Endoscopic cholangiopancreatography in the infant: evaluation of a new prototype pediatric duodenoscope

Interventional endoscopy for abdominal transplant patients

Interventional endoscopy can play a significant role in the care and management of children pre-and post- abdominal solid organ transplantation. Such procedures primarily include endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), and balloon-assisted enteroscopy (BAE), though additional interventions are available using standard endoscopes (gastroscopes, colonoscopes) for therapeutics purposes such as endoscopic hemostasis. The availability of pediatric practitioners with the advanced training to effectively and safely perform these procedures are most often limited to large tertiary care pediatric centers. These centers possess the necessary resources and ancillary staff to provide the comprehensive multi-disciplinary care needed for these complex patients. In this review, we discuss the importance of interventional endoscopy in caring for transplant patients, during their clinical course preceding the potential need for solid organ transplantation and inclusion of a discussion related to endoscopic post-surgical complication management. Given the highly important role of interventional endoscopy in patients with recurrent and chronic pancreatitis, we also include a discussion related to this complex disease process leading up to those patients that may need pancreas surgery including total pancreatectomy with islet autotransplantation (TPIAT).

Endoscopic Retrograde Cholangiopancreatography in Infants: Availability Under Threat: A Survey on Availability, Need, and Clinical Practice in Europe and Israel

Endoscopic retrograde cholangiopancreatography (ERCP) in infants (younger than 1 year of age) is a highly specialized procedure. Since 2014 opportunities to maintain or purchase duodenoscopes for ERCP in infants have disappeared. In a survey among European hepatology centers (including Israel) we evaluated the availability, need, indications, and practice of ERCP procedures in infants. It shows that infant ERCP is a low-volume procedure (median 5 procedures/year) in the 14 centers that perform this procedure. Since 2014 several centers no longer have an infant ERCP duodenoscope due to breakdown. In addition, substantial differences exist between centers in indications, types of interventions performed, and practical execution of ERCP procedures in infants. We conclude that a concerted effort by the pediatric hepatology community is needed to secure the future availability of infant ERCP. In addition, consensus on the indications and optimal use of infant ERCP could improve the quality of ERCP care for infants.

Evaluation of the use of laparoscopic-guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice

BACKGROUND

Once it is established that a jaundiced infant has direct hyperbilirubinemia, the principal diagnostic concern is to differentiate hepatocellular from obstructive cholestasis. Traditional tests such as ultrasonography, percutaneous liver biopsy and technetium 99 m hepatobiliary iminodiacetic acid (HIDA) scan are often not sufficiently discriminating. Definitive exclusion of biliary atresia (BA) in the infant with cholestatic jaundice usually requires mini-laparotomy and intra-operative cholangiography. This approach has many drawbacks because those sick infants are subjected to a time-consuming procedure with the probability of negative surgical exploration.

AIM OF THE STUDY

The aim of this study was to determine the feasibility of laparoscopic-guided cholecystocholangiography (LGCC) and its accuracy and safety in the diagnosis of BA and thus preventing unnecessary laparotomy in infants whose cholestasis is caused by diseases other than BA.

PATIENTS AND METHODS

Twelve cholestatic infants with direct hyperbilirubinemia subjected to LGCC (age, 7-98 days; mean, 56 days) after ultrasound scan and (99 mTc) HIDA scan and percutaneous liver biopsy failed to provide the definitive diagnosis.

RESULTS

One patient had completely absent gall bladder (GB) so the laparoscopic procedure was terminated and laparotomy was done (Kasai operation). Four patients had small size GB; they underwent LGCC that showed patent common bile duct with atresia of common hepatic duct, so laparotomy and Kasai operation was performed. Seven patients had well-developed GB, LGCC revealed patent biliary tree, so laparoscopic liver biopsies were taken for histopathology. Five of those patients had neonatal hepatitis, and two had cholestasis as a complication of prolonged TPN. No perioperative complications or mortalities were recorded.

