Biliary dyskinesia in children

Dyskinesia of the biliary tract in children - disorders of the gallbladder motility and sphincter apparatus of the biliary system, clinically manifested by pain syndrome, a complex of functional disorders lasting over 3 months, accompanied by abdominal pain localized in the right hypochondrium. This is the most common and early pathology of the biliary system in children.

The sphincter apparatus of the bile ducts includes:

• Lutkens' sphincter, located at the point where the cystic duct enters the neck of the gallbladder;
• sphincter of Mirizzi, located at the confluence of the cystic and common bile ducts;
• sphincter of Odney, located at the end of the common bile duct at the site of its entry into the duodenum.

Synonyms: Dysfunctional disorders of the biliary system, hypertonic dyskinesia of the sphincter of Oddi, spasm of the sphincter of Oddi.

ICD-10 code

K82.0. Dysfunctional disorders of the biliary system.

Epidemiology

Statistical data based on the principles of evidence-based medicine have not been collected to date. The incidence rates of biliary system dysfunction in children cited in domestic literature are based on clinical dysfunctions that cause frequent visits to a pediatrician and rank second among gastrointestinal diseases. The incidence of hypomotor dyskinesia of the gallbladder in children varies from 40 to 99%.

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Causes of biliary dyskinesia in children

Gallbladder dysfunctions often occur against the background of general neurosis, diencephalic vegetative crisis, viral hepatitis, other infections and intoxications. It is assumed that various anomalies in the development of the bile ducts are one of the main factors in biliary tract dysfunctions.

Many authors consider cholecystectomy as an important cause of sphincter of Oddi dysfunction. Removal of the gallbladder leads to disruption of bile deposition and regulation of sphincter of Oddi motility. Free, constant release of bile into the duodenum provokes the development of duodenitis, an increase in the frequency of duodenogastric reflux, and stimulates gastrointestinal motility. Dyskinesia of the duodenum, especially of the hypertensive type, often causes spastic contraction of the sphincter of Oddi, preventing normal bile outflow.

The bile ducts are often involved in the pathological process in primary lesions of the Vater's papilla and the sphincter of Oddi (for example, in stenosis of the major duodenal papilla). Stenosing duodenal papillitis can develop secondarily against the background of acute or exacerbated chronic pancreatitis, duodenal ulcer and other diseases.

The provoking factors of biliary dyskinesia are considered to be:

• dietary errors (especially the abuse of fried and fatty foods);
• intestinal parasitosis (especially giardiasis);
• a number of infections (acute hepatitis, salmonellosis, dysentery);
• food allergies;
• duodenitis, peptic ulcer, liver disease, intestinal disease, dysbacteriosis;
• inadequate level of physical and psycho-emotional stress.

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Pathogenesis of biliary dyskinesia in children

The motor activity of the gallbladder, sphincter of Oddi and other parts of the gastrointestinal tract are interconnected. Due to the coordination of the contractile activity of the gallbladder, the migrating motor complex and the sphincter of Oddi, the gallbladder fills between meals. The following participate in the regulation of the contractile activity of the sphincter of Oddi:

• viscero-visceral reflexes caused by the stretching of hollow organs during digestion and under the influence of food components;
• humoral factors (cholecystokinin, gastrin, secretin);
• neurotransmitters vasointestinal polypeptide and nitric oxide, which cause relaxation of smooth muscle cells of the bile ducts, as well as acetylcholine and tachykinins, which promote contraction of smooth muscle cells;
• γ-aminobutyric acid and somatostatin stimulate, and opioid peptides suppress, the release of relaxing mediators;
• Endogenous opiates, when binding to opioid receptors of myocytes, stimulate motor activity, and when binding to K-receptors, reduce it.

