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© Borgis - Postępy Nauk Medycznych 3/2014, s. 202-207
*Elwira Kołodziejczyk, Karolina Wejnarska, Jarosław Kierkuś, Grzegorz Oracz
Endoskopowa cholagiopankreatografia wsteczna (ECPW) u dzieci z chorobami trzustki
Endoscopic retrograde cholangiopancreatography (ERCP) in children with pancreatic diseases
Department of Gastroenterology, Hepatology and Feeding Disorders, The Children’s Memorial Health Institute, Warszawa
Head of Department: prof. Józef Ryżko, MD, PhD
Endoskopowa cholangiopankreatografia wsteczna (ECPW) jest wartościową metodą diagnostyczno-terapeutyczną w chorobach dróg żółciowych oraz trzustkowych w populacji pediatrycznej. Technika wykonywania ECPW nie jest trudniejsza u dzieci niż u dorosłych i z wyjątkiem niemowląt nie ma potrzeby stosowania specjalnego endoskopu pediatrycznego. U dzieci zabiegi ECPW są najczęściej przeprowadzane w znieczuleniu ogólnym. Rutynowa profilaktyka antybiotykowa budzi wiele kontrowersji, ponieważ brak jest dostępnych danych pediatrycznych dotyczących tego zagadnienia. Wskazania do wykonywania ECPW u dzieci są podobne jak u pacjentów dorosłych, chociaż ze znacznie mniejszą częstością występowania nowotworów. Wśród dzieci z chorobami trzustki do najczęstszych wskazań do wykonania ECPW należą: ostre lub nawracające ostre zapalenie trzustki, przewlekłe zapalenie trzustki, ból brzucha mogący mieć podłoże w schorzeniu trzustki czy dróg żółciowych, podejrzenie anomalii przewodu trzustkowego, uraz trzustki, diagnostyka różnicowa zmian ogniskowych trzustki oraz ocena przedoperacyjna trzustki. Procedury terapeutyczne stanowią 30-78% wszystkich zabiegów ECPW i odgrywają dużą rolę w leczeniu pacjentów z chorobami trzustki, w niektórych przypadkach oferując alternatywę dla leczenia chirurgicznego. Badania przeprowadzone wśród dzieci pokazują, iż ECPW ma wysoki stopień skuteczności i niski wskaźnik powikłań, gdy wykonywane jest przez doświadczonych endoskopistów. Rezonans magnetyczny dróg żółciowych (MRCP) w dzisiejszych czasach stał się narzędziem diagnostycznym pierwszego wyboru w diagnostyce chorób trzustki i dróg żółciowych. Można się spodziewać, iż w przyszłości zabiegi ECPW będą przeprowadzane przede wszystkim jako interwencja terapeutyczna.
Endoscopic retrograde cholangiopancreatography (ERCP) is nowadays a valuable method for detailed diagnostic evaluation and minimally invasive therapy for biliary and pancreatic diseases in pediatric population. The technique of ERCP is no more difficult in children than in adults, and except infants, there is no need for use a special pediatric endoscope. In children ERCP is usually performed with the patient under general anesthesia. Routine antibiotic prophylaxis is controversial, because there is no pediatric data regarding this problem. Pediatric indications for ERCP are similar to those for adults, though with a much lower incidence of malignant diseases. Among children with pancreatic diseases a common indications are: acute or recurrent acute pancreatitis, chronic pancreatitis, abdominal pain suspected to be of pancreaticobiliary origin, suspicion of pancreatic ductal anomaly, pancreatic trauma, differential diagnosis of focal pancreatic lesions and preoperative evaluation. Therapeutic ERCP constitutes 30-78% of all ERCPs and has a significant impact on the management of patients with pancreatic diseases, offering an alternative to surgical treatment in some cases. Pediatric studies demonstrates that ERCP has a high degree of technical success and a low rate of complications when performed by experienced endoscopists. MRCP nowadays has become the first-line diagnostic tool for biliopancreatic diseases and in the future ERCP may play a role mainly as a therapeutic intervention.