CONCLUSION

When the diagnosis neonatal cholestasis remains elusive after traditional investigations, LGCC is an accurate and simple method for differentiating BA from hepatocellular causes.

Endoscopic approach to the patient with congenital anomalies of the biliary tract

Congenital biliary tract anomalies typically present with neonatal cholestasis. In children and adults, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound are used to evaluate and treat choledochal cysts. Contrarily, endoscopy has traditionally played a minor role in the diagnosis of the cholestatic infant. Recent studies support the incorporation of ERCP into the diagnostic algorithm for biliary atresia and neonatal cholestasis. But at present, most pediatric liver centers do not consider its use essential. This article reviews the congenital biliary tract anomalies in which endoscopy has been shown to contribute to the evaluation of the cholestatic infant.

Endoscopic retrograde cholangiopancreatography is useful and safe in children

PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) is a recognized diagnostic and therapeutic tool in the adult population. Its use in children has been more common in the last years. There are little data on safety and usefulness of that procedure in children. The aim of this study was to review the experience with ERCP in a tertiary university center dedicated to children.

METHOD

We conducted a retrospective chart review of patients seen at the Centre Hospitalier Universitaire Ste-Justine (Montreal, Quebec, Canada) who had undergone an ERCP between September 1990 and July 2007. Data on demographics, diagnosis, anesthesia type, treatments, and complications were collected.

RESULTS

Thirty-eight ERCPs were performed on 29 patients. There were 21 girls (72%), and median age at time of procedure was 10.3 years old (range, 3-17 years). Most had only one procedure performed. Two children had 2 interventions, and 1 child with papillary stenosis had 8 interventions linked to stent treatment. The ampulla was cannulated, and the procedure was successfully completed in 97% (37/38) of cases. General anesthesia and sedation were performed in 74% and 26% of procedures, respectively. Indications for ERCP were 29 recurrent or chronic pancreatitis (76%), 8 common bile duct obstructions (21%), and 1 choledochal cyst (3%). Endoscopic treatment was done in 29% of cases. The complication rate was 13.5%, and 4 clinical acute pancreatitis resolved with conservatory treatment. No severe pancreatitis, perforation, or bleeding was noted. Of the patients, 79% had their follow-up at the Centre Hospitalier Universitaire Ste-Justine for a median length of 43 months (range, 1-53 months).

CONCLUSION

Endoscopic retrograde cholangiopancreatography is used as a diagnostic and therapeutic procedure in children with a complication rate similar to that seen in adults. The need for general anesthesia is much more frequent with children. When performed by well-trained endoscopists, ERCP is useful and safe in children.

[Endoscopic retrograde cholangiopancreatography in patients aged less than 18 years old: our experience]

BACKGROUND

There is scant information on the use of endoscopic retrograde cholangiopancreatography (ERCP) in patients under 18.

OBJECTIVE

To analyze our experience in all patients under 18 who underwent ERCP.

PATIENTS AND METHODS

We performed a retrospective study of all ERCP conducted in patients under 18 between 1993 and 2006. We analyzed indications, endoscopic and radiologic findings, diagnostic and therapeutic success, and complications.

RESULTS

We included 31 patients who underwent 36 ERCP in total. The mean age was 9.89 +/- 5 years old. We used general anesthesia in 58.3% (21 patients), with a mean age of 8 +/- 5 years. The most frequent indications were complications after liver transplantation in 33.3% (12 patients), suspicion of biliary obstruction in 27.7% (10 patients), and pancreatitis in 22.2% (8 patients). We achieved cannulation and repletion in the selected duct in 94.4%. The most frequent pathologic findings were changes in the biliary tract after liver transplantation in 25% (9 patients). The results of ERCP were normal in 10 patients (27.7%). Therapeutic maneuvers were indicated in 17 out of the 34 (50%) examinations considered, achieving therapeutic success in 76.47% (13/17). Complications consisted of hemorrhage after simple sphincterotomy in one patient (2.8%) and mild pancreatitis in two patients (5.6%).

