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 26 May 2018

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Editor: Peter B. Cotton

10. ERCP in children

Moises Guelrud

Top of page Synopsis  Next section

ERCP has substantially influenced the evaluation and treatment of adult patients with suspected pancreatic and biliary disease. The first reports of ERCP in infants and children were chiefly from adult gastroenterologists experienced with such techniques. The growth in number and availability of skilled endoscopists has resulted in more frequent performance of ERCP in children. Moreover, the acquired ability to perform therapeutic endoscopic procedures is also applicable to children and adolescents. Techniques such as endoscopic sphincterotomy, biliary drainage, extraction of common bile duct and pancreatic duct stones, implantation of endoprostheses, and drainage of pancreatic pseudocysts are beginning to be used in children with an overall success rate similar to that reported for adult patients. In this chapter we define the technique, the indications, the complications, and the diagnostic and therapeutic applications of ERCP in children.

Top of page Introduction  Previous section Next section

Endoscopic retrograde cholangiopancreatography (ERCP) is the most demanding endoscopic procedure in children. It is the most sensitive and specific technique in the evaluation and treatment of children with suspected disorders of the pancreas and the biliary tract. The disadvantage is that it is an invasive procedure that frequently needs general anesthesia. The use of this technique in children has been limited. This may be due to the relative low incidence of diseases, low incidence of clinical suspicion, limited availability of pediatric duodenoscopes, lack of pediatric gastroenterologists well-trained in ERCP due to little exposure to the procedure, impression that ERCP in children is technically difficult to accomplish, difficulty in the effective evaluation of the therapeutic result, and because the indications and safety of ERCP in children have not been well defined. Since the procedure is frequently performed by experienced adult endoscopists, it is important to have a close working collaboration between them and pediatric gastroenterologists.

Top of page Patient preparation  Previous section Next section

Sedation for ERCP in children  Previous section Next section

The preparation and sedation of a child undergoing ERCP is similar to that used for upper gastrointestinal endoscopy. Since young children and some adolescents are unable to fully cooperate with procedures under conscious sedation, a state of deep sedation from which the patient is not easily aroused is often required. The endoscopist must choose between conscious sedation and general anesthesia after considering the pertinent risks and taking into account personal skill and experience, expected complexity of the procedure, and lastly, cost.

Most children can be adequately sedated with a combination of meperidine (2–4 mg/kg, maximum 100 mg) and diazepam (0.1–0.3 mg/kg, maximum 15 mg) or midazolam (0.1–0.3 mg/kg, maximum 15 mg). To obtain adequate sedation, children frequently require much higher doses of midazolam on a milligram per kilogram basis than adults. Post-procedure monitoring is the same as for other endoscopic procedures requiring sedation.

Antibiotic prophylaxis  Previous section Next section

There are no data to guide antibiotic prophylaxis for ERCP in children. In our experience routine antibiotic prophylaxis is unnecessary in neonates with cholestasis. Prophylactic antibiotics should be used to prevent endocarditis in susceptible patients in the same manner as for upper gastrointestinal endoscopy. Special situations that require a valvular prosthesis, vascular graft material, indwelling catheters, or transplanted organ in an immunosuppressed patient need individual consideration.

Other medication  Previous section Next section

Additional medications, which may be useful during ERCP, include glucagon and buscopan (hyoscine-N-butyl bromide) to reduce duodenal motility, and secretin to facilitate identification and cannulation of the minor papilla.

Top of page Instruments  Previous section Next section

In neonates and infants younger than 12 months, ERCP is performed with a special Olympus pediatric duodenoscope PJF [1] (Olympus America Inc., Melville, NY) which has an insertion tube diameter of 7.5 mm, a channel of 2.0 mm, and an elevator. A standard adult duodenoscope (insertion tube diameter approximately 11 mm) can be used for older children and adolescents. Therapeutic maneuvers, such as placement of endoprostheses and passage of some dilators and retrieval baskets, require instruments with a larger (3.2 mm) channel.

Top of page Technique  Previous section Next section

ERCP is performed in a radiology suite. Pediatric endoscopy assistants and specially trained nurses can help reduce pre-procedure anxiety, monitor the clinical status of the patient, and assist in holding and reassuring, administering medication, handling catheters, and injecting contrast material. The heart rate and oxygen saturation must be continuously monitored. Resuscitation medications and appropriate equipment should be available. ERCP is performed on an ambulatory basis. A recovery area equipped with monitors and specialized pediatric nurses familiar with the needs of children is necessary.

The principles of cannulation are those used in adult patients, with the additional limitations of space within the duodenum that depend on age. In young infants, such as those undergoing investigation for neonatal cholestasis, it is important to minimize the procedure time to avoid abdominal overdistension and respiratory compromise.

Indications  Previous section Next section

In general, children with suspected biliary and pancreatic disease should undergo MRCP nowadays before considering ERCP (which is more often used for therapy).

Biliary indications  Previous section Next section

The only indication of ERCP in neonates and young infants is cholestasis. Biliary indications for ERCP in children older than 1 year and in adolescents are:

  • obstructive jaundice
  • known or suspected choledocholithiasis
  • abnormal liver enzymes in children with inflammatory bowel diseases
  • evaluation of biliary ductal leaks after cholecystectomy or liver transplantation
  • evaluation of abnormal scans (ultrasound, computerized tomography (CT), or MRCP)
  • therapeutic ERCP.

Pancreatic indications  Previous section Next section

Pancreatic indications for ERCP in children are:

  • non-resolving acute pancreatitis
  • idiopathic recurrent pancreatitis, chronic pancreatitis
  • evaluation of persistent elevation of pancreatic enzymes
  • evaluation of abnormal scans (ultrasound, CT, or MRCP)
  • evaluation of pancreatic pseudocysts and pancreatic ascites
  • evaluation of pancreatic ductal leaks from blunt abdominal trauma
  • therapeutic ERCP.

Top of page Success rates for ERCP in children  Previous section Next section

Successful cannulation of the common bile duct in neonates and young infants is lower than in adults. It varies from 27% to 95% according to the endoscopist's experience [1–7] (Fig. 1). In our unpublished experience with 184 neonates and young infants with neonatal cholestasis, the procedure was successful technically in 93% of the cases. Failure was due to duodenal malrotation in two cases and inability to cannulate in six.

In older children, the success rate for cannulation of the desired duct is comparable to that achieved in adults [8–24] (Fig. 2). Our ERCP success in 220 children older than 1 year was 98%.