Słowa kluczowe: ECPW, choroby trzustki, dzieci.
Endoscopic retrograde cholangiopancreatography (ERCP) is a complex procedure that has been extensively used in the evaluation and treatment of pancreaticobiliary disorders among adults since the late sixties of the last century. In 1976, Waye performed the first successful cannulation of the ampulla of Vater in a 3.5-month old infant using the duodenoscope intended for adult patients (1). Initially pursuance of ERCP was limited to older children. Since the development in the technique and construction of a pediatric duodenoscope in 1991, the frequency of it’s use in younger patients, infants and newborns has increased. At present ERCP has become an established method for detailed diagnostic evaluation and minimally invasive therapy for biliary and pancreatic diseases in the pediatric population.
This article will review the current state of knowledge about ERCP in pediatric patients with pancreatic disorders, concentrating on the equipment, technique, indications, contraindications and the complications.
Conventional “adult” duodenoscopes can be safely used in the most pediatric patients more than 1 year of age or weighing more than 10 kg (2-7). For smaller infants and neonates, a pediatric duodenoscope with an outer diameter of 7.5 mm is available. This instrument has a 2.0-mm operative channel, delimiting the range of accessories that can be used. However sphincterotomes, extraction baskets, and retrieval balloons are commercially accessible, in the most of medical centers standard duodenoscopes are employed for therapeutic interventions. The 2.0-mm working channel enables appliance up to a 5-Fr stent (8). The procedures are performed under fluoroscopy control with an exposure of radiation kept to the minimum.
In small children and neonates there is a significantly greater airflow resistance and increased risk of dynamic or static episodes of airway occlusion than in adults. Furthermore, the semiprone position used for ERCP can be conducive to hypoventilation. With regard to these factors, the longer duration and degree of difficulty of many pediatric ERCPs, as well as the poor children cooperation during the procedure, they are most commonly performed under general anesthesia (3, 4, 7, 9). Among older children often conscious sedation is equally well used (6, 10, 11).
The important factor appears to be the experience of the endoscopist with ERCP. There are no established criteria of minimum number of interventions that must be performed before gaining competence in this age-group, but in conformity to the results of different studies and guidelines of the major gastrointestinal and surgical endoscopy societies (ASGE, SAGES, AGA) a minimum threshold of 50-100 ERCPs is usually mentioned (5, 12).
Routine antibiotic prophylaxis is controversial, because there is no pediatric data regarding this problem. In adults antibiotic prophylaxis is recommended before an ERCP in patients with communicating pancreatic cysts or pseudocysts and before transpapillary or transmural drainage of pseudocysts (13). Further investigation and analysis is needed to answer this challenging question.
Considered altogether, the contraindications for ERCP are the same as for upper endoscopy and include such as unstable pulmonary, cardiovascular or neurologic condition and suspected bowel perforation (2, 14, 15). Prior hepatoportoenterostomy (Kasai procedure) and anomaly or obstruction of oesophagus or stomach, which unable access to the duodenum, makes ERCP almost impossible (14). Coagulation disorders are a relative contraindication and should be corrected before ERCP. Insufficient experience in performing ERCP among pediatric patients should be also take into account.
Pediatric indications for ERCP are similar to those for adults, though with a much lower incidence of malignant diseases (15). It has been widely used to evaluate and treat pancreaticobiliary disorders.
In 1994, Werlin reviewed the 6 largest pediatric studies with a total of 260 ERCPs and noted that pancreatic disease was twice as common as biliary tract disease in children (16).