CONCLUSIONS

We found ERCP to be a safe procedure with a high diagnostic and therapeutic success rate, and a low rate of early complications.

[Endoscopic management of severe pancreatic and biliary diseases in children]

Endoscopic treatment of pancreatic pseudocysts and choledocal lithiasis is a first-line treatment in adults. Nevertheless, due to technical difficulties such a management is not always feasible in children. This series reports our results in the management of pancreatic and biliary diseases in children. Seven children, two months to 12 years old, underwent endoscopic management of pancreatic and biliary diseases. Two of them had choledocal lithiasis with jaundice or acute pancreatitis, two had pancreatic pseudocyst due to abdominal traumatism, two had chronic pancreatitis with a communicating pseudocyst in one case, and one had a biliary leakage after traumatism. All the endoscopic treatments were performed under general anesthesia. In six cases, the duodenoscope was a regular one with a large operating channel (Olympus TJF 160; Japan) employed for children aged 33 months to 12 years. In the case of the two months child, a "rendez-vous" technique was performed with a percutaneous approach of the common bile duct followed by an endoscopic sphincteroclasy using an axial endoscope allowing the extraction of a choledocal stone. In two cases, post-traumatic pancreatic pseudocysts (eight and 12 year-old children) were managed with the transgastric insertion of two double pig-tail stents. In two cases, children with chronic pancreatitis (38 months and 12 years old) were managed with pancreatic sphincterotomy. Biliary leakage in an 11-year-old child was managed with biliary sphincterotomy and stenting. All the children became symptom-free without any procedural complications with an 11 months median follow-up. Endoscopic treatment of pancreatic and biliary diseases is possible in children like in adults with the same procedures and results.

Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

For the primary care provider, cholestatic jaundice in infancy, defined as jaundice caused by an elevated conjugated bilirubin, is an uncommon but potentially serious problem that indicates hepatobiliary dysfunction. Early detection of cholestatic jaundice by the primary care physician and timely, accurate diagnosis by the pediatric gastroenterologist are important for successful treatment and a favorable prognosis. The Cholestasis Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has formulated a clinical practice guideline for the diagnostic evaluation of cholestatic jaundice in the infant. The Cholestasis Guideline Committee, consisting of a primary care pediatrician, a clinical epidemiologist (who also practices primary care pediatrics), and five pediatric gastroenterologists, based its recommendations on a comprehensive and systematic review of the medical literature integrated with expert opinion. Consensus was achieved through the Nominal Group Technique, a structured quantitative method. The Committee examined the value of diagnostic tests commonly used for the evaluation of cholestatic jaundice and how those interventions can be applied to clinical situations in the infant. The guideline provides recommendations for management by the primary care provider, indications for consultation by a pediatric gastroenterologist, and recommendations for management by the pediatric gastroenterologist. The Cholestasis Guideline Committee recommends that any infant noted to be jaundiced at 2 weeks of age be evaluated for cholestasis with measurement of total and direct serum bilirubin. However, breast-fed infants who can be reliably monitored and who have an otherwise normal history (no dark urine or light stools) and physical examination may be asked to return at 3 weeks of age and, if jaundice persists, have measurement of total and direct serum bilirubin at that time. This document represents the official recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition on the evaluation of cholestatic jaundice in infants. The American Academy of Pediatrics has also endorsed these recommendations. These recommendations are a general guideline and are not intended as a substitute for clinical judgment or as a protocol for the care of all patients with this problem.

Endoscopic retrograde cholangiopancreatography in children and adolescents

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is becoming a more frequently used diagnostic and therapeutic tool in children. We sought to determine the indications, feasibility, safety, and effect on patient management of ERCP in pediatric patients of varying age.