Top of page Complications  Previous section Next section

The incidence of complications in pediatric patients is not well established. In neonates and young infants with neonatal cholestasis there were no major complications in the series reported in the literature [1–7]. In our unpublished experience with 184 neonates and young infants, minor complications without clinical significance occurred in 24 patients (13%). Two neonates had transient narcotic-induced respiratory depression and four young infants had non-narcotic respiratory depression, which resolved with oxygen administration. In 17 patients, minor acute duodenal erosions were observed without clinical consequences. One neonate had abdominal distension for 10 h after completion of ERCP, which resolved without treatment. There were no major complications.

Complications in children older than 1 year vary according to the system studied, biliary or pancreatic. The overall incidence is approximately 4.7% [8–24]. In our unpublished experience with 220 ERCPs in children older than 1 year, ERCP was performed for diagnostic purposes in 108 cases with 2 (1.8%) complications. In 112 therapeutic ERCPs, complications occurred in 12 (10.7%).

Top of page Biliary findings (Fig. 3)  Previous section Next section

Biliary atresia vs. neonatal hepatitis  Previous section Next section

The differential diagnosis of neonatal cholestasis is critical in the first 2 months of life. In approximately 30% of patients a specific metabolic or infectious disease can be recognized. In the remaining 70% of neonates the key differentiation is between biliary atresia and neonatal hepatitis. Discriminating analysis using duodenal drainage, ultrasound, scintigraphy, and liver biopsy permitted accurate diagnosis of either biliary atresia or neonatal hepatitis in 80–90% of patients [25]. Thus, 10–20% of neonates required laparotomy to establish the diagnosis. In these patients, visualization of a patent biliary tree by ERCP may help.

Clearly, the success of ERCP in this context depends upon the experience of the endoscopist, who must have confidence that non-visualization of the common bile duct was not related to technical problems and to positioning the catheter. ERCP is the most direct method of establishing a diagnosis in the hands of skilled endoscopists, and may be appropriate as the first-line test when expertise and equipment are available.

ERCP findings  Previous section Next section

Three types of ERCP findings have been described in patients with biliary atresia [26] (Fig. 4). Type 1, no visualization of the biliary tree (Fig. 5); Type 2, visualization of the distal common duct and gallbladder (Fig. 6); Type 3, is divided in two subtypes: Type 3a, visualization of the gallbladder and the complete common duct with biliary lakes at the porta hepatis (Fig. 7), and Type 3b, in which both hepatic ducts are seen with biliary lakes.

Several authors [2,4–6,27] have shown that in half of the patients in whom extensive investigations failed to distinguish intra- from extrahepatic cholestasis, the biliary tree was opacified, thus avoiding surgery. When the biliary tree was partially visualized (Type 2 and Type 3) the diagnosis of biliary atresia was made and confirmed by surgery. When the biliary tree was not opacified and only the pancreatic duct was visualized (Type 1), the diagnosis of biliary atresia was suspected and exploratory laparotomy was indicated. Of the 310 infants with neonatal cholestasis reported in the literature (Fig. 8), the diagnosis by ERCP was incorrect in only 5 (1.6%) patients.

Miscellaneous genetic cholestatic diseases  Previous section Next section

In Alagille syndrome, the extrahepatic ducts are normal. ERCP shows marked and diffuse narrowing of the intrahepatic duct and reduced arborization [27,28]. Congenital hepatic fibrosis is characterized by disordered terminal interlobular bile ducts, which form multiple macroscopic and microscopic cysts (Fig. 9) that can be demonstrated by ERCP [27]. In Caroli's disease there are multiple segmental cylindrical or saccular dilatations of small biliary radicals with normal common bile duct that can be demonstrated by ERCP [27]. Diagnosis of these conditions is necessary in order to avoid needless surgery.

Bile plug syndrome  Previous section Next section

Bile plug syndrome represents a correctable cause of obstruction of the extrahepatic bile ducts by bile sludge in patients with normal biliary tract. The diagnosis is suspected by ultrasonography and confirmed by ERCP, which offers therapeutic possibility. Improvements of patients after ERCP suggest that simple irrigation with contrast material may be helpful [27].

Choledochal cyst  Previous section Next section

Choledochal cyst is a congenital malformation of the biliary tract characterized by saccular dilatation of the biliary tree. Choledochal cyst is primarily a disease of children and young adults, and 60% of reported cases are diagnosed before age 10 [29]. The diagnosis of this congenital malformation of the biliary tract is made by abdominal ultrasound, CT, or MRCP. ERCP confirms the diagnosis and helps surgical planning.

Pathogenesis of choledochal cyst  Previous section Next section

Many theories have been proposed to explain the development of choledochal cysts. The more generally accepted theory proposes that cysts are acquired. The majority of patients with choledochal cysts have an anomalous pancreatico-biliary union [30–34] located outside the duodenal wall (Fig. 10) and are not under the influence of the sphincter of Oddi mechanism. According to this theory, there is reflux of pancreatic juice upward into the biliary system that can produce damage to the common duct lining resulting in saccular dilatation of the duct [35].

The maximum normal length of the common channel in neonates and infants younger than 1 year is 3 mm. It increases with age to a maximum of 5 mm in children and adolescents between 13 and 15 years of age [36].

Classification of anomalous ductal union  Previous section Next section

There are three types of anomalous ductal union [37]. If it appears that the pancreatic duct is joining the common bile duct it is denoted as P–B type. If the common bile duct appears to join the main pancreatic duct it is denoted as B–P type, and if there is only a long common channel it is denoted as Long Y type (Fig. 11).

Classification of choledochal cysts  Previous section Next section

The anatomical classification by Todani et al. [38] of bile duct cysts is most often used (Fig. 12).

Type I  Previous section Next section

The Type I cyst is the most common and accounts for 80–90% of all choledochal cysts [29]. Type I is subdivided into: Type A, a typical cyst dilatation of the choledochus; Type B, segmental choledochal dilatation; and Type C, diffuse or fusiform dilatation (Figs 13 and 14).

Type II  Previous section Next section

Type II is a diverticulum anywhere in the extrahepatic duct.

Type III  Previous section Next section

Type III, a choledochocele, involves only the intraduodenal duct.

Type IV  Previous section Next section

Type IV represents multiple intrahepatic and extrahepatic cysts (Fig. 15).

Type V  Previous section Next section

Type V (Caroli's disease) includes single or multiple intrahepatic cysts.

Choledochocele  Previous section Next section

Although classified as one of the forms of choledochal cysts, choledochocele is probably not related. It is a rare cause of obstructive jaundice. The diagnosis is established with certainty by ERCP, and it may be effectively treated with endoscopic sphincterotomy [39].

The presence of a distal bile duct stricture at its point of connection with the pancreatic duct is frequently observed (Fig. 15). Primary cystolithiasis occurs in 8% of patients and usually is multiple (Fig. 14), involving intrahepatic and extrahepatic ducts [29].