The pressure gradient between the duct system and the duodenum is regulated by the sphincter of Oddi. Episodes of increased tone ("locking activity") of the sphincter of Oddi are accompanied by passive expansion of the gallbladder, with no noticeable increase in pressure in the biliary tract. However, the gallbladder can act as a buffer reservoir only if its contractile function is preserved. Impaired coordination between the sphincter of Oddi and the gallbladder leads to increased pressure in the biliary system and the development of pain syndrome of varying intensity. Spasm of the sphincter of Oddi in combination with increased tone of the gallbladder leads to a sharp increase in pressure in the duct system, the development of acute abdominal pain. Spasm of the sphincter of Oddi in combination with atony of the gallbladder contributes to a slow increase in pressure, accompanied by a dull aching pain in the abdomen. Insufficiency of the sphincter of Oddi and hypotension of the gallbladder lead to spontaneous leakage of bile into the duodenum with the development of sphincteritis, etc. There are many variants of discoordination of the gallbladder and sphincter of Oddi, the pathogenesis of these disorders is complex and insufficiently studied.

What causes biliary dyskinesia?

Symptoms of biliary dyskinesia in children

The group of general symptoms of biliary dyskinesia includes fatigue, irritability, decreased performance in schoolchildren, tearfulness in preschoolers. Some children experience motor disinhibition, others - hypodynamia, sweating, palpitations and other symptoms are possible. A connection has been established between deterioration of health and psychosocial factors. Character traits significantly affect the condition of patients; children from this group are characterized by conscientiousness, punctuality, obligation, vulnerability, suspicion, high demands on personal hygiene, self-blame and isolation.

In case of dysfunctions of the biliary system caused by gastrointestinal diseases, the child is bothered by a feeling of heaviness in the epigastric region, nausea, vomiting, belching, bitterness in the mouth, changes in stool frequency and other disorders, the occurrence of which is associated with untimely release of bile into the duodenum, impaired digestion of fats, duodenogastric and gastroesophageal reflux, etc.

Functional disorders of the biliary tract in children are closely related to vegetative dysfunctions, as a result of which they manifest in preschool age, progress in the early school period, and at the age of over 10 years can be registered as a disease. The most stable symptom of biliary tract dysfunction is abdominal pain, which varies in origin, duration, periodicity, localization, intensity.

With hyperfunction of the gallbladder (hyperkinetic form), pains of a paroxysmal nature occur, stabbing, cutting, squeezing, accompanied by nausea, belching, vomiting. In the intervals between attacks, children do not present complaints.

With gallbladder hypofunction (hypotonic form), the pains acquire a constant pressing character, periodically increasing. A feeling of distension or heaviness in the right hypochondrium is characteristic. Kehr's, Ortner's, Boas's, etc. gallbladder symptoms are possible. Children complain of bitterness in the mouth, nausea, and sometimes vomiting occurs.

Hyperfunction of the sphincter of Oddi can lead to acute pain in the right hypochondrium, reminiscent in intensity of an attack of biliary colic, accompanied by nausea and vomiting, and yellowing of the sclera and skin is possible.

With sphincter of Oddi insufficiency, the child is bothered by early pain after eating fatty foods, combined with nausea and vomiting, belching and heartburn are possible.

None of the described symptoms are pathognomonic for dysfunctional disorders of the biliary tract, which makes it extremely difficult for an outpatient physician to establish a clinical diagnosis.

Symptoms of biliary dyskinesia

Classification

Rome III criteria (2006) in the section "Functional disorders of the gallbladder and sphincter of Oddi" include the following headings.

• E - functional disorders of the gallbladder and sphincter of Oddi.
• E1 - functional disorder of the gallbladder.
• E2 - functional biliary disorder of the sphincter of Oddi.
• FPD - functional pancreatic disorder of the sphincter of Oddi.

Compared with Rome II criteria, the changes are related to strict limitation of unnecessary invasive procedures and surgical interventions in patients with upper abdominal pain. Biliary and pancreatic pain should be defined by location, severity, time of onset, duration and association with typical symptoms of GERD, functional dyspepsia and irritable bowel syndrome.

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Screening

Ultrasound of the gallbladder with contractile function testing allows to establish the type of dysfunction. The state of the sphincter of Oddi is determined by hepatobiliary scintigraphy.

Diagnosis of biliary dyskinesia

When collecting anamnesis, the nature, frequency and localization of pain are specified. During objective examination, the color of the skin, size of the liver, color of stool and urine are assessed. It is extremely rare to detect point symptoms (Ortner, Kehr, etc.).

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Laboratory research

According to the results of a biochemical analysis of blood serum, the activity of enzymes that are markers of cholestasis (alkaline phosphatase, y-glutamyl transpeptidase) may be increased.

