ERCP in the Pediatric Population

Ross Goshorn

M4

USC SOM - Radiology

Goals of this presentation

• Gain Basic Understanding of ERCP

• History of and Indications for ERCP in Pediatrics

• Exposure to ERCP Imaging

• Complications in Pediatrics

ERCP Basics

• What Does ERCP Stand for?– Endoscopic retrograde

cholangiopancreatography

• How is it Performed?– Anatomy review

ERCP in Pediatrics

• History and Indications for ERCP– History of ERCP for pediatrics

• Has reported use since the 1980’s

• Began with adult sized scope

• Used primarily for evaluation of neonatal cholestasis and suspected biliary tract abnormalities

• Originally instituted to help establish definitive diagnoses without need for laparoscopy/laparotomy

– Indications for procedure• Depends on your source

Indications for ERCP

• North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)– Evaluation of Neonatal Cholestasis– Recurrent Pancreatitis

• Other Resources – Congenital Biliary Tract Disorders– Acquired Bililary Tract Disorders

Neonatal Cholestasis

• Congenital (Neonatal Cholestasis)– Biliary Atresia

– Alagille Syndrome

– Caroli’s Disease

– Choledochal Cysts

– Biliary Strictures

• Acquired– Sclerosing Cholangitis

– Ascariasis

– Choledocholithiasis

– Bile Plug Syndrome

– Malignant Biliary Strictures

Biliary Atresia• Incidence

– occurs in approximately 1/10,000 - 20,000 births

• Pathophysiology– characterized by inflammation of the bile ducts leading to

progressive obliteration of the extrahepatic biliary tract

• Clinical Presentation– Newborn with persistently elevated conjugated bilirubin with

“clay colored” acholic stool

• Diagnosis– Ultrasound Scintigraphy Duodenal Aspirate– Liver Biopsy ERCP MRCP

ERCP Findings with Biliary Atresia

Type 1 - non visualization of the biliary tree

Type 2 - visualization of the distal common duct and the gallbladder

Type 3a - Visualization of the gallbladder and the complete common duct with biliary lakes at the porta hepatis

Pediatric ERCP Specifics

• The Scope - Pediatric duodenoscope used in neonates and infants < 12 mo

• The MD - Adult endoscopist or tertiary care facility performed in radiology suite

• The Pt - typically requires deep sedation if not general anesthesia

• Constraints – Time, contrast, fluoro, selective cannulation

Pediatric ERCP Specifics

• Complications– Less than 12 months

• Rates vary but range from 2.4-13%, complications mostly related to sedation, a few had duodenal erosions and one episode of abdominal distension.

– Greater than 12 months • Complications in 4.7 % of cases including fever,

and mild pancreatitis in pts with history of pancreatitis

Goals of this presentation

• Gain Basic Understanding of ERCP

• History of and Indications for ERCP in Pediatrics

• Exposure to ERCP Imaging

• Complications in Pediatrics

References

• Journal of Pediatric Gastroenterology and Nutrition 39:115-128 © Aug 2004 Lippincott Williams & Wilkins, Philadelphia

• Varadarajulu, et al. Technical outcomes and complications of ERCP in children. Gastrointest Endosc 2004; 60:367

• UpToDate - “ERCP in children: Technique, success, and compliations,” “ERCP for biliary disease in children,” “Approach to neonatal cholestasis.”