Treatment of choledochal cysts  Previous section Next section

The anomalous anatomical configuration of the pancreatico-biliary ductal system observed in most patients with choledochal cysts has certain technical implications in regard to management. In most patients, endoscopic sphincterotomy is probably not indicated, and endoscopic access to the biliary system for removal of stones or sludge is therefore not possible. In selected cases, with fusiform bile duct dilatation and widely dilated common channel, endoscopic sphincterotomy has been attempted, with encouraging results [40].

Fusiform choledochal dilatation and carcinoma  Previous section Next section

Fusiform choledochal dilatation, as opposed to cystic dilatation, has been observed to be more commonly associated with low-grade, short strictures located at or distal to the pancreatico-biliary junction [41]. Moreover, carcinoma seldom, if ever, develops in fusiform dilatation [42].

Primary sclerosing cholangitis  Previous section Next section

In children, primary sclerosing cholangitis (PSC) is associated with histiocytosis X [43], immune deficiency states [44], and, less frequently, in patients with reticular cell sarcoma [45] and sickle cell anemia [46]. The association with inflammatory bowel disease is relatively uncommon (14%), suggesting that genetic and immunological factors are the most important factors [47,48].

Most benign biliary strictures in children are due to sclerosing cholangitis. ERCP provides an accurate and sensitive method of diagnosing sclerosing cholangitis. Recently, MRCP has been shown to be a useful non-invasive diagnostic technique [49]. The cholangiogram will show pruning of the peripheral biliary tree and areas of stenosis and ectasia [27,48]. Patients with major ductal strictures are candidates for endoscopic treatment with sphincterotomy and balloon dilatation to relieve the obstruction in order to delay the progression to cirrhosis [50]. Hydrostatic balloon dilatation has been used to dilate biliary strictures [51]. We developed a tapered hydrophilic balloon to dilate hepatic duct strictures and to avoid small intrahepatic duct rupture (Fig. 16)[52].

Parasitic infestation  Previous section Next section

Ascaris infestation can produce acute biliary obstruction with cholangitis. The worm can be seen with ERCP and can be removed with a tripod basket [27].

Choledocholithiasis  Previous section Next section

Choledocholithiasis occurs rarely in both infants and children [53]. Conditions associated with the presence of stones include biliary tract malformations such as choledochal cyst, chronic liver disease, hemolysis, and infection. The diagnostic approach is more difficult, and identification of the cause of obstruction by ultrasonography is often impossible. MRCP is the best non-invasive technique in demonstrating common bile duct stones and is clearly superior to ultrasonography [54].

ERCP for stones  Previous section Next section

The role and value of ERCP and endoscopic sphincterotomy in children with choledocholithiasis are not well established. Sphincterotomy with common bile duct stone removal has been successfully performed in young infants [55], and in children and adolescents [11,56–60]. Endoscopic papillary balloon dilatation with stone extraction is an alternative technique for stone removal [61]. However, pancreatitis can occur in 7% of cases. In children, published experience with this technique is limited [59].

Most infants with asymptomatic gallstones and no factors that would make them susceptible to stone formation can be managed conservatively [62]. However, larger stones are less likely to resolve, whereas smaller stones, sludge, and mucus should be able to pass in response to oral feeding without symptoms or complications. In children, sphincterotomy should be reserved for symptomatic patients or those with underlying lithogenic disorders.

A combined endoscopic sphincterotomy with common stone extraction followed by laparoscopic cholecystectomy has been successfully reported in children [63]. Although the combined procedure seems to be safe, additional experience is awaited so that the true advantages, limitations, and complications of this approach can be placed into clinical perspective.

Biliary strictures and leaks  Previous section Next section

Primary stricture  Previous section Next section

Primary stricture of the common hepatic duct has been reported [64]. Hydrostatic balloon dilatation may be use in the treatment of dominant common duct strictures [27].

Malignant strictures  Previous section Next section

Malignant strictures of the common bile duct are uncommon in children and have been successfully treated by placements of stents [65,66].

Liver transplantation  Previous section Next section

In patients whose liver is transplanted, the integrity of the anastomosis can be studied. ERCP is an alternative to percutaneous transhepatic cholangiography, and is the procedure of choice in patients with coagulopathy when the biliary tree must be imaged. When a stricture is found, the area may be dilated and a stent may be placed for a limited period of time.

Bile leaks  Previous section Next section

Bile leaks may be found and can be treated by endoscopic sphincterotomy or with stent placement [67].

Top of page Pancreatic findings (Fig. 17)  Previous section Next section

Recurrent pancreatitis  Previous section Next section

ERCP has been found useful in the identification of treatable causes in approximately 75% of children with recurrent pancreatitis [10–14,18,21,24,68–70]. Whatever the etiology of pancreatitis, the possibility of an anatomical abnormality amenable to endoscopic therapy or surgery should always be considered.

The timing of performing an ERCP in children is controversial. In children with idiopathic pancreatitis in whom recovery has occurred with standard medical treatment, there is no consensus as to when an ERCP to look for an obstructive cause is indicated. The potential benefit of proceeding with ERCP after the first episode as opposed to waiting for a second attack of pancreatitis is, of course, of preventing that second episode with its associated morbidity and mortality. No randomized controlled clinical trials have been performed that directly address this issue. Although not reported in the literature, it is the experience of the author that children with normal MRCP after the first episode of pancreatitis should not be studied.

Choledochal cyst and anomalous pancreatico-biliary union  Previous section Next section

Choledochal cysts have been associated with recurrent pancreatitis in 6–18% of the cases [9–13,18,21,69,70]. An anomalous pancreatico-biliary union has been observed in most children with choledochal cysts and recurrent pancreatitis (Fig. 18)[37,71,72]. In this subgroup of patients, sphincter of Oddi dysfunction has been demonstrated, suggesting that this motor abnormality might be related to the development of recurrent pancreatitis [72]. Moreover, because the sphincter of Oddi muscular segment is located within the duodenal wall, endoscopic sphincterotomy prior to surgery has been performed with excellent results, supporting this theory [72]. Occasionally, pancreatic stones or protein plugs may be endoscopically removed (Fig. 19)[27]. Choledochoceles have been reported in patients with recurrent pancreatitis [27,73,74]. Treatment by endoscopic sphincterotomy provides excellent results [70,75].

Pancreas divisum  Previous section Next section

Pancreas divisum is a congenital anomaly caused by failure of fusion of the dorsal and ventral endodermal buds. Each duct drains via its own separate orifice, the major papilla of Vater for the ventral duct of Wirsung, and the minor accessory papilla for the dorsal duct of Santorini.

