Synopsis  

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.

 Introduction   

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.

 Patient preparation   

Sedation for ERCP in children   

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   

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   

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.

 Instruments   

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.

 Technique   

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   

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   

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   

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.
  

 Success rates for ERCP in children   

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%.

 Complications   

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%).

 Biliary findings (Fig. 3)   

Biliary atresia vs. neonatal hepatitis   

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   

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   

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   

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   

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   

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   

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   

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

Type I   

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   

Type II is a diverticulum anywhere in the extrahepatic duct.

Type III   

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

Type IV   

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

Type V   

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

Choledochocele   

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   

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   

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   

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   

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   

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   

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   

Primary stricture   

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   

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

Liver transplantation   

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   

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

 Pancreatic findings (Fig. 17)   

Recurrent pancreatitis   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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   

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].

 Outstanding issues and future trends   

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.

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