Version May 2024
INTRODUCTION — Experience with endoscopic retrograde cholangiopancreatography (ERCP) in children has been limited due to multiple factors, including the relatively low incidence of diseases requiring ERCP in this age group, the impression that the procedure is technically difficult in children, and because the indications and safety of ERCP in children have not been well defined. As a result, patients are generally referred to a tertiary care facility or to adult endoscopists who perform a high volume of procedures. Few facilities have advanced endoscopists specifically trained in pediatric therapeutic endoscopy or a high enough volume of these procedures to ensure optimal outcomes. However, in the centers where this special expertise is available, pediatric therapeutic endoscopy can sometimes be used as an alternative to more invasive procedures, such as percutaneous transhepatic cholangiography with catheter placement or surgeries.
This topic review will focus on the technical aspects of performing ERCP in children. Indications for ERCP in children are discussed separately:
●(See "Endoscopic retrograde cholangiopancreatography (ERCP) for biliary disease in children".)
●(See "Endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic disease in children".)
PATIENT PREPARATION AND SEDATION
Clinical setting — Although major pediatric centers often have a pediatric gastroenterologist with expertise in performing ERCP, many ERCP procedures in children are performed by adult gastroenterologists, so a close working collaboration between an adult and a pediatric gastroenterologist is important during patient preparation and the procedure itself.
The preparation and sedation of a child undergoing ERCP is similar to that used for upper gastrointestinal endoscopy. The procedure should be explained to the child in a manner appropriate for their age and level of intellectual and emotional development, if possible, and the parent or legal guardian must provide procedure consent.
Anesthesia and monitoring — The endoscopist, together with the anesthesiologist, must choose between monitored anesthesia care and general anesthesia, after considering the pertinent risks and taking into account personal skill and experience and the expected complexity of the procedure.
Postprocedure monitoring is the same as for other endoscopic procedures requiring sedation. Personnel with appropriate training in pediatric sedation and monitoring are required for either conscious sedation or general anesthesia.
Antibiotic prophylaxis — There are no data to guide recommendations for antibiotic prophylaxis for ERCP in children. As a result, the principles of antibiotic prophylaxis in adults are frequently applied in children. (See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)
ERCP is generally associated with a higher risk for bacteremia than upper endoscopy alone, particularly in the presence of biliary obstruction. We suggest the following approach:
●Patients with cystic or obstructing lesions of the biliary or pancreatic ducts should be given antibiotic prophylaxis to prevent cholangitis or infective pancreatitis.
●Antibiotic prophylaxis should be administered to any patient at increased risk for infection, including organ transplant recipients, patients who are immunocompromised, certain cardiac conditions, and those with indwelling catheters.
ENDOSCOPIC EQUIPMENT — In neonates and infants younger than 12 months, ERCP is performed with a pediatric duodenoscope, which has an insertion tube diameter of 7.5 mm, a channel size of 2 mm, and an elevator [1,2]. If the appropriate duodenoscope is not available, the vendor may be able to loan the device for the procedure. These pediatric instruments are very scarce in the United States and may not even be available as loaned instruments [3]. Use of a pediatric duodenoscope is mandatory in neonates and in infants younger than 12 months and is sometimes preferred for small children (eg, younger than three years). Pediatric duodenoscopes have a smaller working channel, and the maximum catheter diameter may be 7 French. This is important when choosing the appropriate sphincterotome, dilators, retrieval baskets, and stents for use in the procedure.
When the child is large enough, an adult duodenoscope (outer diameter 10.8 to 12.1 mm) with all the accessories should be used for therapeutic interventions. This is usually possible for children older than 12 months of age or weighing more than 10 to 15 kg [2]. This was shown in a study that evaluated the safely and efficacy of ERCP in the pediatric population using standard adult duodenoscopes [4]. Among 48 children with a mean age of 13 years (range 2 to 17) who underwent a total of 65 ERCPs with a standard adult duodenoscope, the cannulation success rate was 93.8 percent, with post-ERCP pancreatitis 9.2 percent and no procedure-related mortality. The rate of post-ERCP pancreatitis was somewhat higher than that reported in some larger case series (closer to 3 percent [5]), but due to the small size of this series, it is unclear if this represents a true difference.
An international prospective multicenter study evaluated the technical outcomes in pediatric ERCP [6]. Among 857 children, a total of 1124 ERCPs were performed. Technical success was achieved in the majority of cases (90.5 percent), with success more commonly encountered for biliary indications (odds ratio 4.2) and less commonly for native papilla (odds ratio 0.4) and in children younger than three years old. Cannulation was more often successful with biliary cannulation (95.5 percent) compared with pancreatic cannulation via the major papilla (89.6 percent) or minor papilla (71.2 percent). Post-ERCP pancreatitis occurred in 5 percent of cases.
