Introduction
Biliary obstruction is defined as the
blockage of the extrahepatic
biliary system (1). The etiology of the benign or malignant extrahepatic
biliary system blockage involves various reasons, including gall stones
in the cystic duct causing pressure on the bile duct (Mirizzi syndrome),
choledochal cysts, and choledocholithiasis. Benign blockage of the
extrahepatic biliary system can be due to stricture diseases such as
fibrotic strictures from gall stone passage, PSC, and iatrogenic
strictures from bile duct cannulation. Neoplastic cases are presented
with stricture diseases causing biliary obstruction, including
pancreatic head cancer (causing distal CBD stricture), ampullary
carcinoma or adenoma, and cholangiocarcinoma (2). The most common cause
of biliary obstruction in developed countries is choledocholithiasis due
to cholesterol stones. Pigmented stones due to hemolysis and infectious
diseases, recurrent pyogenic cholangiohepatitis with increased risk for
cholangiocarcinoma, and calculi in intrahepatic bile ducts are common
etiologies in the Asian population which are rare in western countries.
Recurrent pyogenic cholangiohepatitis is characterized by recurrent
bacterial cholangitis, stricture, and dilatation of the biliary system.
Gallbladder malignancy is more common in East Asia, Central and South
America, Central and Eastern Europe, and the north of India (2, 3).
In general, choledocholithiasis is uncommon in children. Since the
extrahepatic biliary obstruction in children is very rare, most reports
describe the condition’s etiology in adult patients. The prevalence of
cholelithiasis in pediatrics has been reported to be 0.13% - 0.3%.
However, the incidence is higher in obese children and adolescents and
is estimated at 2% - 6.1% (4).
More than 80% to 90% of all patients with CBD stones can be treated by
non-surgical methods through sphincterotomy and stone extraction in
combination with Dormia baskets or balloon catheters. In case of
non-extractable stones >1 cm, additional procedures such as
mechanical lithotripsy, including balloon dilatation, extracorporeal
shock-wave lithotripsy, electrohydraulic probe lithotripsy, laser
lithotripsy, stenting for immediate and definitive stone treatment are
applied (4). Endoscopic
retrograde cholangiopancreatography is a diagnostic and therapeutic
technique routinely used for adults (5).
Relative to the published studies
regarding adult ERCP, the articles on pediatric ERCP remain limited for
several reasons (6). Firstly, it is technically more challenging to be
used for children. Secondly, pancreaticobiliary pathology in the
pediatric population is rare, so the study cannot have an adequate
sample size. Additionally, in children weighing more than 10 kg,
pediatric ERCP duodenoscopes and accessories have limited application
(8). Moreover, the advancement of MRCP has limited the use of ERCP for
diagnosis.
This case report presents a CBD stone case with a left-sided gall
bladder treated with ERCP in an otherwise healthy 5-year-old male.
Left-sided gallbladder refers to a gallbladder located on the left side
of the ligamentum teres. It is a rare anomaly usually related to the
absence of segment Ⅳ, portal vein anomalies, or biliary system
anomalies. Diagnosis of the associated anomalies is essential for
managing liver transplantation, liver resection, and complicated
hepatolithiasis. Preoperative diagnosis of the left-sided gallbladder
with associated anomalies is required to reduce the risks of operative
complications (7).