Instrumental research

Sphincter of Oddi manometry with separate cannulation of the biliary and pancreatic segments, considered the “gold standard” for diagnosing biliary tract dysfunctions, is not used in children due to its invasiveness, traumatic nature, and the possibility of complications.

The diameter of the bile duct can be measured by ultrasound. An increase in the diameter of the common bile duct after fatty food or the administration of cholecystokinin reflects a violation of the outflow of bile, which may indicate the presence of dysfunction of the biliary tract.

Hepatobiliary scintigraphy is considered the most acceptable for practical use in children, supplemented if necessary by pharmacological tests (neostigmine morphine, administration of the muscle relaxant nitroglycerin).

Scanning begins after oral administration of imidodiacetic acid preparations labeled with technetium (Tc). After 1 hour, the maximum activity of the drug is recorded in the bile ducts, gall bladder and duodenum, and the minimum in the liver. A close correlation has been proven between the results of cholescintigraphy and manometric examination of the sphincter of Oddi.

Differential diagnostics

Functional disorders of the biliary system are differentiated from acute abdomen, biliary colic attack, acute pancreatitis and cholecystitis. Hypotonic conditions and sphincter of Oddi insufficiency may be similar to chronic diseases of the stomach, duodenum, chronic pancreatitis.

Acute cholecystitis (acute cholecystocholangitis)is an acute inflammation of the gallbladder. It is rare in children, and occurs twice as often in boys as in girls. The most important predisposing condition is bile stagnation in the gallbladder, for example, in developmental anomalies.

Characteristics:

• sudden increase in body temperature to febrile;
• cramping pains in the right half, and sometimes throughout the entire abdomen. An attack of pain can last from several minutes to several hours. The pain intensifies when lying on the right side;
• nausea and vomiting;
• signs of intoxication: pale, moist skin, dry lips and mucous membranes of the mouth, coated tongue, headache, loss of appetite, constipation, tachycardia;
• Jaundice may occur (in 50% of cases).

When examining the abdomen, some distension is noted, the upper sections lag behind in breathing. When palpating, rigidity of the muscles of the anterior abdominal wall on the right is found, more in the upper sections and in the hypochondrium. As a rule, the symptoms of Mendel, Ortner, Murphy are positive. The Shchetkin-Blumberg symptom is often positive. When analyzing the blood of patients, leukocytosis with neutrophilia and increased ESR are detected.

The course of acute cholecystitis in children is usually benign, but in most cases acute cholecystitis is the beginning of chronic cholecystitis.

Chronic cholecystitisis a recurrent inflammatory disease of the gallbladder. Chronic cholecystitis often develops after hepatitis, often accompanies cholelithiasis and duodenobiliary reflux. Predisposing factors for the development of cholecystitis are biliary tract abnormalities, dyscholia, and dysbacteriosis. It is rare in children.

Unlike dyskinesia, clinical manifestations of cholecystitis are characterized by stereotypy, the presence of periods of exacerbation with severe intoxication, and possible subfebrile temperature.

Chronic cholecystitis in children is characterized by:

• right hypochondrium pain syndrome,
• dyspeptic, inflammatory-intoxication, asthenovegetative, cholestatic syndromes.

Differential diagnostic criteria for biliary tract diseases in children

Criterion	Chronic cholecystocholangitis	Gallstone disease
Anamnesis Family predisposition Seasonality of exacerbation Duration of the disease	Weakness, lethargy, signs of intoxication, polyhypovitaminosis Characteristic Autumn-spring period 1.5-2 years	Previous diseases of the biliary system Characteristic Not typical Long-term (indefinite)
Pain syndrome: Constant pain Link to dietary errors Paroxysmal pain Pain in the right hypochondrium Irradiation	Characteristic 1.5-2 hours after eating, especially fatty and fried foods Characteristic during exacerbation Characteristic In the right shoulder and shoulder blade	Not typical Immediately after eating Characteristic of colic Characteristic of colic Same
Ultrasound	Thickening, hyperechogenicity of the bladder wall, heterogeneity of the contents	Mobile hyperechoic formation in the bladder with echo

The most common objective symptoms of cholecystitis in children are: resistance of the muscles in the right hypochondrium, Ortner's symptom, Murphy's symptom, Mendel's symptom, and pain on palpation in the Chauffard triangle.