Nowadays, however, it seems that such indications may be changing. Basing on the survey presented by Gilger in 19 published series in children between 1979 and 2002 with a total of 695 procedures performed, biliary indications account for 47%, pancreatic indications for 40%, pain for 12% and other causes for 1 to 3% (17). Also in successive investigations percentage of pancreatic indications occurs to be the minority and varies between 16-45% (10, 11, 14, 18). These results indicates a recent tendency toward increasing share of biliary indications for ERCP in children. Reasons for this change may be inter alia an exposure of MRCP’s role in detecting diseases of pancreatobiliary tract and becoming ERCP mainly therapeutic procedure performed for such purposes as extracting biliary stones, which are more and more frequently found in children population (19).
Among children with pancreatic diseases a common indications are: acute or recurrent acute pancreatitis, chronic pancreatitis (CP), abdominal pain suspected to be of pancreaticobiliary origin, preoperative evaluation. ERCP is also attempted when there is a suspicion of pancreatic or pancreatic ductal anomaly, pancreatic trauma or in differential diagnosis of focal pancreatic lesions (tab. 1).
Table 1. Indications for ERCP.
Indications for ERCP
Chronic pancreatitis (CP)
Recurrent acute pancreatitis (RAP)
Acute pancreatitis (AP)
Abdominal pain suspected to be of pancreaticobiliary origin
Suspicion of pancreatic or pancreatic ductal anomaly
Suspicion of pancreatic trauma
Preoperative evaluation
Mass in the pancreas
ERCP is valuable in the evaluation and management of chronic pancreatitis. Direct pancreatography provides thorough information about anatomic changes in the main pancreatic duct or it often may be required to confirm definitive diagnosis. Ideally, ERCP should be used for treatment of abnormalities defined by non-invasive imaging techniques. MRCP enable pancreatic and biliary anatomy to be found less invasively, without risk of pancreatitis and radiation exposure. Related to adult studies, ERCP is effective in treating symptomatic strictures in CP (15). Dilation and stenting of pancreatic duct strictures appears to be successful and safe also in children (4, 7, 18), however long-term outcomes remains unknown. One of the most common indications for therapeutic ERCP in children with CP is the presence of calculi within a dilated pancreatic duct. Case series among adults have shown varies results (54-100%) with regard to relief in pain after pancreatic endotherapy (15). Unfortunately pediatric data is limited to a small group of patients (20-22). In some patients pancreatic sphincterotomy and stone removal can be difficult because of underlying duct stricture and may require extracorporeal shock wave lithotripsy (ESWL) to fragment the stones before endoscopic removal (fig. 1) (6).
Fig. 1. ERCP – picture of the chronic pancreatitis. Endotherapy, Warsaw.
In case of acute pancreatitis ERCP is indicated only if therapeutic procedure may resolve the acute episode, such as in gallstone pancreatitis. According to the studies among adult patients, early ERCP (within 24-48 hours of occurrence of symptoms) is advisable in acute biliary pancreatitis when a stone is localized in the common bile duct or when biliary obstruction or cholangitis is noticeable (14). Similar data about ERCP usage in AP in children population are very limited. Rocca et al. (3) described a small group (5 patients) of children with common bile duct stones initially presented with severe acute pancreatitis. After endoscopic sphincterotomy and stone extraction an immediate clinical improvement with complete symptomatic remission was observed.
Acute pancreatitis can lead to recurrent acute pancreatitis if the underlying factor remains uncorrected. On the faith of review of published experience analyzed by Benifla et al. recurrence is reported in 9% patients with an acute pancreatitis episode, most of them with idiopathic and structural etiologies (23). Biliary stones, family history of pancreatitis, drug ingestion, hypercalcemia, hypertriglycerydemia, pancreas divisum and genetic mutations occurres as an etiological factor in patients with RAP (24).

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otrzymano: 2013-12-20
zaakceptowano do druku: 2014-02-06

Adres do korespondencji:
*Elwira Kołodziejczyk
Department of Gastroenterology, Hepatology and Feeding Disorders
The Children’s Memorial Health Institute
Al. Dzieci Polskich 20, 04-730 Warszawa
tel. +48 (22) 815-73-84

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