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2002-06-11-12 Gallstones  © Massoc www.thefetus.net/


Gallstones 

Philippe Massoc L.1, Carlos Henríquez B.1, Fernando Heredia M.1, Víctor Quiroz G.1, Marcela Muñoz F.2

1.-Servicio de Ginecología y Obstetricia, Departamento de Ultrasonografía; Hospital Guillermo Grant Benavente, Concepción Chile.
2.-Servicio de Imagenología, Hospital Guillermo Grant Benavente, Concepción, Chile

Synonyms: cholelithiasis, calculi.

Definitions: Single or multiple hyperechogenic foci in the fetal gallbladder:

Cases reports:

Case 1

33-year-old, G2P1, no remarkable personal or familial history, with previous normal ultrasound examination at 34 and 37 weeks. During a routine US examination performed at 41 weeks, a hyperechoic structure with a posterior acoustic shadow was observed inside the fetal gallbladder measuring 10.5 x 7.0 mm diameter with regular and flat borders. No other associated anomalies could be seen. (Figure 1). Spontaneous normal vaginal delivery occurred at 41 weeks. The 2-month-old infant is developing normally.

There was no evidence of neither ABO nor Rh (D) incompatibility, nor sepsis or other pathology. Two days after birth, an abdominal sonography was performed, confirming the finding of a normal sized gallbladder with thin walls, containing a 9 mm diameter gallstone with posterior acoustic shadow, in the neck. (Figure 2).

An ultrasound examination performed three months later showed no findings, demonstrating the complete spontaneous resolution of the gallstone.

Case 2

19-year-old, primigravida, unremarkable personal or familiar history, with previous normal ultrasound controls. During a routine US examination performed at 39 weeks of gestation, a hyperechoic structure with a posterior acoustic shadow inside the fetal gallbladder measuring 10,3 x 5,0 mm diameter was observed. (Figure 3).

No other anomalies were detected. A female neonate was born by cesarean section at 39 weeks of gestation. That same day an abdominal ultrasound was performed confirming the presence of a 10,5 x 4,5 mm gallstone in the neck. (Figure 4).

There was no evidence of ABO or Rh (D) incompatibility, sepsis or other pathology.

An ultrasound performed 29 days later showed no findings, demonstrating the complete spontaneous resolution of the gallstone.

Case 3

29 years patient, G4P3, with a prior twin gestation and previous normal ultrasound controls. She had been receiving iron supplementation between 12th and 36th weeks of gestation. During an ultrasound examination performed at 41 weeks, a hyperechoic structure with regular flat borders and no posterior echogenic shadow was observed inside a distended fetal gallbladder measuring 6.6 x 3.4mm diameter. (Figure 5).

No other anomalies were detected. The day after, a male neonate was born delivered by cesarean section, weighing 3620 gr; Apgar score was 9 at 1st and 9 at 5 minute.

Abdominal ultrasound performed the next day showed a distended gallbladder containing multiple echogenic tiny nodules with no posterior echogenic shadow. (Figure 6).

Case 4

An 18-year-old primigravida, with unremarkable personal or familiar history had been receiving iron and calcium supplementation from the 26th week. During a routine ultrasound examination in the 38th week, 4 hyperechoic structures of 1mm in diameter each and no posterior echogenic shadow were observed inside the fetal gallbladder (Figure 7).

The following day after, a female neonate was delivered vaginally, weight 3180 gr. The Apgar score was 9 at 1’ and 9 at 5’ minute.

Abdominal ultrasound performed the next day showed a distended gallbladder containing multiple mobile echogenic tiny nodules with no posterior echogenic shadow. (figure 8).

Prevalence: Fetal gallstones are an uncommon sonographic finding despite the increasing number of US scans performed during pregnancy1. The etiology is unknown and their presence is benign. The described incidence is quite variable, ranging between 5/1000 to 1/3000 live newborn2,3,4. The prevalence is unknown, suspected to be around 0.5-0.7:10.0004; as well as the risk factors. For some authors they are more common in boys5; and some have even suggested a link between fetal cholelithiasis and adult gallstones6.

Pathogenesis: Gallstones are found more frequently in infants who develop hemolytic anemias, ileum pathologies, biliary tract congenital anomalies and/or cholestasia related to septic states, furosemide use, phototherapy, overfeeding, prolonged hospitalizations, cephalosporin use and Down’s syndrome6,7-11.

Several hypotheses for the formation of this echogenic material have been formulated. Fanaroff et al. suggested that hemoglobin transformed in bilirubin passed through the placenta, increasing fetal indirect bilirubin serum levels12,13. Brown et al. proposed that an increase in estrogen serum levels could increase the risk of pigmented stone formation by increasing the cholesterol excretion and diminishing the biliary pigment synthesis9,11. It has also been suggested that narcotic use during pregnancy, hemolytic anemia, Rh (D) incompatibility, and anomalies such as choledochal cysts might be considered as risk factors14. Finally, pregnancy induced cholestasia has also been considered as a risk factor, which has not been confirmed13, and which we consider not valid in circumstances that in our country the incidence of this disease is around 3.5-10% of all pregnancies, and yet we do not have a higher incidence of fetal cholelithiasis compared with other countries15,16.

