BACKGROUND: Cholelithiasis, characterized by hardened deposits in the gallbladder, presents symptoms such as abdominal pain, jaundice, nausea, and potential complications like cholecystitis and choledocholithiasis. Despite increasing diagnoses, literature on pediatric cholelithiasis is limited, with undefined protocols. OBJECTIVE: This study aims to evaluate the clinical, laboratory characteristics, and outcomes of pediatric cholelithiasis cases, identifying factors associated with cholecystectomy. METHODS: A retrospective case series study was conducted on patients treated at a tertiary service, diagnosed with cholelithiasis via ultrasound from 2007 to 2021. Clinical profiles, comorbidities, examinations, procedures, and patient evolution were assessed. Patients were categorized into two groups: Group NC (no cholecystectomy) and Group C (cholecystectomy). RESULTS: Thirty-five patients were included, with 51% females and 60% having comorbidities with abdominal pain was the predominant symptom. Thirty-three patients were managed outpatient while two patients continued follow-up at another facility. Twelve opted for expectant management (Group NC), while 21 underwent cholecystectomy (Group C). Elective laparoscopic cholecystectomy was performed in Group C, with a median age of 11 years and 3 months. Group C showed a higher frequency of abdominal pain compared to Group NC, and this difference was significant (P=0.04). No differences were observed in gender, comorbidities, jaundice, fever, laboratory findings, symptom duration, follow-up time, or age at diagnosis. The median follow-up duration in Group NC was 1 year and 7 months. CONCLUSION: Abdominal pain was the predominant symptom in patients undergoing cholecystectomy, while comorbidities and laboratory abnormalities showed no significant associations. Although surgical intervention is typically recommended, expectant management proved viable in select cases without ensuing complications during the evaluation period.