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Etiology-Based Decision-Making Protocol for Pediatric Cholelithiasis. OBJECTIVES: We reviewed hospital records of pediatric cholelithiasis to develop an etiology-based decision-making protocol. METHODS: This retrospective study was conducted on consecutive pediatric cholelithiasis patients from July, 2014 to June, 2019 in a tertiary care center. Pediatric cholelithiasis was classified according to etiology, and the outcome of medical/surgical treatment was noted. RESULTS: Data of 354 pediatric patients were analyzed. Commonest (56.2%) etiology was idiopathic; followed by ceftriaxone pseudo-lithiasis (26.8%). Pigment stones were associated with the highest rate of complications. Non-hemolytic stones had a lower complication rate and a high rate of resolution with medical therapy. CONCLUSIONS: Hemolytic and symptomatic stones warrant an early cholecystectomy, whereas asymptomatic idiopathic stones, ceftriaxone stones, and TPN-induced stones are candidates for medical therapy under close observation.