METHODS

All ERCPs performed during a 4-year period in patients aged 18 years or less at an academic hospital were retrospectively reviewed. The indications, type of anesthesia administered, type of duodenoscope used, diagnostic findings, therapeutic interventions, complication rate, and effect on management were compared between children (age 0-12 years) and adolescents (age 13-18 years).

RESULTS

A total of 53 procedures were performed in 43 patients whose median age was 13.5 years. ERCP was successful in 50 of 53 cases (94%) with a complication rate of 6%. Endoscopic therapy was provided in 24 of 53 cases (45%). Compared with adolescents (n = 28), children (n = 25) were more likely to receive general anesthesia (96% vs. 29%; P < 0.001) and undergo ERCP with a pediatric duodenoscope (0% vs. 40%). ERCP affected management in 73% of cases, equally in both groups.

CONCLUSION

ERCP is a successful and safe diagnostic and therapeutic modality in a variety of pancreatobiliary disorders that directly affects management in children of all ages.

Therapeutic ERCP in the management of pancreatitis in children

BACKGROUND

The use of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is increasing in the management of pancreatobiliary diseases in children.

METHODS

Over a 32-month period, we performed 34 ERCP procedures for the treatment of pancreatitis in 22 children at two university hospitals. Demographics and clinical data and ERCP findings were documented. Clinical status was assessed 6 months before the first ERCP and 6 months after the last ERCP, according to general condition, severity and frequency of pain, and health care encounters (emergency department visits, clinic visits, and hospital admissions related to the pancreatitis).

RESULTS

Mean age of the patients was 10.7 years (range 1.5 to 17 years). Abdominal pain was the main presenting symptoms with hyperamylasemia and hyperlipasemia. Clinical diagnoses included acute pancreatitis (6), recurrent pancreatitis (5), and chronic pancreatitis (11). The mean follow-up was 16.4 months. Nine patients had sphincter manometry, with abnormal results leading to biliary sphincterotomy in 4. Fifteen patients underwent a total of 23 therapeutic ERCP procedures unrelated to sphincter dysfunction. There were 2 complications of 34 procedures (6%), both being mild pancreatitis after sphincter manometry. There were no deaths. There was a significant reduction in frequency (p < 0.01) and severity of pain (p < 0.01) after intervention. Patients without pancreatographic changes of chronic pancreatitis had the most marked clinical improvement (p < 0.05). In those with ductal changes of chronic pancreatitis, clinical improvement was not predicted by the extent of ductal changes. There was a significant decrease in health care encounters (p < 0.05) and improvement in general condition (p < 0.01) after endoscopic therapy, especially in those with a normal pancreatogram.

CONCLUSIONS

Therapeutic ERCP is safe in pediatric patients with pancreatitis. Significant clinical improvement is achieved in patients with biliary or pancreatic stone disease. Prospective studies with long-term follow-up are needed to determine the impact of endoscopic therapy in patients with chronic pancreatitis and sphincter of Oddi dysfunction.

Endoscopic retrograde cholangiopancreatography in paediatric patients with biliary disorders

Endoscopic retrograde cholangiopancreatography (ERCP) has long been used in children. The usefulness of ERCP in paediatric patients with various biliary disorders, however, has not been well documented. Thirty-two sessions of ERCP performed in 29 paediatric patients ranging in age from 1 month to 15 years were evaluated. Endoscopic retrograde cholangiopancreatography was to confirm diagnosis or to obtain detailed information about their pancreaticobiliary system. Cannulation was successful in all patients. Opacification of the biliary tracts was also successful in all except for three patients with extrahepatic biliary atresia. Endoscopic retrograde cholangiopancreatography was assessed to be successful in making a differential diagnosis of neonatal hepatitis from extrahepatic biliary atresia, and in having a confirmed diagnosis of anomalous arrangement of the pancreaticobiliary ductal system associated with choledochal cyst. The procedure was also useful for obtaining detailed information on the pancreaticobiliary system in the other children. No accidents occurred during the endoscopic procedures in any of the paediatric patients. When a confirmed diagnosis or detailed information is needed in paediatric patients with biliary disorders, ERCP is a useful and safe technique.