Prevalence of pancreas divisum  Previous section Next section

Pancreas divisum is the most common congenital anomaly of the pancreas. In adults, it has been found in 5–14% of autopsy series and 0.3–8% of ERCP studies [76,77].

The prevalence of pancreas divisum in children is not known. In our experience with 272 consecutive cases of successful ERCP performed in children, pancreas divisum was found in 9 (3.3%) children [78]. Two patient groups were identified on the basis of the age at which ERCP was performed. Group 1 included 147 neonates or young infants in which ERCP was performed to evaluate neonatal cholestasis. Two (1.4%) neonates had pancreas divisum, one with neonatal hepatitis and the other with biliary atresia. Group 2 included 125 children older than 1 year in which ERCP was performed to evaluate pancreatic and biliary disorders. Seven (5.6%) children had pancreas divisum.

Significance of pancreas divisum  Previous section Next section

The clinical significance of pancreas divisum is controversial. An association between pancreas divisum and pancreatitis has been suggested [76,79–83]. However, others [84–86] have considered it to be a coincidental finding. It appears that the combination of pancreas divisum with accessory papilla stenosis would lead to a real functional obstruction. In 296 children with recurrent pancreatitis, pancreas divisum has been found in 10.8% of patients (Fig. 20).

ERCP diagnosis of pancreas divisum  Previous section Next section

ERCP is mandatory in the diagnosis of pancreas divisum. Cannulation of the major papilla shows a short duct of Wirsung (ventral pancreas) that quickly tapers and undergoes arborization (Fig. 21). To confirm the diagnosis it is most important to cannulate the minor papilla to demonstrate the dorsal pancreas. Interventional treatment in patients with pancreas divisum is applied to those whose symptoms are disabling.

Treatment of pancreas divisum  Previous section Next section

Surgical minor papilla sphincteroplasty used to be the treatment of choice, with a 70% improvement [87]. Endoscopic treatment has been utilized to decompress the dorsal duct by a variety of methods, including endoscopic minor papilla sphincterotomy with or without insertion of an endoprosthesis.

Endoscopic sphincterotomy of the minor papilla is indicated in patients with disabling symptoms. It has been attempted in conjunction with temporary stent placement in the dorsal pancreatic duct (Fig. 22), and has led to improvement in approximately 75% of children [16,18,70]. Overall, these results indicate that in certain children with recurrent pain or pancreatitis and pancreas divisum, endoscopic therapy can offer relief or improvement in symptoms.

Other pancreatic congenital anomalies  Previous section Next section

Annular pancreas has been associated with recurrent pancreatitis in children [70,89,90]. However, the relationship with pancreatitis is unclear. In 14 cases of annular pancreas reported in the English literature there were 5 with coexistent pancreas divisum, suggesting that pancreas divisum occurs more often in the presence of annular pancreas than in the general population [89]. This association may explain pancreatitis in some patients.

Other pancreatic congenital anomalies found to cause pancreatitis include short pancreas [70,91] and cystic dilatation or pancreatocele of the distal pancreatic duct [60].

Duodenal duplication cyst  Previous section Next section

Duodenal duplication cyst is a congenital anomaly which has been associated with recurrent pancreatitis due to intermittent obstruction of the pancreatic duct [92,93]. ERCP has been shown to be useful in the diagnosis as well as for definitive treatment [92]. If the cyst is bulging into the intestinal lumen, a wide cystoduodenostomy can be endoscopically performed, with excellent results [94].

Sphincter of Oddi dysfunction  Previous section Next section

Sphincter of Oddi manometry is the diagnostic procedure of choice for this functional motor disorder. It was found in 17 out of 139 (12.2%) children with recurrent pancreatitis [9,16,18,70]. These patients are generally treated by standard biliary sphincterotomy and, in general, they do not respond well [16], presumably because the pancreatic sphincter is not transected. Recurrent attacks of pancreatitis may be attributed to an affected pancreatic sphincter [95]. Dual endoscopic sphincterotomy of the pancreatic and common duct sphincters may be necessary to improve outcome [70]. However, safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Pancreatic trauma  Previous section Next section

Recent evidence has suggested that it is safe to perform ERCP during non-resolving traumatic pancreatitis and it may be helpful in identifying the need for endoscopic therapy or surgery [96–98]. Early ERCP may identify the presence and location of duct leakage. Patients with normal ductograms are treated conservatively. Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time [98]. Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.

Acquired immunodeficiency syndrome  Previous section Next section

Little has been written regarding pancreatic involvement in children with AIDS. Opportunistic infections may involve the pancreas, just as they do the other digestive organs in children with AIDS [99]. Most common are cytomegalovirus and Cryptosporidium, followed by Pneumocystis carinii, Toxoplasma gondii, and Mycobacterium avium. Drug-induced pancreatitis is a common complication of pentamidine [99] and dideoxyinosine [100]. ERCP has been shown to be useful in the evaluation and treatment of children with AIDS [101,102]. Pancreatic duct dilatation in two children with pancreatic duct stricture produced significant clinical improvement of pain.

Chronic pancreatitis  Previous section Next section

ERCP has been found useful in the identification of chronic pancreatitis in 14–69% of children with recurrent pancreatitis [9–22,69,70]. Two major morphological patterns can be demonstrated: (a) chronic calcifying pancreatitis, most often due to hereditary pancreatitis, fibrosing pancreatitis, or juvenile tropical pancreatitis; (b) chronic obstructive pancreatitis, which is associated with congenital or acquired lesions of the pancreatic duct, or biliary tree similar to those etiological factors found in recurrent pancreatitis.

In children with chronic pancreatitis, debilitating pain and recurrent attacks may be caused by strictures of the main duct, pancreatic stones, or pseudocysts that impair the normal outflow of pancreatic juice. ERCP demonstrates evidence of these abnormalities that can be treated endoscopically [10,14–16,18,24,70,103].

Endoscopic treatment of chronic pancreatitis in children  Previous section Next section

The aim of endoscopic therapy is based on the concept of pancreatic duct decompression. Pancreatic sphincterotomy has been performed to improve pancreatic drainage and to allow intraductal therapeutic maneuvers, severe stenosis has been dilated and bypassed with stents, and obstructing ductal stones have been removed after destruction by electrohydraulic lithotripter or extracorporeal shock-wave lithotripter [Fig. 23]. These endoscopic techniques constitute an excellent alternative to relieve recurrent abdominal pain and to avoid progressive parenchymal damage to the gland.

Pancreatic endotherapy has been reported in children in abstract form in five different centres [18–20,22,88], demonstrating that endoscopic pancreatic therapy in childhood is well tolerated, safe, and likely to be technically successful in experienced hands. Overall, there is an 80% short-term symptomatic improvement after pancreatic endoscopic therapy in children with chronic pancreatitis [10,18,70,103]. A longer follow-up period will be necessary to determine whether endoscopic success produces long-standing clinical improvement.

