Rethinking Risk: Predictive Factors for Choledocholithiasis in Pediatric Patients

Introduction Pediatric cholelithiasis incidence is increasing. Adult guidelines and the recently developed pediatric DUCT criteria aim to identify patients at risk for choledocholithiasis, but pediatric validation is lacking. This study aimed to identify predictive factors for pediatric choledocholithiasis. Methods We conducted a retrospective cohort study of children ≤18 y undergoing cholecystectomy from January 1, 2018 to May 31, 2023 at an academic medical center. Patients with cancer, chronic pancreatitis, or acalculous cholecystitis were excluded. Demographic and clinical data were abstracted from electronic records. Choledocholithiasis was defined by positive intraoperative cholangiogram or endoscopic retrograde cholangiopancreatography detection of stones/sludge. Univariate analyses identified potential predictors, and multivariable logistic regression assessed independent associations controlling for age and sex. Receiver operating characteristic curves determined optimal cutoff values for total bilirubin and common bile duct (CBD) size. Results Among 283 patients (median age 15 y, 74.7% female, 82.1% public insurance, 74.2% minority race/ethnicity), total bilirubin, alanine aminotransferase, aspartate aminotransferase, and sonographic CBD size were associated with choledocholithiasis on univariate analysis ( P < 0.01). Multivariable analysis showed CBD size independently increased odds of choledocholithiasis by 57% per 1 mm ( P < 0.001) and total bilirubin increased odds of choledocholithiasis by 21% per 0.1 mg/dL increase in bilirubin ( P = 0.012). Optimal cutoffs were 6 mm CBD (area under curve: 0.87) and bilirubin of 1.4 mg/dL (area under curve: 0.79). Conclusions CBD dilation ≥6 mm predicted choledocholithiasis, consistent with DUCT criteria, but a lower total bilirubin (≥1.4 mg/dL) was also associated with increased risk. These findings support the need for a validated pediatric-specific predictive tool to guide timely intervention and optimize resource use.