In laboratory studies of cholecystitis, indicators of the activity of the inflammatory process may be increased (hypergammaglobulinemia, hyperfibrinogenemia, increased ESR, leukopenia).

During an ultrasound examination, arguments in favor of cholecystitis include the detection of a thickened (more than 1.5 mm), layered, hyperechoic wall of the gallbladder, as well as heterogeneity of the bile.

Thermal imaging reveals hyperthermia in the area of the gallbladder projection.

Changes in the composition of the bile are diagnostically significant :

• decrease in arachidonic and oleic acids, increase in pentadecanoic and cuprous fatty acids;
• increased concentration of immunoglobulins G and A, R proteins, C-reactive protein;
• increase in enzymes (5-nucleotidase and alkaline phosphatase);
• decrease in lysozyme.

Increased levels of transaminases, bilirubin and beta-lipoproteins in the blood are possible.

Gallstone diseaseis a dystrophic-dysmetabolic disease characterized by the formation of stones in the yellow bladder or in the yellow ducts.

In children the cause may be:

• diseases accompanied by increased hemolysis;
• familial hypercholesterolemia;
• hepatitis and inflammatory lesions of the biliary system;
• factors leading to the development of cholestasis (eg, cystic fibrosis);
• diabetes mellitus.

Stagnation of bile, dyskinesia, and inflammation are important in pathogenesis.

In most cases, cholelithiasis in children has a latent course. The clinical picture is manifested either by symptoms of cholecystitis or by symptoms of obstruction of the biliary tract - biliary colic. Complications (dropsy, empyema or gangrene of the gallbladder) are rare in children.

Sonography, X-ray cholecystography, and computed tomography play a leading role in diagnostics. To clarify the composition of stones, it is advisable to study the composition of bile.

Diagnosis of biliary dyskinesia

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Treatment of biliary dyskinesia in children

Treatment of patients with diseases of the biliary system should be comprehensive, step-by-step and as individual as possible.

Treatment tactics are determined by:

• nature of dyskinetic disorders;
• state of the choledochopancreatoduodenal zone;
• severity of vegetative reactions.

Treatment methods for biliary dyskinesia in children

1. Regime.
2. Diet therapy (table No. 5).
3. Drug therapy:
   • choleretics;
   • cholekinetics;
   • Cholespasmolytics; phytotherapy;
4. mineral water treatment; physiotherapy;
5. spa treatment.

How are biliary dyskinesias treated?

Diet therapy

It is recommended to eat multiple meals during the day (5-6 times), exclude fried foods, chocolate, cocoa, coffee, strong broths, smoked meats, carbonated drinks. In case of hypertonic dyskinesia, fractional meals are recommended with limitation of products that cause contraction of the bladder - fatty meat, fish, poultry, products made from fatty dough, broths, garlic, onions, marinades, smoked meats, peas, beans. In case of hypotonic dyskinesia, it is necessary to include fruits, vegetables, vegetable and butter, sour cream, cream, eggs in the diet.

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Drug therapy

One of the leading places in the complex therapy of patients with biliary dyskinesia is given to the prescription of choleretic agents. All choleretic drugs are classified as follows.

1. Medicines that stimulate the bile-forming function of the liver (choleretics).
2. Drugs that increase the formation of bile and stimulate the formation of bile acids,
   • true choleretics;
   • drugs containing bile acids (decholine, chologon, allochol, etc.);
   • synthetic drugs (nicodine, osalmid, cyclovalone);
   • herbal preparations containing sandy immortelle, mint, St. John's wort, turmeric, etc. (flamin, cholagol, holaflux, cholagogum).
3. Preparations that increase bile secretion mainly due to the water component (hydrocholeretics) - mineral waters, corn silk, valerian preparations, etc.
4. Medicines that affect the bile-excreting function of the liver.
5. Drugs that increase the tone of the gallbladder and decrease the tone of the bile ducts (cholekinetics) - cholecystokinin, magnesium sulfate, xylitol, herbal preparations from barberry, turmeric (including cholagogum).
6. Drugs that cause relaxation of the bile ducts (cholespasmolytics) - papaverine, atropine, belladonna and mint extract.