Disposable duodenoscopes are available for adults. (See "Preventing infection transmitted by gastrointestinal endoscopy", section on 'Duodenoscopes with disposable designs'.)
TECHNIQUE — Carbon dioxide should be used instead of room air for insufflation for all age groups. Because carbon dioxide is absorbed faster than air, its use for insufflation reduces postprocedure abdominal distension.
Medications that may be useful during ERCP include glucagon and scopolamine (hyoscine) butylbromide (Buscopan, not available in the United States) to reduce duodenal motility as well as secretin to facilitate identification and cannulation of the minor papilla in patients with pancreas divisum.
Cannulation of the papilla — The principles of cannulation are similar to those used in adult patients, with the additional limitations of space within the duodenum in small patients. We strongly favor the clinician wire-guided cannulation technique, which reduces the risk of post-ERCP pancreatitis and increases the success rate of primary cannulation compared with the standard contrast-assisted method, based on experience in adults. A tapered catheter (3.5 French at the distal end) or a small sphincterotome (4 French at the distal end) is introduced into the papilla. The contrast agent is injected manually using a 5- or 10-mL syringe. Dilution of the contrast material to 30 percent is preferred for optimal visualization if ducts are known to be dilated or if filling defects are anticipated. Judicious use of fluoroscopy to decrease radiation exposure is also important; filling of common bile duct or pancreatic duct should be monitored continuously during contrast injection.
It is important to minimize the procedure time to avoid abdominal overdistension and respiratory compromise, especially in young infants. To reduce the time of the procedure, the endoscopist must anticipate the equipment that will be used (based on the indication) and have it ready. The pancreatic duct orifice is localized in the right lower quadrant of the major papilla, with the biliary opening located in the left upper quadrant. Having an endoscopic "frontal view" of the major papilla will help gain access to the pancreatic duct, while a "top view," in which the major papilla is localized in the upper field of view, will help gain access to the bile duct.
Monitoring — Because ERCP requires fluoroscopy, it is usually performed in a radiology suite designed for adult patients. Pediatric endoscopy assistants, pediatric anesthesiologists, and specially trained nurses can help reduce preprocedure anxiety, monitor the clinical status of the patient, administer medications, handle catheters, and inject contrast material. The heart rate and oxygen saturation must be continuously monitored. Resuscitation medications and appropriate equipment should be available. A recovery area equipped with monitors and specialized pediatric nurses familiar with the needs of children is necessary.
Because therapeutic ERCP has a greater potential risk for adverse events compared with diagnostic ERCP, we recommend overnight observation after a therapeutic procedure.
SUCCESS — In children older than one year and adolescents, the rate of successful cannulation is more than 95 percent, comparable with reports in adults [6-13]. In neonates and young infants, the rate of successful cannulation of the common bile duct is often lower than in adults, ranging from 27 to 95 percent in various reports [4,14-16]. Experience of the endoscopists may account for a large part of the variability.
A retrospective study compared outcomes of more than 200 therapeutic ERCPs performed in pediatric patients (average age 13.3) with those for adult patients with similar procedural indications and matched for complexity [13]. There were no differences in technical success, clinical success, complication rates, or fluoroscopy time between the two cohorts. The pediatric patients were more likely to require general anesthesia and had a longer average length of stay.
ADVERSE EVENTS — Adverse events of ERCP in all age groups include pancreatitis, infection, hemorrhage, and perforation, and are more common among patients undergoing therapeutic ERCP as compared with diagnostic ERCP. Major adverse events are rare.
The frequency of adverse events was reported in a systematic review that included 32 studies involving more than 3000 ERCPs in children [5]. The pooled complication rate was 6 percent overall and 3 percent among ERCPs for neonatal cholestasis. The most common adverse event was post-ERCP pancreatitis (pooled estimate 3 percent), followed by bleeding and infection (both less than 1 percent). Similar findings were reported in other large series [6,13,17].
●Post-ERCP pancreatitis – Post-ERCP pancreatitis occurs in approximately 3 to 12 percent of pediatric ERCPs, similar to that seen among adults [5,10,17,18]. It is defined as an increase in amylase or lipase (eg, >3 times the upper limit of normal) with associated abdominal pain and unintended hospital admission or prolongation of hospital stay for at least two days [19]. Most cases (60 to 80 percent) are mild [17,18]. It is more likely after pancreatic duct manipulation (duct injection, dilation or stenting, or sphincterotomy) [17,18].