Pancreatic pseudocysts  Previous section Next section

Pancreatic pseudocysts are common consequences of acute and chronic pancreatitis. Most of the pseudocysts resolve spontaneously. Symptomatic, large (> 4 cm), or persistent pseudocysts beyond 6 weeks are unlikely to resolve and are at risk of complication [104]. In these cases treatment is indicated. Recently, there has been increased interest in non-operative management of pancreatic pseudocysts. Endoscopic methods have been developed as an alternative to surgical treatment and percutaneous drainage of pseudocysts. These endoscopic methods include endoscopic cystogastrostomy, cystoduodenostomy, and transpapillary drainage (Fig. 24). In adults, successful pseudocyst resolution has been reported in approximately 80% of cases [105–107]. As with other therapeutic interventions, pediatric experience is limited to a few case reports [9,18,70,103].

Top of page Outstanding issues and future trends  Previous section Next section

ERCP is an established procedure in children. Even though there is an increased number of pediatric gastroenterologists doing ERCP, there is not enough volume for them to gain proficiency. This has become more apparent since, nowadays, ERCP is less diagnostic and more therapeutic. It is my belief that, in future, ERCP in children will be performed by highly trained endoscopists working in tertiary care facilities, which maintain a high volume of such activity. Further studies should be directed to assess the usefulness of MRCP in the diagnosis of biliopancreatic diseases in children. In general, children with suspected biliary and pancreatic disease should undergo MRCP before ERCP is considered, with the latter increasingly being reserved for therapy.

Top of page References  Previous section

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64 Chapoy, PR, Kendall, RS & Fonkalsrud, E et al. Congenital stricture of the common hepatic duct: an unusual case without jaundice. Gastroenterology 1981; 80: 380–3.

65 Bickerstaff, KI, Britton, BJ & Gough, MH. Endoscopic palliation of malignant biliary obstruction in a child. Br J Surg 1989; 76: 1092–3.

66 Guelrud, M, Mendoza, S & Zager, A et al. Biliary stenting in an infant with malignant obstructive jaundice. Gastrointest Endosc 1989; 35: 259–61.

67 Pfau, PR, Kochman, ML & Lewis, JD et al. Endoscopic management of postoperative biliary complications in orthotopic liver transplantation. Gastrointest Endosc 2000; 52: 55–63.

68 Blustein, PK, Gaskin, K & Filler, R et al. Endoscopic retrograde cholangiopancreatography in pancreatitis in children and adolescents. Pediatrics 1981; 68: 387–93.

69 Forbes, A, Leung, JW & Cotton, PB. Relapsing acute and chronic pancreatitis. Arch Dis Child 1984; 59: 927–34.

70 Guelrud, M, Mujica, C & Jaen, D et al. The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents. Gastrointest Endosc 1994; 40: 428–36.

71 Mori, K, Nagakawa, T & Ohta, T et al. Pancreatitis and anomalous union of the pancreaticobiliary ductal system in childhood. J Pediatr Surg 1993; 28: 67–71.

72 Guelrud, M, Morera, C & Rodriguez, M et al. Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept. Gastrointest Endosc 1999; 50: 194–9.

73 Greene, FL, Brown, JJ & Rubinstein, P et al. Choledochocele and recurrent pancreatitis. Diagnosis and surgical management. Am J Surg 1985; 149: 306–9.

74 Weisser, M, Bennek, J & Hormann, D. Choledochocele-a rare cause of necrotizing pancreatitis in childhood. Eur J Pediatr Surg, 2000; 10: 258–64.

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76 Cotton, PB. Congenital anomaly of pancreas divisum as a cause of obstructive pain and pancreatitis. Gut 1980; 21: 105.

77 Bernard, JP, Sahel, J & Giovanni, M et al. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases. Pancreas 1990; 5: 248.

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80 Gregg, JA. Pancreas divisum: it association with pancreatitis. Am J Surg 1977; 1 (34): 539.

81 Heiss, FN & Shea, JA. Association of pancreatitis and various ductal anatomy, dominant drainage of the duct of Santorini. Am J Gastroenterol 1978; 70: 158.

82 Richter, JM, Shapiro, RH & Mulley, AG et al. Association of pancreas divisum and pancreatitis, and its treatment by sphincterotomy of the accessory ampulla. Gastroenterology 1981; 81: 1104.

83 Neblett, WW & O'Neill, JA. Surgical management of recurrent pancreatitis in children with pancreas divisum. Ann Surg 2000; 231: 899.

84 Delhaye, M, Engelholm, L & Cremer, M. Pancreas divisum: congenital anatomic variant or anomaly? Contribution of endoscopic retrograde dorsal pancreatography. Gastroenterology 1985; 89: 951.

85 Mitchell, CJ, Lintott, DJ & Ruddell, WSJ et al. Clinical relevance of an unfused pancreatic duct system. Gut 1979; 20: 1066.

86 Rosch, W, Koch, H & Schaffner, O et al. The clinical significance of pancreas divisum. Gastrointest Endosc 1976; 22: 206.

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89 Lehman, GA & O'Connor, KW. Coexistence of annular pancreas and pancreas divisum – ERCP diagnosis. Gastrointest Endosc 1985; 31: 25–8.

90 Yogi, Y, Shibue, T & Hashimoto, S. Annular pancreas detected in adults, diagnosed by endoscopic retrograde cholangiopancreatography: report of four cases. Gastroenterol Jpn 1987; 22: 92.

91 Rosenstock, F & Achkar, E. A 'short pancreas'. Gastrointest Endosc 1986; 32: 296.

92 Holstege, A, Barner, S & Brambs, HJ et al. Relapsing pancreatitis associated with duodenal wall cysts. Diagnostic approach and treatment. Gastroenterology 1985; 88: 814.

93 Lavine, JE, Harrison, M & Heyman, MB. Gastrointestinal duplications causing relapsing pancreatitis in children. Gastroenterology 1989; 97: 1556.

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96 Hall, RI, Lavelle, MI & Venables, CW. Use of ERCP to identify the site of traumatic injuries of the main pancreatic duct in children. Br J Surg 1986; 73: 411–2.

