The role of endoscopic retrograde cholangiopancreatography in cholestatic infants

Comparison of different diagnostic methods for differentiating biliary atresia from idiopathic neonatal hepatitis

AIM

To retrospectively analyze different methods in differentiating biliary atresia from idiopathic neonatal hepatitis.

METHODS

Sixty-nine infants with cholestatic jaundice and final diagnosis of idiopathic neonatal hepatitis (INH) and biliary atresia (BA) were studied retroprospectively from January 2004 to December 2006. A thorough history and physical examination were undertaken. All cases underwent abdominal magnetic resonance cholangiography (MRCP), ultrasonography (US), hepatobiliary scintigraphy (HBS), HBS single-photon emission computer tomography (HBS SPECT), and operation or percutaneous liver biopsy. The accuracy, sensitivity, specificity, and predictive values of these various methods were compared.

RESULTS

There were 39 girls and 30 boys, among whom 35 had INH (age, 61+/-17 days) and 34 had BA (age, 64+/-18 days). The mean age at onset of jaundice was significantly lower in cases of BA when compared to INH cases (9+/-13 vs. 20+/-21 days; P=.032). The diagnostic accuracy of different methods was as follows: liver biopsy, 97.1%; HBS SPECT, 91.30%; MRCP, 71.01%; HBS, 66.67%; US, 65.22%.

CONCLUSION

Our results indicate that biopsy of the liver is considered as the most reliable method to differentiate INH from BA. The accuracy of HBS SPECT is higher than that of MRCP, HBS, and US. There was no significant difference in diagnostic accuracy among MRCP, HBS, and US.

Endoscopic retrograde cholangiopancreaticography prior to explorative laparotomy avoids unnecessary surgery in patients suspected for biliary atresia

BACKGROUND/AIMS

Timely diagnosis of biliary atresia (BA) requires key investigations that are less invasive but as accurate as possible. Non-invasive imaging preselects patients before explorative laparotomy is performed. The purpose of this prospective study was to evaluate the accuracy of endoscopic retrograde cholangiopancreaticography (ERCP) in these patients and to discuss its relevance to future diagnostic guidelines in neonatal jaundice.

METHODS

Over a 7-year period, ERCP was routinely performed in cholestatic patients less than 6 months of age suspected for an extrahepatic origin of cholestasis, most likely BA. Endoscopic diagnosis was correlated with intraoperative findings.

RESULTS

In 140 consecutive patients (mean age: 60 days; weight: 4 kg), ERCP excluded BA in 34 (25%) but failed in 18 newborns (13%) for technical reasons. The average procedure time was 23 min, and no severe complications occurred. Explorative laparotomy was performed in 106 patients and revealed BA in 80 cases. In this series, the sensitivity of ERCP for diagnosing biliary atresia was 92% and specificity was 73%.

CONCLUSIONS

In preselected patients, ERCP is not an alternative to non-invasive imaging, but it avoids unnecessary surgical procedures in almost 25% of the cases. Hence, ERCP is recommended prior to explorative laparotomy in all patients suspected for BA.

Is endoscopic retrograde cholangiopancreatography valuable and safe in children of all ages?

OBJECTIVE

To evaluate indications, findings, therapies, safety, and technical success of endoscopic retrograde cholangiopancreatography (ERCP) in children of the Emma Children's Hospital Academic Medical Centre in Amsterdam, the Netherlands.

DESIGN

Descriptive. Retrospective analysis by medical records.

PATIENTS AND METHODS

Information was obtained by chart review of patients between 0 and 18 years who underwent ERCP from 1995 to 2005 in our center. The following data were analyzed: indications, findings, therapies, safety, and technical success. Success was defined as obtaining accurate diagnostic information or succeeding in endoscopic therapy.

RESULTS

Sixty-one children (age 3 days to 16.9 years, mean age 7.0 years) underwent a total of 99 ERCPs. Of those patients, 51% (31/61) were younger than 1 year, 84% had biliary indications, and 16% had pancreatic indications for the performance of ERCP. The complication rate was 4% (4/99) and included substantial pancreatitis and mild irritated pancreas. No complications occurred in children younger than 1 year.

CONCLUSIONS

ERCP is a safe and valuable procedure for children of all ages with suspicion of pancreaticobiliary diseases. Indications for ERCP are different for children and adults. A laparotomy could be prevented in 12% of children with suspicion of biliary atresia. Further research is required to determine the role of MRCP versus ERCP.

[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.

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.

Anaesthesia, perioperative management and outcome of correction of extrahepatic biliary atresia in the infant: a review of 50 cases in the King's College Hospital series

Extrahepatic biliary atresia (EHBA) is an uncommon condition presenting in the first few weeks of life. It has an incidence of 0. 5-1 per 10 000 live births and is the end result of a destructive inflammatory process involving the extrahepatic biliary system of unknown aetiology occurring in utero. The net result is neonatal jaundice due to bile stasis, with subsequent hepatocellular damage and cirrhosis. In the untreated, patient death is inevitable within 2 years. Precise diagnosis (or exclusion) of EHBA in the persistently jaundiced infant must be made urgently and major surgery (hepatic portoenterostomy: Kasai procedure) carried out as soon as possible, preferably before 6-8 weeks of age. This review is concerned with anaesthesia for correction of EHBA in 50 consecutive patients and also outlines the experience gained in the largest European centre for correction of EHBA where the number of cases now approaches 500.

Biliary atresia in neonates and infants: triangular area of high signal intensity in the porta hepatis at T2-weighted MR cholangiography with US and histopathologic correlation

PURPOSE

To correlate a triangular area of high signal intensity in the porta hepatis on T2-weighted magnetic resonance (MR) cholangiograms of biliary atresia with ultrasonographic (US) and histopathologic findings in a portal mass observed during a Kasai procedure.

MATERIALS AND METHODS

Twenty-one consecutive neonates and infants (age range, 13-88 days; mean age, 59 days) with cholestasis underwent US and single-shot MR cholangiography. In 12 patients with biliary atresia diagnosed at histopathologic examination, MR cholangiographic findings in the porta hepatis were correlated with US and histopathologic findings in the portal mass.

RESULTS

At US, eight of the 12 patients had round, linear, or tubular hypoechoic portions within a triangular cord; MR cholangiography revealed a triangular area of high signal intensity confined to the porta hepatis. Histopathologic examination of the portal mass revealed a cystic or cleftlike lesion surrounded by loose myxoid mesenchyme and platelike fetal bile ducts. Neither the large cystic lesion without ductal epithelium nor the small cleftlike lesion with scanty epithelium demonstrated bile staining. Similar areas of high signal intensity were not seen on T2-weighted images in the remaining patients (four with biliary atresia and nine with neonatal hepatitis).

CONCLUSION

In biliary atresia, T2-weighted single-shot MR cholangiography can show a triangular area of high signal intensity in the porta hepatis that may represent cystic dilatation of the fetal bile duct.

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.