Edited by: Jorge Amil Dias, Centro Hospitalar de São João, Portugal
Reviewed by: Corentin Babakissa, Université de Sherbrooke, Canada; Tudor Lucian Pop, Iuliu Haieganu University of Medicine and Pharmacy, Romania
This article was submitted to Pediatric Gastroenterology, Hepatology and Nutrition, a section of the journal Frontiers in Pediatrics
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The superiority and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of biliary and pancreatic diseases in children have been increasingly recognized (
A 99-day-old boy was admitted to our hospital because of “abdominal B-ultrasound indicating gallbladder sludge for 2 months.” The infant was diagnosed with left nephroblastoma at birth. In the second cycle of chemotherapy, abdominal B-ultrasound indicated a low echo area in the gallbladder, and the diagnosis of gallbladder sludge was accordingly considered. The child exhibited jaundice and a progressive elevation in gamma-glutamyl transferase (γ-GT). He was transferred to our hospital for further treatment. The physical examination on admission revealed the following: temperature: 36.7°C, pulse rate: 154 times/min, respiratory rate: 36 times/min, blood pressure: 90/62 mmHg, percutaneous oxygen saturation: 97%, and weight: 7.5 kg. Mild jaundice was noted. He had no rash or blood spots on his skin. The heart and lung examinations were unremarkable. His abdomen was flat and non-tender and had no rebound tenderness. No mass was palpated. Murphy's sign was negative. The laboratory results revealed the following (
Changes in laboratory results before and after treatment.
TB (μmol/L) | 73.4 | 28.3 |
CB (μ/L) | 55.9 | 23.7 |
ALT (U/L) | 84 | 33 |
AST (U/L) | 103 | 31 |
γ-GT (U/L) | 2,189 | 1,033 |
AKP (U/L) | 607 | 201 |
Blood amylase (U/L) | 3 | 3 |
WBC(No./L) | 10.9 × l09 | 9.8 × l09 |
Neutrophils (%) | 8.9 | 24.1 |
Lymphocytes (%) | 81.5 | 62.3 |
After full communication and preoperative examinations were completed, the infant underwent ERCP. He was placed in the prone position and underwent ERCP under general anesthesia with intubation. An Olympus JF240 duodenal endoscope was used. The duodenal papilla appeared and had a granular, fluffy opening. An Olympus triple-lumen needle knife and a 0.025-inch Loach guide wire were used to achieve successful selective biliary cannulation. The bile sample obtained during backsuction was cloudy and dark. Under fluoroscopy, cholangiography was performed from the upper to lower segment of the CBD and showed dilation of the CBD (1.1 cm in diameter). Multiple contrast filling defects were observed in the CBD. At the 12 o'clock site of the bile duct, a small, 0.2 cm longitudinal incision was made in the papilla. No bleeding was observed at the cutting edge. A grasping basket was used to remove multiple black stones. Finally, a stone retrieval balloon was used to remove the stones in the bile duct. A 6 Fr straight-tip nasobiliary drainage catheter was placed at the end of the ERCP (
Operation process.
ERCP is an invasive procedure, and its application in children is still limited. It has been reported that ERCP in children accounts for 3.3% of all ERCP procedures (
ERCP has been applied in children since the mid-1970s. Although it has similar processes as adult ERCP, it has its own characteristics: children often cannot tolerate an ERCP and need sedation or anesthesia (
The success rate of ERCP (~90%) in children is similar to or slightly lower than that of adults (
Second, the operator should have sufficient skill in duodenoscopy. Particular caution should be paid when passing the endoscope through the upper corner of the duodenum at an appropriate angle according to the anatomical shape of duodenum. The endoscopist should not pull back blindly; pushing the endoscope forward is more important. When the endoscope reaches the papilla, the papilla should be fully exposed and evaluated. According to the axial direction of the pancreatobiliary tract, selective biliary cannulation should be performed, and the curve of the three-lumen needle knife should also be adjusted. The papilla in children is very delicate. Therefore, controlling the force required to push the guide wire is especially important. It is important to distinguish the difference when the guide wire is in the bile duct, pancreatic duct (PD), submucosal layer or circular muscle. It is necessary to stop the operation if the guide wire enters the submucosal layer or circular muscle. If repeated cannulation fails, ERCP should be abandoned to avoid complications. With regard to the prevention of PEP, there is no conclusion that the use of rectal non-steroidal anti-inflammatory drugs is beneficial, and the placement of PD stents is still controversial. A large-scale study showed that the prophylactic placement of PD stents during ERCP in children could increase the incidence of PEP (
When cannulation is successful, experimental backsuction is necessary to obtain bile to confirm successful catheter placement. Bile can be used for bacterial culture. Moreover, backsuction can reduce the pressure in the bile duct. The injection of contrast agent into the bile duct should be gentle and at an even rate under fluoroscopy. Excessive force or a high injection rate should not be used because they can cause excessive pressure in the biliary tract, which can cause retrograde infection (
A conscious child cannot tolerate the ERCP operation. ERCP in children must be under proper sedation or anesthesia to reduce the risk of mucosal damage, bleeding and perforation (
General anesthesia with intubation has the advantages of ensuring good ventilation and oxygenation. Due to relatively high airway resistance in children, they are prone to airway obstruction in any situation. In addition, the lateral position during ERCP can inhibit breathing and cause insufficient ventilation. For this infant, we used general anesthesia with intubation. The anesthetics were discontinued when the endoscope was withdrawn. Hand-controlled ventilation began to quickly expel sevoflurane. The tracheal tube was removed when the child awoke spontaneously and could respond to outside stimulation with eye opening. The child was transferred to a postoperative room for further observation. To reduce respiratory and oropharyngeal secretions in children and maintain a patent airway, atropine and low-dose dexamethasone can be routinely used before induction to inhibit glandular secretions; to prevent possible allergic reactions to the contrast agent, postoperative throat discomfort and edema; and to ensure the smoothness of the airway during and after ERCP.
In conclusion, ERCP is increasingly being widely used in children and should attract the attention of clinicians, especially endoscopists. We need more experience with adult duodenoscopy in children, and we hope that this technology will benefit more children. However, in terms of implementing pediatric ERCP, a sufficient risk assessment must be carried out, and informed consent must be obtained. The prevention of complications during ERCP, corresponding emergency plans and cooperation with anesthesia should be maintained to ensure the safety of ERCP in children. Otherwise, this procedure could have serious consequences.
All datasets generated for this study are included in the article/supplementary material.
Written informed consent for ERCP in this infant was obtained from the patient's legal guardian. Written informed consent from the patient's legal guardian was obtained for the publication of this case report and accompanying images. Copies of the written consent form are available for review from the editors of this journal.
QL assisted in the ERCP procedure, drafted and revised the manuscript, and approved the final manuscript. JS completed the whole anesthesia process, drafted the manuscript, and approved the final manuscript. XZ conceived the study, identified the disease, performed most of the ERCP procedure, revised and reviewed the manuscript, and approved the final manuscript. HS conceived the study and assisted with the ERCP procedure, drafted and revised the manuscript, reviewed the manuscript, and approved the final manuscript. All authors contributed to the article and approved the submitted version.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
total bilirubin
conjugated bilirubin
alanine aminotransferase
aspartate aminotransferase
gamma-glutamyl transferase
alkaline phosphatase
white blood cells.