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Historical background
The changing world of pancreatic–biliary medicine
  The impact of scanning radiology
  Extending the indications for therapeutic ERCP
  Improvements in surgery
  Patient empowerment
  Current focus
Benefits and risks
  Degree of difficulty and expertise
  Report cards
  Unplanned events
  Clinical success and value
The future
  Imaging of the pancreatico-biliary system
   ERCP vs. PTC
Section I: Preparation for ERCP
  Room set-up and floor plan (Figs 1, 2)
   Position of monitors and endoscopy cart (Fig. 2)
  Essential equipment for ERCP
   Side-viewing duodenoscopes
   Forward-viewing scopes
   Sedatives and analgesics
   Smooth muscle relaxants
   Reversal agents
  Monitoring during conscious sedation
  Contrast agents
   Syringes for aspiration and irrigation
  Organization and storage of accessories (Fig. 4)
  Organization of the worktop (Fig. 5)
  Fluoroscopy for ERCP
   Fluoroscopy units (Fig. 6)
   KV and mA
   Split screen
   Magnified view
   Orientation of fluoroscopic images
   Personnel protection (Fig. 8)
   Other protective gear
   Positioning of the patient
  Radiological interpretation
   Scout film (Fig. 7)
   Contrast studies
   Drainage films
   The pancreatogram
   Normal anatomy
   Pathological changes
   Congenital anomalies
   The cholangiogram
   Normal anatomy
   Pathological strictures
   Bile duct stones (Fig. 11)
   Underfilling and delayed drainage
Section II: Diagnostic and therapeutic ERCP
  Diagnostic ERCP
   Accessories (Fig. 13)
   Preparation of patient
   Informed consent
  ERCP procedure
   Intubation and examination of the stomach
   Approaching the main papilla
   Cannulation of the papilla
   Ease and success in cannulation
   Minor papilla cannulation
  Complications of diagnostic ERCP
   Respiratory depression and other complications
  Failed cannulation and special situations
   What to do with a difficult intubation
   Failure to insert the duodenoscope
   Lost in the stomach
   Failure to identify the papilla
   Tip of endoscope is too proximal
   Tip of scope is too distal
   Obscured papilla
   What to do if cannulation is difficult
   Abnormal papilla
   Failed common duct cannulation
   Failed pancreatic duct cannulation
   Failed accessory (minor) papilla cannulation
   Failure to obtain get deep CBD cannulation
   Precut sphincterotomy to assist in CBD cannulation
   Needle-knife precut technique
   Selective cannulation of the intrahepatic system (IHBD)
   Cannulation of the papilla in a Billroth II situation(Fig. 17)
  Therapeutic ERCP
   Standard endoscopic sphincterotomy or papillotomy (Fig. 18)
   Preparation of patients
   Laboratory tests
   The sphincterotome (or papillotome)
   Electrosurgical unit
   Adequacy of sphincterotomy
   Wire-guided sphincterotomes
   Periampullary diverticula and sphincterotomy
   Distorted anatomy
   Precut sphincterotomy for impacted stone
   Indications for sphincterotomy and results
   Complications of sphincterotomy
   Post sphincterotomy bleeding
   What to do if the sphincterotomy fails to cut
   The risk of a half cut
   What to do with a deviated cut
   Sphincterotomy in Billroth II cases
   Stone extraction (Figs 19, 20)
   Endoscopic nasobiliary catheter drainage for bile duct obstruction (Fig. 24)
   Endoscopic plastic stent insertion for malignant biliary obstruction (Fig. 26)
   Preparation of patient
   One-step introducer system
   Bilateral stenting for hilar obstruction
   Brushing cytology for bile duct strictures (Fig. 27)
   Single-lumen system
   Double-lumen system
   Assessment of response to biliary stenting
   Results of biliary stenting
   Complications of stenting
   Early complications
   Late complications
   Self-expandable metal stents
   Stent configurations
   Lengths of stents
   Introducer system for SEMS
   Balloon dilation of biliary strictures (Fig. 28)
   Endoscopic management of bile leaks
Outstanding issues and future trends
  Incidence of CBD stones
  Traditional management
  Non-operative approach to CBD stones
  Classification of CBD stones
   Primary CBD stones
   Bacteriology of primary CBD stones
   Secondary CBD stones
Clinical presentations
  Asymptomatic biliary stones
  Symptomatic biliary stones
   Obstructive jaundice
   Clinical cholangitis
   Biliary pancreatitis
   Oriental cholangitis or recurrent pyogenic cholangitis
  Clinical diagnosis
   Abdominal ultrasound scan
   Endoscopic retrograde cholangiopancreatography (ERCP)
   Magnetic resonance cholangiogram (MRC) for CBD stones
   Endoscopic ultrasonography (EUS) for CBD stones
Management for CBD stones
  ERCP, sphincterotomy, and stone extraction
   Endoscopic sphincterotomy
   Choice of endoscopes
   Cannulation with sphincterotome
   Stone extraction
   Basket stone extraction
   Balloon stone extraction
  Acute pancreatitis
  Sphincterotomy vs. balloon sphincteroplasty
   Balloon sphincteroplasty
   Balloon sphincteroplasty for CBD stones
   Sphincterotomy for CBD stones
   Long-term complications of sphincterotomy
  ERCP vs. laparoscopic common duct exploration for retained CBD stones
   Preoperative ERCP
   Operative removal of CBD stones
   Factors that predict CBD stones
   MRC for detection of CBD stones
   Risk scores for prediction of CBD stones
Alternative approaches to CBD stones
  Precut sphincterotomy for failed deep cannulation
   Complications of precut sphincterotomy
  Percutaneous transhepatic cholangiogram and drainage
   Rendezvous procedure (two-hands technique)
   Percutaneous stone extraction
The challenge: giant CBD stones
  Basket mechanical lithotripsy (BML)
  Through-the-scope BML using a metal sheath
   Results of BML
  Mother and baby choledochoscopy and intraductal lithotripsy
   Electrohydraulic lithotripsy (EHL)
   Intraductal laser lithotripsy
  Stenting and interval endoscopic lithotripsy
   Effects of stenting on CBD stones
   The need for stone extraction after stenting
  Extracorporeal shock-wave lithotripsy (ESWL)
   Results of ESWL for CBD stones
  Open surgery
Intrahepatic duct stones
  ERCP and basket removal
  Wire-guided basket
  Percutaneous transhepatic cholangioscopy (PTC)
   Results of percutaneous treatment of intrahepatic stones
ERCP and sphincterotomy in Billroth II gastrectomy
  Precaution and alternatives for Billroth II gastrectomy
  Side-viewing vs. forward-viewing scope for ERCP in Billroth II gastrectomy
   Effect of biliary obstruction on the reticuloendothelial system
   Bacteriology of cholangitis