Choleretic therapy must be carried out over a long period of time, in intermittent courses, systematically alternating choleretic agents, which prevents hepatocyte dystrophy and the body's addiction to drugs.

When choosing a drug, it is necessary to consider:

• type of dyskinesia;
• initial tone of the gallbladder and sphincter apparatus. Correction of biliary tract motility begins with finding the cause and eliminating it, treating the underlying disease and normalizing the vegetative status.

For increased motility, antispasmodics, sedatives, herbal medicine, and physiotherapy are used.

In case of decreased motor skills, tubages are performed, tonic agents are used, and cholekinetics are used.

Tubage with various stimulants is a highly effective cholekinetic agent. Tubage with mineral water is often used: the patient drinks 100-150 ml of warm mineral water without gas on an empty stomach, then lies on the right side, under which a warm heating pad is placed, for 45 minutes. Additional components (sorbitol, magnesium sulfate, Barbara salt) can be added to the mineral water. The course consists of 10 procedures (once every 3 days).

Many plants have a choleretic and cholekinetic effect: calamus, artichoke, barberry, sandy immortelle, silver birch leaves and buds, corn silk, burdock root, wormwood, garden radish, rowan, hops, lingonberry, oregano, calendula, dandelion, rhubarb root. The medicinal principle of artichoke is included in the drug chophytol, produced in the form of tablets and a solution, used 3 times a day before meals. Hymecromone is indispensable in the treatment of diseases of the gallbladder and bile ducts. The drug has an antispasmodic, choleretic effect, prevents the development of cholelithiasis by influencing the circulation of bile. Use 3 times a day 30 minutes before meals at a dose of 100 mg for children under 10 years of age and 200 mg 3 times a day after 10 years of age.

Cholespasmolytics are an important component of treatment. Mebeverine (Duspatalin) occupies a special place. The drug has a dual mechanism of action, which prevents the development of hypotension - a side effect of antispasmodic therapy. Mebeverine blocks Na + channels, preventing depolarization of the muscle cell and the development of spasm, thereby disrupting the transmission of impulses from cholinergic receptors. On the other hand, it blocks the filling of Ca2 + depots, depleting them and limiting the release of potassium ions from the cell, which prevents the development of hypotension. The drug has a modulating effect on the sphincters of the digestive organs.

Some medicinal plants also have a cholespasmolytic effect: mountain arnica, medicinal valerian, high elecampane, St. John's wort, peppermint, immortelle, medicinal sage. Preparations of plant origin include: flamin (used, depending on age, 1/4-1 tablet 3 times a day), cholagogum (1 capsule 2 times a day), cholagol (1-5 drops, depending on age, on sugar 3 times a day before meals), holosas (1 teaspoon 2-3 times a day, washed down with hot water).

Combined choleretics include: allochol (1-2 tablets 3 times a day; the drug contains dry animal bile, dry garlic extract, activated carbon), digestal (1-2 dragees 3 times a day during meals; contains pancreatin, bile extract, hemicellulase), festal (1/2-1-2 tablets, depending on age, after meals 3 times a day; contains pancreatic enzymes, bile components), holenzym (1 tablet 3 times a day; contains bile, dried pancreas, dried mucous membrane of the small intestines of slaughtered cattle).

Holaflux tea promotes the formation and outflow of bile, has an antispasmodic effect. Tea composition: spinach leaves, milk thistle fruits, celandine herb, yarrow herb, licorice root, rhubarb rhizome, dandelion root, turmeric oil and rhizome, aloe extract.

Neurotropic agents are prescribed taking into account the nature of dyskinesia and autonomic dysfunction. Tonics - caffeine, ginseng; sedatives - bromides, valerian tincture, motherwort tincture. The choice of drug should be discussed with a neurologist.

In case of hypertension of the biliary tract, hepatoprotectors are used, which provide protection of liver cells and ducts from the damaging effect of bile. Preparations of chemical origin (ursodeoxycholic acid, methionine, essential phospholipids), plant origin (milk thistle, turmeric, artichoke, pumpkin seeds), as well as hepabene and tykveol (1 teaspoon 3 times a day 30 minutes before meals) are used.