The role of ERCP in biliary atresia

BACKGROUND

It is not easy to discriminate between infantile hepatitis and biliary atresia in spite of several diagnostic tests including laboratory analyses, ultrasound, and hepatobiliary scans. ERCP is the most useful procedure for visualization of the extrahepatic biliary system, but ERCP is still an uncommon procedure in children.

METHODS

ERCP examination was performed in 52 infants with biliary atresia (10 with infantile hepatitis, 5 with congenital biliary dilatation, 3 with paucity of intrahepatic bile duct, 2 with duodenal atresia, and 1 with postoperative jaundice of hepatoblastoma) aged from 8 days to 300 days (mean, 71 days).

RESULTS

ERCP was successful in 47 with biliary atresia, in 9 with infantile hepatitis, and 10 with another disease. Liver biopsy was performed in 1 infant with hepatitis in whom the cannulation failed; in 9 with hepatitis in whom the cannulation was successful, exploratory laparotomy could be avoided. The ERCP findings in 46 patients with biliary atresia (excluding 1 in whom evaluation could not be performed because of poor x-ray quality) were classified into four patterns.

CONCLUSIONS

A success rate of ERCP examinations in infants was 88%, so ERCP is recommended to make a correct decision regarding the need for surgery in cholestatic disorders.

Endoscopic retrograde cholangiopancreatography (ERCP) in biliary tract disease of infants less than one year old

We performed a total of 75 examinations with endoscopic retrograde chlangiopancreatography (ERCP) in 73 infants aged from 8 days to 300 days (mean 71 days) between 1977 and 1995. ERCP examination was performed with a prototype duodenoscope and was successful in 47 of 52 examinations in biliary atresia, 9 of 11 in neonatal hepatitis, all 4 in paucity of intra-hepatic bile duct, 4 of 5 in congenital biliary dilatation, 1 of 2 in duodenal stricture, and 1 case of in postoperative jaundice of hepatoblastoma. In 46 infants with biliary atresia, excluding one in whom the findings could not be evaluated due to poor x-ray image quality, we distinguished the following four patterns of ERCP findings: Pattern 1, only the pancreatic duct could be demonstrated and no bile duct was visualized (76%); Pattern 2, only a part of the distal common bile duct with the pancreatic duct was visualized (2%); Pattern 3, the entire length of the common bile duct with the pancreatic duct was visualized without the gallbladder and the common hepatic duct (4%); and Pattern 4, the common bile duct and the gallbladder with the pancreatic duct were visualized without the common hepatic duct (18%). In all of these 46 patients, laparotomy, an operative cholangiogram, and histological evaluation of the biliary duct were performed. In 9 neonates with neonatal hepatitis, the biliary tract was opacified and biliary atresia was excluded. Laparotomy was thus avoided in these neonates. There was no complication caused by either ERCP or by anesthesia.

Neonatal cholestasis. New approaches to diagnostic evaluation and therapy

Neonatal cholestasis remains a major diagnostic challenge despite increasing knowledge regarding its pathogenesis. The time constraint and urgency in the investigational process is underscored by the age-dependent success rate of the surgical corrective procedures for EHBA. Appropriate interpretation of imaging and pathologic studies requires a pediatric center familiar with the entities causing neonatal cholestasis. When liver failure or progressive hepatic dysfunction is likely to occur, early referral to a liver transplant center is recommended. Despite the increasing experience and excellent results of pediatric liver transplantation, at this point, surgical corrective procedures such as the Kasai procedure remain the first line of treatment for most patients with EHBA.

