2+/-3.1 yr.)(p<0.05), and older than 24 months were probably the significant risk associated with this phenomenon (p<0.05). However, no significant differences in sex, type of infection, fasting, and ceftriaxone treatment regimen (dose, duration of therapy). 3) The abnormality found on gallbladder ultrasonography was a strikingly hyperechogenic material with post-acoustic shadowing in 5 patients without post-acoustic shadowing in 3 patients 4) Follow up of gallbladder ultrasound was performed in 6 patients after cessation of ceftriaxone treatment. Sonographic abnormalities completely resolved within 14 days post cessation of therapy in 2 patients; 30 days, 1 patient; 80 days, 3 patients. CONCLUSIONS: We suggest that routine abdominal ultrasound should be considered in all children who received high dose ceftriaxone in more than 24 months of age and developed hepatobiliary symptoms during or just after ceftriaxone treatment.

A Case of Ceftriaxone-induced Pseudocholelithiasis

Ceftriaxone, a third-generation cephalosporin, is a very potent, broad spectrum antibiotic commonly used in patients with meningitis, osteomyelitis, pyelonephritis, Lyme disease and many other severe infectious diseases. Up to 46% of those receiving this antibiotic develop gallbladder sludge. Most of them are asymptomatic, but a small proportion may develop right upper quadrant pain, nausea, vomiting and even cholecystitis. We report a case of ceftriaxone-induced pseudocholelithiasis in a 5-year-old boy. We also emphasize the fact that surgical interventions such as cholecystectomy is not necessary, because the condition may resolve spontaneously after cessation of the drug.

A Case of Reversible Biliary Pseudolithiasis After Ceftriaxone Therapy

Ceftriaxone, a potent third-generation semisynthetic cephalosporine, is widely used for treatment various bacterial infections in children. There have been some reports that transient appearance of gallbladder sludge was often demonstrated by abdominal sonography in patients treated with ceftriaxone. Reversible biliary pseudolithiasis was used to describe this phenomenon. We present a case of biliary pseudolithiasis which appeared to be related to intravenous ceftriaxone therapy in children who received ceftriaxone to treat meningitis. The recommended ceftriaxone dose was 100mg/kg/day and a total duration of administrations was 21 days. Abdominal sonographic examination showed nothing prior to antibiotic therapy, however, multiple tiny hyperechogenic materials were observed in gallbladder on day 7 of treatment. This patient did not demonstrate any symptoms. Follow-up abdominal sonography examination revealed that gallbladder materials began to resolve spontaneously on third day of posttherapy and complete resolution was observed on day 13 after cessation of ceftriaxone therapy.