   Effect of raised intrabiliary pressure and cholangiovenous reflux
  Clinical presentation
   Simple cholangitis: Charcot's triad
   Suppurative cholangitis: Reynold's pentad
  Clinical management
   Initial conservative management
   Urgent biliary decompression
   Role of ERCP
   Endoscopic drainage vs. surgery
   ERCP vs. PTBD
   Nasobiliary catheter drainage vs. stenting in acute cholangitis
   Surgery to prevent recurrent cholangitis
   Types of operation
Outstanding issues and future trends
ERCP in diagnosis of pancreatico-biliary malignancies
  Radiological diagnosis
   Significance of 'double duct stricture' sign
  Tissue diagnosis
   Brush cytology, biopsy, and FNA
  Tumor markers in bile or pancreatic juice
Direct endoscopic examination of pancreatico-biliary malignancies
Intraductal ultrasound [IDUS]
Magnetic resonance cholangiopancreatography
Palliation of inoperable pancreatico-biliary malignancies
  Endoscopic stenting for malignant jaundice
   Technique of endoscopic stent insertion
   Types of stents
   Plastic stents
   Metal stents
   Metal vs. plastic stents
   Covered and uncovered metal stents
   Biodegradable stents
   Endoscopic stenting for hilar strictures
   Bismuth classification for hilar obstruction
   Unilateral vs bilateral drainage for hilar obstruction
  Other techniques of endoscopic palliation
   Intraductal photodynamic therapy
ERCP in management of ampullary neoplasms
  Benign tumors
   Ampullary carcinoma
Outstanding issues and future trends
Classification of bile duct injuries
Diagnostic protocol
Management of bile duct leakage after cholecystectomy
  Type A injury (peripheral leaks)
  Type B injury (main duct leaks)
  Type C injuries (postoperative biliary strictures)
  Type D injury (transections)
   Delayed reconstruction
Surgical treatment of postoperative biliary strictures
Percutaneous treatment of postoperative strictures
Endoscopic treatment of postoperative biliary strictures
  Reported results
  Phases of endoscopic treatment
   Stent insertion phase
   Stenting phase
   Follow-up phase
Postoperative biliary strictures: surgery or endoscopy [43]?
  Recurrent strictures after surgery
Metal stents for benign strictures
A more aggressive treatment protocol?
Outstanding issues and future trends
  Sphincter of Oddi dysfunction
  Sphincter of Oddi stenosis
Classification of SOD
  SOD in patients with gallbladder disease
  SOD after cholecystectomy
  SOD in the biliary or pancreatic sphincter, or both
  SOD and pancreatitis
Clinical presentation
  The Rome criteria
Initial evaluation
  Serum chemistries
  Standard imaging
Non-invasive diagnostic methods for SOD
  Morphine–prostigmin provocative test (Nardi test)
  Radiographic assessment of extrahepatic bile duct and main pancreatic duct diameter after secretory stimulation
   Ultrasound provocation testing
   Endoscopic ultrasound monitoring
   MRCP monitoring
  Quantitative hepatobiliary scintigraphy
   Adding morphine provocation
  Comparing non-invasive tests
  Current status of non-invasive methods
Invasive diagnostic methods for SOD
  Intraductal ultrasonography (IDUS)
Sphincter of Oddi manometry
  Sphincter of Oddi manometry: technique and indications
   Drug interactions
   Manometry catheters
   Cannulation techniques
   Study both sphincters
  Interpretation of manometry traces
   Normal values
  Complications of SOM
   Methods to reduce complications
   Aspirating catheter system
   Prophylactic stenting
  Sphincter of Oddi manometry; conclusion
   Type I patients
   Type II patients
   Type III patients
Therapy for sphincter of Oddi dysfunction
  Medical therapy
   Electrical nerve stimulation
  Surgical therapy
  Endoscopic balloon dilation and biliary stent trials
  Endoscopic sphincterotomy
   Randomized controlled trials of endoscopic sphincterotomy for SOD
   Is pancreatic sphincterotomy necessary?
  Risks and benefits of endoscopic treatment for SOD
  Botulinum toxin injection
Sphincter of Oddi dysfunction in recurrent pancreatitis
  Endoscopic sphincterotomy for SOD in pancreatitis
   Lans and colleagues
   Guelrud and colleagues
   Kaw and Brodmerkel
   Toouli and colleagues
   Okolo and colleagues
  Endoscopic sphincterotomy as a cause of pancreatic sphincter stenosis
  Endoscopic Botox injection
  SOD in recurrent pancreatitis: conclusion
Outstanding issues and future trends
Interdisciplinary management; complex ERCP
Acute gallstone pancreatitis
  Clinical diagnosis of acute gallstone pancreatitis
  Predicting severity of acute pancreatitis
  Acute treatment
  The role of early ERCP
   British study
   Hong Kong study
   Polish study
   German study
   Meta-analysis of studies of early ERCP, and current consensus
   ERCP is rarely indicated before cholecystectomy in patients with gallstone pancreatitis
   Acute pancreatitis postcholecystectomy
   Treatment by biliary sphincterotomy alone?
Pancreatic duct disruptions
  Stenting for duct disruption
Smoldering pancreatitis
Acute recurrent pancreatitis
  'Idiopathic' pancreatitis
  Microlithiasis and occult gallstones
   Detecting microlithiasis
   Bile crystals
   Empiric cholecystectomy?
  Sphincter of Oddi dysfunction (SOD)
   Diagnosis of SOD
   Endoscopic therapy for SOD
   Sphincterotomy without sphincter manometry?
   Is sphincter manometry dangerous?
   SOD in patients with intact gallbladders
  Pancreas divisum
   Does pancreas divisum cause pancreatitis?
   Endoscopic treatment for pancreas divisum
   Stenting for pancreas divisum
   Problems with endoscopic therapy
  Chronic pancreatitis (idiopathic, alcohol, familial, other)
   Endoscopic therapy for chronic pancreatitis
  Pancreatitis due to neoplastic obstruction
   Endoscopic management of neoplastic obstruction
   Stenting for smoldering pancreatitis due to malignancy
  Other rare causes of pancreatitis
Overall approach to unexplained acute pancreatitis
  Concerns about ERCP and empiric sphincterotomy in recurrent acute pancreatitis
   Risks of ERCP
  Investigations other than ERCP
  Recommended approach to ERCP for acute recurrent pancreatitis
  Final diagnosis in recurrent acute pancreatitis after extensive investigation
   Our experience
   Occult neoplasms
   Endoscopic treatment and results
Outstanding issues and future trends
Chronic pancreatitis
Treatments for chronic pancreatitis
  Medical therapy
  Surgical therapy
  Endoscopic treatment for chronic pancreatitis
   Safety issues
   Indications for endoscopic treatment
   Results of endoscopic treatment
Pancreatic ductal strictures
  Pancreatic stent placement techniques
  Efficacy of pancreatic duct stenting