The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents

ERCP was performed in 51 patients, aged 1 to 18 years, as part of diagnostic evaluation for recurrent pancreatitis without obvious cause or as therapeutic intervention. ERCP was successful in 50 patients (98%). Thirty-four patients (68%) had anatomic findings indicating a possible cause of recurrent pancreatitis. Three patients (6%) had findings suggestive of sphincter of Oddi dysfunction. Eighteen of the 37 patients (49%) with ductal abnormalities underwent endoscopic therapy, with a favorable outcome in 15 (83%). Eleven patients were treated surgically, and 8 of these patients (73%) improved symptomatically. Eight patients received no treatment, and 6 of them (67%) had recurrent bouts of clinical pancreatitis. One mild case of pancreatitis (1.9%) occurred after ERCP, and 3 mild cases followed endoscopic therapy. In conclusion, ERCP is a relatively safe technique that produces opacification of the desired ductal system with a high degree of accuracy and provides useful information in the evaluation of children with idiopathic recurrent pancreatitis. These data suggest that endoscopic pancreatic therapy may result in symptomatic improvement, eliminating the need for surgery in selected children. Furthermore, the study demonstrates that manipulation of the pancreatic duct is comparatively safe and less hazardous than formerly believed.

Endoscopic therapy of pancreatitis in the pediatric population

Six children with chronic relapsing pancreatitis or acute post-traumatic pancreatic pseudocyst underwent therapeutic pancreatography at the time of ERCP. Procedures included pancreaticobiliary sphincterotomy, pancreatic duct stone removal, and endoprosthesis placement. Four of five patients with chronic pancreatitis had significant symptomatic improvement, whereas the patient with pseudocyst had rapid resolution of symptoms and cyst. Complications were limited to mild pancreatitis in a subset of patients. With the capability of obviating or delaying the need for palliative pancreatic surgery, therapeutic pancreatography deserves additional evaluation in the pediatric patient.

ERCP and endoscopic sphincterotomy in infants and children with jaundice due to common bile duct stones

ERCP was performed in two infants (29 and 62 days old) and eight children (5 to 12 years old) with jaundice due to common bile duct stones. Seven patients had hemolytic anemia and three patients had a family history of gallstone disease. Successful cannulation of the common bile duct demonstrating stones was accomplished in all patients. Four patients had coexisting gallstones and were treated surgically. Six children who had previously undergone cholecystectomy were treated by endoscopic sphincterotomy and stone extraction without complication. We believe that ERCP should be utilized by expert endoscopists in children with evidence of extra-hepatic cholestasis, and endoscopic sphincterotomy should be the treatment of choice in children who have previously undergone cholecystectomy, and who are jaundiced secondary to common bile duct stones.

ERCP in the diagnosis of extrahepatic biliary atresia

This study assessed the usefulness of ERCP in the diagnosis of biliary atresia. We evaluated 57 infants with prolonged cholestasis with abdominal ultrasound, liver biopsy, and ERCP. Using clinical observations alone, 22 infants were thought to have biliary atresia; whereas 35 children were thought to have neonatal hepatitis. The ERCP was performed with a prototype duodenoscope and was successful in all infants except two with biliary atresia. In 20 infants three types of radiological findings consistent with biliary atresia were seen: type 1, no visualization of biliary tree (35%); type 2, opacification of the distal common duct and gallbladder without visualization of the main hepatic duct (35%); and type 3, opacification of the distal common duct, the gallbladder, and a segment of the main hepatic duct with biliary lakes at the porta hepatis (30%). Twenty-five of 35 infants with suspected neonatal hepatitis were excluded because of a liver biopsy that was diagnostic. In the remaining 10 infants the liver biopsy had some features of extrahepatic biliary atresia and ERCP was performed prior to surgery. A normal extrahepatic biliary tree was obtained in all of them. In conclusion, ERCP permits the visualization of the biliary tree in young infants and is useful in selecting those infants who should be considered for exploratory laparotomy.