In a retrospective study looking at factors associated with post-ERCP pancreatitis and the effect of pancreatic duct stenting in a pediatric population [18], a total of 432 ERCPs were performed in 313 patients younger than 19 years of age. Post-ERCP pancreatitis occurred in 10.9 percent, and was positively associated with pancreatic duct injection and pancreatic sphincterotomy. Among patients who had a pancreatic duct injection, placing a prophylactic pancreatic duct stent was associated with significantly increased rates of post-ERCP pancreatitis compared with those who had no attempt at stent placement. In multivariate analysis, a history of chronic pancreatitis was negatively associated with post-ERCP pancreatitis.
●Age considerations – In general, adverse event rates of ERCP in infants and children seem to be similar to those in adults [17].
Data are conflicting regarding whether complication rates differ in infants younger than one year compared with older children. Early case series suggest slightly higher complication rates [14-16]. In our unpublished experience with 184 neonates and young infants, minor adverse events without clinical significance occurred in 24 patients (13 percent), which is higher than our complication rate in children older than one year (1.6 percent). Two neonates had transient opiate-induced respiratory depression, and four young infants had nonopioid respiratory depression, which resolved with oxygen administration. In 17 patients, minor acute duodenal erosions were observed without clinical consequences. One neonate had abdominal distention for 10 hours after completion of ERCP, which resolved without treatment. There were no major adverse events. By contrast, another large series reported no complications in children younger than one year [20], and another reported fewer adverse events in young infants undergoing ERCP for neonatal cholestasis (3 percent) compared with other pediatric ERCPs (6 percent) [5]. These discrepant findings may be related to different patient populations (ie, proportion of neonatal cholestasis versus other indications for ERCP), different definitions of adverse events, and/or expertise in performing ERCP in infants.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)
SUMMARY
●Clinical setting and preparation – Endoscopic retrograde cholangiopancreatography (ERCP) in infants and children is generally performed at a tertiary care facility or by adult endoscopists who perform a high volume of procedures. In either case, the team must include providers with pediatric experience for patient preparation and for the procedure itself. Few facilities have experts specifically trained in pediatric therapeutic endoscopy or a high enough volume of these procedures to ensure optimal outcomes. (See 'Clinical setting' above.)
●Anesthesia – ERCP in infants and children is performed using monitored anesthesia care or general anesthesia. The choice depends on the pertinent risks, skill and experience of the endoscopist, and the expected complexity of the procedure. Collaboration with a pediatric anesthesiologist and therapeutic endoscopy nurses is strongly recommended. (See 'Anesthesia and monitoring' above.)
●Antibiotic prophylaxis – ERCP is generally associated with a higher risk for bacteremia than upper endoscopy alone, particularly in the presence of biliary obstruction. In general, patients with cystic or obstructing lesions of the biliary or pancreatic ducts should be given antibiotic prophylaxis to prevent cholangitis or infective pancreatitis. Prophylaxis is sometimes appropriate in patients at increased risk for infection, including organ transplant recipients, those who are otherwise immunocompromised, and patients with indwelling catheters. (See 'Antibiotic prophylaxis' above and "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)
●Endoscopic equipment – Use of a pediatric duodenoscope (insertion tube diameter of 7.5 mm, a channel of 2 mm, and an elevator) is mandatory in neonates and in infants younger than 12 months and is sometimes needed for children one to two years old. A standard adult duodenoscope can be used in older children (older than 12 months of age or weighing more than 10 to 15 kg) and adolescents. (See 'Endoscopic equipment' above.)
●Technique – The principles of cannulation are similar to those used in adult patients, but special techniques may be required in small patients because of the limited space within the duodenum and small size of the common bile duct. It is important to minimize radiation exposure and the procedure time to avoid abdominal overdistension and respiratory compromise, especially in young infants. The use of carbon dioxide and wire-guided cannulation technique is also favored. (See 'Technique' above.)
●Success – In children older than one year and adolescents, the rate of successful cannulation of the common bile duct at ERCP is more than 95 percent, comparable with reports in adults. In neonates and young infants, the rate of successful cannulation of the common bile duct is often lower than in adults, ranging from 27 to 95 percent in various reports. Experience of the endoscopists may account for a large part of the variability. (See 'Success' above.)
●Adverse events – The most common complication of ERCP is post-ERCP pancreatitis, which occurs in 3 to 12 percent of procedures in children. Other adverse events include infection, hemorrhage, and perforation (<1 percent of procedures). When the procedure is performed by experts with experience in this age group and with appropriate precautions, the incidence of adverse events is probably similar to that in adults. Major complications are rare. (See 'Adverse events' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Moises Guelrud, MD, who contributed to earlier versions of this topic review.
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