   Cremer and colleagues
   Ponchon and colleagues
   Smits and colleagues
   Ashby and Lo
   Hereditary and early onset pancreatitis
   Predicting the outcome
  Duration of stenting
  Does response to stenting predict the outcome of surgery?
  Long-term follow-up
  Complications associated with pancreatic stents
   Stent-induced duct changes
   Brief mini-stents
Pancreatic ductal stones
  Causes of pancreatic ductal stones
  Stones cause obstruction
  Endoscopic techniques for stone extraction
   Pancreatic sphincterotomy
   Biliary sphincterotomy also?
   Pancreas divisum
   Stone removal
   Results of endoscopic treatment for stones
   Sherman and colleagues
   Smits and colleagues
   Cremer and colleagues
   Summary results
   Endoscopic therapy with ESWL
   Sauerbruch and colleagues
   The Brussels group
   Kozarek and colleagues
   Farbacher and colleagues
   Intraductal lithotripsy
   Medical treatment for stones
   Overall results for stone treatment
Pancreatic pseudocysts
  Endoscopic treatment for pseudocysts
Biliary obstruction in chronic pancreatitis
  Standard biliary stents
   Deviere and colleagues
   The Amsterdam group
   Barthet and colleagues
  Metal stents for biliary obstruction?
  Biodegradable stents
  Stenting for biliary strictures and chronic pancreatitis: conclusion
Sphincter of Oddi dysfunction in chronic pancreatitis
  Pathogenesis of SOD in chronic pancreatitis
  Frequency of SOD in chronic pancreatitis
  Surgical sphincter ablation
  Endoscopic pancreatic sphincterotomy
Pancreas divisum
  Pancreas divisum: a cause of pancreatitis?
  Minor papilla ablation
Outstanding issues and future trends
Toxic and metabolic complications
Pancreatic fluid collections
Pseudocysts and abscesses
Pancreatic necrosis
  Organizing necrosis
Miscellaneous complications
  Pancreatic fistulas
  Ductal disruption
  Vascular complications
   Venous thrombosis
Arterial complications
Outstanding issues and future trends
Patient preparation
  Sedation for ERCP in children
  Antibiotic prophylaxis
  Other medication
  Biliary indications
  Pancreatic indications
Success rates for ERCP in children
Biliary findings (Fig. 3)
  Biliary atresia vs. neonatal hepatitis
   ERCP findings
  Miscellaneous genetic cholestatic diseases
  Bile plug syndrome
  Choledochal cyst
   Pathogenesis of choledochal cyst
   Classification of anomalous ductal union
   Classification of choledochal cysts
   Type I
   Type II
   Type III
   Type IV
   Type V
   Treatment of choledochal cysts
   Fusiform choledochal dilatation and carcinoma
  Primary sclerosing cholangitis
  Parasitic infestation
   ERCP for stones
  Biliary strictures and leaks
   Primary stricture
   Malignant strictures
   Liver transplantation
   Bile leaks
Pancreatic findings (Fig. 17)
  Recurrent pancreatitis
   Choledochal cyst and anomalous pancreatico-biliary union
   Pancreas divisum
   Prevalence of pancreas divisum
   Significance of pancreas divisum
   ERCP diagnosis of pancreas divisum
   Treatment of pancreas divisum
   Other pancreatic congenital anomalies
   Duodenal duplication cyst
   Sphincter of Oddi dysfunction
   Pancreatic trauma
   Acquired immunodeficiency syndrome
  Chronic pancreatitis
   Endoscopic treatment of chronic pancreatitis in children
  Pancreatic pseudocysts
Outstanding issues and future trends
The risks of ERCP
  Risks for endoscopists and staff
  Technical failure
   Degree of difficulty scale for ERCP procedures (Fig. 1)
   Level 1
   Level 2
   Level 3
   Defining intent
   Risk consequences of technical failure
  Clinical failure
Unplanned adverse clinical events—complications
  When does an event become a complication?
   Complication definition
   Severity criteria
  Types of adverse clinical events
  Timing of events and attribution
  A dataset for unplanned events
Overall complication rates
  Accuracy of data collection
  Changes in complications over time
  Complication rates at MUSC
General risk issues
  Operator-related issues
  Patient-related issues; clinical status, indications, and comorbidities
   Illness and associated conditions
   Anatomical factors
   Complication-specific risk factors
  Procedure performed
   Diagnostic or therapeutic?
   Biliary sphincterotomy
   Pancreatic sphincterotomy
   Precut sphincterotomy
   Repeat sphincterotomy
   Balloon sphincter dilation
   Endoscopic papillectomy
   Pseudocyst drainage
Reducing the risks of ERCP: general issues
  The contract with the patient; informed consent
   Educational materials
  Care after ERCP
   Early refeeding?
Pancreatitis after ERCP
  Incidence of pancreatitis after ERCP
  Risk factors for pancreatitis
   Patient factors increasing the risk [114,115,122,123]
   Procedure factors increasing the risk
   Pancreatic manipulation
   Sphincter manometry
   Biliary sphincter dilation
   Biliary stenting
   Pancreatic stenting
   Combining patient- and procedure-related factors
  Prevention of pancreatitis after ERCP
   Avoiding ERCP, especially in high-risk patients
   Mechanical factors
   Contrast agents
   Pharmacological prophylaxis
   Pancreatic stenting to prevent pancreatitis
   Feeding and monitoring
  Post-ERCP pancreatitis, recognition, and management
  Post-ERCP pancreatitis, conclusion
  Duct and tumor 'penetrations'
  Sphincterotomy-related perforation
   Risk factors for sphincterotomy perforation
   Recognition of sphincterotomy perforation
   Reducing risks of sphincterotomy perforation
   Management of sphincterotomy perforation
  Perforation remote from the papilla
   Recognition and management of endoscopic perforation
  Stent migration perforation
Infection after ERCP
  Nosocomial infection
  Pancreatic sepsis
  Prophylactic antibiotics
  Delayed infection
Bleeding after ERCP
  Definition of bleeding, and incidence
  Risk factors for bleeding, and avoidance
  Management of sphincterotomy bleeding
   Delayed bleeding
Complications of stents
  Blockage of (plastic) biliary stents
  Stent migration
  Duct damage due to stents
Basket impaction
Cardiopulmonary complications and sedation issues
Rare complications
Deaths after ERCP
Late complications
  Diagnostic error
  Late infection
  Late effects of sphincterotomy
  Sphincterotomy with the gallbladder in place
  Pancreatic sphincterotomy
Managing adverse events
  Prompt recognition and action
  Professionalism and communication
Learning from lawsuits
  Financial concerns
  Standard of care practice
   The procedure
   Postprocedure care
Outstanding issues and future trends

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