ERCP in the Pediatric Population


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ERCP in the Pediatric Population

  1. 1. ERCP in the Pediatric Population Ross Goshorn M4 USC SOM - Radiology
  2. 2. Goals of this presentation <ul><li>Gain Basic Understanding of ERCP </li></ul><ul><li>History of and Indications for ERCP in Pediatrics </li></ul><ul><li>Exposure to ERCP Imaging </li></ul><ul><li>Complications in Pediatrics </li></ul>
  3. 3. ERCP Basics <ul><li>What Does ERCP Stand for? </li></ul><ul><ul><li>Endoscopic retrograde cholangiopancreatography </li></ul></ul><ul><li>How is it Performed? </li></ul><ul><ul><li>Anatomy review </li></ul></ul>
  4. 6. ERCP in Pediatrics <ul><li>History and Indications for ERCP </li></ul><ul><ul><li>History of ERCP for pediatrics </li></ul></ul><ul><ul><ul><li>Has reported use since the 1980’s </li></ul></ul></ul><ul><ul><ul><li>Began with adult sized scope </li></ul></ul></ul><ul><ul><ul><li>Used primarily for evaluation of neonatal cholestasis and suspected biliary tract abnormalities </li></ul></ul></ul><ul><ul><ul><li>Originally instituted to help establish definitive diagnoses without need for laparoscopy/laparotomy </li></ul></ul></ul><ul><ul><li>Indications for procedure </li></ul></ul><ul><ul><ul><li>Depends on your source </li></ul></ul></ul>
  5. 7. Indications for ERCP <ul><li>North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) </li></ul><ul><ul><li>Evaluation of Neonatal Cholestasis </li></ul></ul><ul><ul><li>Recurrent Pancreatitis </li></ul></ul><ul><li>Other Resources </li></ul><ul><ul><li>Congenital Biliary Tract Disorders </li></ul></ul><ul><ul><li>Acquired Bililary Tract Disorders </li></ul></ul>
  6. 8. Neonatal Cholestasis <ul><li>Congenital (Neonatal Cholestasis) </li></ul><ul><ul><li>Biliary Atresia </li></ul></ul><ul><ul><li>Alagille Syndrome </li></ul></ul><ul><ul><li>Caroli’s Disease </li></ul></ul><ul><ul><li>Choledochal Cysts </li></ul></ul><ul><ul><li>Biliary Strictures </li></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Sclerosing Cholangitis </li></ul></ul><ul><ul><li>Ascariasis </li></ul></ul><ul><ul><li>Choledocholithiasis </li></ul></ul><ul><ul><li>Bile Plug Syndrome </li></ul></ul><ul><ul><li>Malignant Biliary Strictures </li></ul></ul>
  7. 9. Biliary Atresia <ul><li>Incidence </li></ul><ul><ul><li>occurs in approximately 1/10,000 - 20,000 births </li></ul></ul><ul><li>Pathophysiology </li></ul><ul><ul><li>characterized by inflammation of the bile ducts leading to progressive obliteration of the extrahepatic biliary tract </li></ul></ul><ul><li>Clinical Presentation </li></ul><ul><ul><li>Newborn with persistently elevated conjugated bilirubin with “clay colored” acholic stool </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Ultrasound Scintigraphy Duodenal Aspirate </li></ul></ul><ul><ul><li>Liver Biopsy ERCP MRCP </li></ul></ul>
  8. 13. ERCP Findings with Biliary Atresia Type 1 - non visualization of the biliary tree
  9. 14. Type 2 - visualization of the distal common duct and the gallbladder
  10. 15. Type 3a - Visualization of the gallbladder and the complete common duct with biliary lakes at the porta hepatis
  11. 16. Pediatric ERCP Specifics <ul><li>The Scope - Pediatric duodenoscope used in neonates and infants < 12 mo </li></ul><ul><li>The MD - Adult endoscopist or tertiary care facility performed in radiology suite </li></ul><ul><li>The Pt - typically requires deep sedation if not general anesthesia </li></ul><ul><li>Constraints </li></ul><ul><ul><li>Time, contrast, fluoro, selective cannulation </li></ul></ul>
  12. 17. Pediatric ERCP Specifics <ul><li>Complications </li></ul><ul><ul><li>Less than 12 months </li></ul></ul><ul><ul><ul><li>Rates vary but range from 2.4-13%, complications mostly related to sedation, a few had duodenal erosions and one episode of abdominal distension. </li></ul></ul></ul><ul><ul><li>Greater than 12 months </li></ul></ul><ul><ul><ul><li>Complications in 4.7 % of cases including fever, and mild pancreatitis in pts with history of pancreatitis </li></ul></ul></ul>
  13. 18. Goals of this presentation <ul><li>Gain Basic Understanding of ERCP </li></ul><ul><li>History of and Indications for ERCP in Pediatrics </li></ul><ul><li>Exposure to ERCP Imaging </li></ul><ul><li>Complications in Pediatrics </li></ul>
  14. 19. References <ul><li>Journal of Pediatric Gastroenterology and Nutrition 39:115-128 © Aug 2004 Lippincott Williams & Wilkins, Philadelphia </li></ul><ul><li>Varadarajulu, et al. Technical outcomes and complications of ERCP in children. Gastrointest Endosc 2004; 60:367 </li></ul><ul><li>UpToDate - “ERCP in children: Technique, success, and compliations,” “ERCP for biliary disease in children,” “Approach to neonatal cholestasis.” </li></ul>