Pancreatic ascites presenting in infancy, with review of the literature

We report a 4-month-old boy with massive ascites in whom a diagnosis of pancreatitis was made on a raised ascitic amylase level after two inconclusive laparotomies. He developed a pseudocyst which was managed with repeated percutaneous needle aspirations, nutrition being maintained intravenously. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a congenital intra-pancreatic cyst. He thrived after operation drainage for recurrent pseudocyst, but repeat ERCP shows that the cyst in the head of the pancreas remains. Pancreatic ascites is rare in children and diagnosis is frequently delayed. A third of reported cases in childhood present in the first year of life. A search for the underlying cause should include an ERCP to demonstrate abnormalities of the pancreaticobiliary ducts.

Endoscopic retrograde cholangiopancreatography in infantile cholestasis

The difficulty of distinguishing surgically correctable causes of conjugated hyperbilirubinaemia in infants from other causes means that some infants may undergo laparotomy and intraoperative cholangiography unnecessarily, and others may be referred for surgery too late. In an attempt to improve the diagnostic accuracy in infants with conjugated hyperbilirubinaemia when standard methods produced equivocal results, we have been using prototype paediatric duodenoscopes (PJF 7.5 and XPJF 8.0; Olympus) to perform endoscopic retrograde cholangiopancreatography (ERCP). From 159 infants with conjugated hyperbilirubinaemia, 11 were referred for ERCP, which was performed in nine. In four in whom bile ducts were definitely visualised laparotomy was avoided. Operative cholangiography confirmed patent bile ducts in one in whom visualisation had been uncertain. Three of four in whom bile ducts were not seen had extrahepatic biliary atresia. Visible bile drainage in the fourth excluded atresia. No major complications ensued but there was radiological evidence of gall bladder perforation in one (common hepatic duct block) and overinflation with air was a problem until finer cannulae (Wilson-Cook) were introduced. In appropriately selected patients with conjugated hyperbilirubinaemia, ERCP with paediatric duodenoscopes in experienced hands may provide useful diagnostic information.

Endoscopic retrograde cholangiography in the diagnosis of biliary malformations in infants

The differentiation of infantile biliary malformations from primary parenchymal diseases is difficult. The recent development of a pediatric side-viewing endoscope (PJF Endoscope; Olympus Corporation of America) provided an opportunity to investigate the usefulness of endoscopic retrograde cholangiography (ERC) for precise visualization of the extrahepatic biliary passages in infants with persistent cryptogenic cholestasis. ERC was performed in 12 patients, with visualization of the existing extrahepatic bile ducts in 4. The entire biliary system was visualized in one, excluding extrahepatic biliary atresia and choledochal cyst. The reduced caliber of the intrahepatic bile ducts and histological observations in a percutaneous liver biopsy supported the diagnosis of intrahepatic biliary hypoplasia in this case. An intact hepatic portochole cystostomy was documented in one, although the intrahepatic biliary system was not delineated. Atresia of the hepatic bile ducts proximal to the gallbladder was documented in two. Of the eight patients in whom extrahepatic bile ducts were not visualized by ERC, six had extrahepatic biliary atresia confirmed at exploratory laparotomy. The papilla of Vater could not be located in four of these six infants. The remaining two had neonatal hepatitis. ERC may offer a useful alternative to operative cholangiography in selected infants with persistent cholestasis and acholic stools.

Fiberoptic upper intestinal endoscopy in infants and children

Fiberoptic upper intestinal endoscopy has been shown in the last decade to be the most sensitive technique to diagnose upper gastrointestinal disease. Diagnostic endoscopy has been shown to be safe, with a low complication rate of less than 2 per cent, and most of those reported have been minor. Furthermore, therapeutic endoscopy has been used to treat bleeding varices by sclerotherapy, avoiding the need for shunting procedures, which often fall in young children. Dilation of strictures with wire-guided dilators, endoscopic incision of antral mucosal diaphragms, and percutaneous placement of gastrostomy tubes are other ways endoscopy is being used as a means of treatment. Electrocoagulation and photocoagulation of bleeding upper gastrointestinal lesions have not been used.