Sonographic findings: Single or multiple hyperechoic structures with a posterior acoustic shadow inside the  fetal gallbladder, with/without regular flat borders and no posterior echogenic shadow.

Differential diagnosis: Single or multiple liver echogenic foci.

Associated anomalies: None.

Prognosis: Good. In fact, cholelithiasis is an unusual finding in the first year of life, being more frequent in patients with bile duct pathology, with an incidence around 1,5%7. But in all our cases, as well as the literature reported, ultrasound showed no biliary tract abnormality and neither the mothers nor the patients had clinical or laboratory findings with liver or biliary diseases.6

Recurrence risk: Unknown.

Management: In most cases fetal gallstones disappear spontaneously weeks or months after birth6,15, or by using ursodeoxycholic acid 15-20 mg/kg 2,5,17. Careful follow-up US examinations are necessary for fetal cholelithiasis in the pre- and postnatal period and conservative management is mandatory17; because as well as seen in this study and others previously reported, they may spontaneously resolve.18

In the majority of cases, gallstones with undistended bladder or gallbladder sludge mimicked intrahepatic calcification or echogenic bowel, and all neonates were born in normal condition with no identifiable malformations.19  

References

  1. Sepulveda W, Stagiannis KD. Echogenic material in the fetal gallbladder in a surviving monochorionic twin. Pediatr Radiol 1996; 26(2):129-30.
  2. Jojart-G. Congenital cholelithiasis. Orv-Hetil. 1995 Jan 8; 136(2): 67-70.
  3. Wendtland-Born-A; Wiewrodt-B; Bender_SW..Prevalence of gallstones in the neonatal period. Ultraschall-Med. 1997 Apr; 18(2): 80-3.
  4. Muller R, Doman S, Kordts U. Fetal gallbladder and gallstones. Ultraschall Med 2000 Jun; 21 (3): 142-4.
  5. Stringer-MD; Lim-P; Cave-M; et col. Fetal gallstones. J-Pediatr-Surg. 1996 Nov; 31(11): 1589-91.
  6. Agnifili A; Carducci A; Biasini G; et col. Fetal biliary lithiasis: ultrasonographic diagnosis and clinical interpretation. Report of 3 cases. Radiol Med (Torino) 1997 Apr; 93 (4): 401-4.
  7. Agnifili A; Mancini E; Palermo P; et col. Prospective research on fetal cholelithiasis: incidence, predisposing conditions, echogenic diagnosis, and clinical features. Gchir 1998 Aug-Sep; 19 (8-9): 329-33.
  8. Aughton DJ.; Gibson P.. Cholelithiasis in infants with Down syndrome. Clin-Pediatr-Phila. 1992 Nov;31(11):650-2.
  9. St-Vil-D.; Yazbeck-S. Luks-FI; et col. Cholelithiasis in newborns and infants. J-Pediatr-Surg. 1992 Oct; 27(10):1305-7.
  10. Almond-PS; Adolph-VR; Steiner-R; et col. Calculus disease of the biliary tract in infants after neonatal extracorporeal membrane oxygenation. J-Perinatol. 1992 Mar; 12(1):18-20.
  11. Brown-DL; Teele-RL; Doubilet-PM; et col. Echogenic material in fetal gallbladder: sonographic and clinical observations. Radiology. 1992 Jan; 182(1): 73-6.
  12. Henschke C, Teele LR. Cholelitiasis in children : recent observations. J Ultrasound Med 1983; 2:481-4.
  13. Fanaroff AA, Martin RJ, Miler MJ. Identification and management of high risk problems in the neonate. In Creasy RK, Resnik R, rds. Maternal-Fetal Medicine, Principles and Practice, 2nd edn. Philadelphia: Saunders, 1989:1176-9.
  14. Beretsky I, Lankin DH. Diagnosis of fetal cholelithiasis using real-time high resolution imagining employing digital detection. J Ultrasound Med 1983; 2:381-3.
  15. Suma V, Marini A, Bucci N, Toffolutti T, Talenti E. Fetal gallstones: sonographic and clinical observations. Ultrasound Obstet Gynecol 1998 Dec; 12(6):439-441.
  16. Abbitt LP, Mc Ilhenuy J. Prenatal detection of gallstones. J Clin Ultrasound 1990; 18:202-4.
  17. Nishi-T. Ultrasonographic diagnosis of fetal cholelithiasis. J-Obstet-Gynaecol-Res. 1997 Jun; 23(3): 251-4.
  18. Klingensmith WC 3rd, Cioffi-Ragen DT. Fetal Gallstones. Radiology 1988 Apr; 167 (1): 143-4.
  19. Petrikovsky B, Klein V, Holsten N. Sludge in fetal gallbladder: natural history and neonatal outcome. Br J Radiol 1996 Nov; 69 (827) : 1017-8.
  20. Suchet-IB; Labatte-MF; Dyck-CS; Salgado LA. Fetal cholelithiasis: a case report and review of the literature. J-Clin_Ultrasound. 1993 Mar-Apr; 21(3): 198-202. 
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