Endoscopic Retrograde Cholangiopancreatography (ERCP) Performed in Children Y. Urakami, H. Seki, S. Kishi 2nd Department of Internal Medicine, School of Medicine, Tokushima University, Japan
Summary
The value of ERCP in children is demonstrated on 3 cases. By using a usual duodenofiberscope (JF-B2), in 2 cases under general anesthesia and in one case after premedication with 1 ml Buscopan® i.m., a similar technique is used as in adults. In congenital choledochal cyst only ERCP
allowed the exact judgement of the distal part of the common bile duct and its relation to the pancreatic duct. Therefore, an exact preoperative
diagnosis can be established. When duodenofiberscope will be more improved ERCP will also be possible in the newborn infant. Than the differential diagnosis of congenital biliary atresia, other congenital failures in infants causing jaundice and hepatitis in infant will be established endoscopically.
Endoskopische retrograde Cholangiopankreatographie (ERCP) bei Kindern
An 3 Fallen wird der Wert der ERCP bei Kindern demonstriert. Unter Verwendung eines üblichen Duodenoskops (JF-B2) wurde bei 2 Fallen in Narkose und bei einem Fall nach Pramedikation mit 1 ml Buscopan i. m. eine ERCP nach der bei Erwachsenen üblichen Technik durchgeführt. In Fallen von kongenitaler Choledochuszyste erlaubt nur die ERCP eine exakte Beurteilung des distalen Ductus choledochus und seine Beziehung zum Ductus pancreaticus. Dadurch kann eine exakte praoperative Diagnose gestellt werden. Durch Verbesserung der Duodenoskope wird es auch möglich sein, die ERCP bei Neugeborenen durchzufiihren. Dann kann auf diese Weise eine
Key-Words: ERCP, endoscopy in children, chole-
Differentialdiagnose von kongenitalen Gallengangsatresien und anderen kongenitalen bildungen, die bei Sauglingen einen Ikterus her-
dochus cyst.
vorrufen, erstellt werden.
In adults the diagnostic value of endo-
after premedication with 1 ml Buscopan®
retrograde cholangiopancreatography (ERCP) is well established. Reports about
i.m. and local anesthesia with Xylocain-
scopic
the use of this procedure in children are rare (2). Therefore, our experiences in 3 cases of children ranging from 6 to 13 years of age may be of interest. We used the normal duodenofiberscope (JF-B2) in 2 cases
under general anesthesia and in one case
Spray. The technique of examination was the same as known in adults. Case Presentation Case I: A 6-years-old boy, of 19 kg body weight,
was admitted to our hospital because of colic abdominal pains. Laboratory findings were normal
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Endoscopy 9 (1977) 86-91 C) Georg Thieme Verlag, Stuttgart
ERCP Performed in Children
Fig. 2
ERCP in left side position. The distal
common duct is narrowed.
Drip infusion cholangiography, tomography. The left hepatic and common bile duct Fig. 1
are grossly dilated. The gallbladder appears normal.
except an elevation of alkaline phosphatase (14.8
BU.). In the upper GI series the duodenal loop was slightly displaced laterally. Drip infusion
cholangiography revealed a dilatation of the left hepatic and common bile duct. The gallbladder appeared normal (Fig. 1). A congenital dila-
tation of the biliary tract was considered from this findings. To receive exact information about
the duct system ERCP was attempted using JF-B, under general anesthesia. The dilatation of the left hepatic and common bile duct were confirmed and furthermore it was demonstrated that the distal common duct was narrowed (Fig. 2). An abnormal connection between the common bile duct and the pancreatic duct was shown (Figs. 3 and 4). Exstirpation of the cyst and hepatojejunostomy (Roux en Y anastomosis) was performed. Case 2: A 8-years-old girl of 22 kg body weight complained of recurrent colic pains in the upper
abdomen. Laboratory findings showed a slight
Fig. 3 ERCP in supine position. The pancreatic duct is also opacified. Both pancreatic and bile duct are connected about 2 cm up to the papilla. elevation of alkaline phosphatase (9.3 B.U.) and of total cholesterol (278 mg/di). Serum bilirubin was within normal range. Upper GI series showed
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Y. Urakami, H. Seki, S. Kishi
an impression of the medial wall of the duodenal
loop caused by an extrinsic mass. By drip indilated (Fig. 5). In celiac angiography the pancreatic duodenal arcade appcared to be widened and displaced laterally (Fig. 6). To clarify the diagnosis ERCP was performed under general anesthesia using JF-B2. The cystic structure of the extrahepatic bile duct and dilatation of the intrahepatic biliary tree was confirmed. Additionally to this findings it was proven that the distal common bile duct was narrowed (Fig. 7, and 8). The pancreatic duct was not visualized. As the result of ERCP a congenital cystic dilatation of the bile duct was diagnosed. Exstirpation of the cyst and hepatojejunostomy (Roux en Y anastomosis) was performed.
Fig. 4 Schema of Fig. 3.
Case 3: The chief complaints of a 13-years-old boy were epigastric pain and abdominal discomfort. By physical examination a tumor was palpable in the upper abdominal region. Upper GI series showed a displacement of the stomach by a large mass to the lateral and anterior portion.
The greater curvature of the antrum and the duodenal bulb also were deformed. On the posterior wall of the gastric body a wallnutsized-submucosal tumor with central ulceration was seen. From this findings a retroperitoneal tumor was considered. ERCP performed only after premedication of Buscopan 1 ml i.m, and local anesthesia with Xylocain-Spray, revealed numerous areas of narrowing and dilatation diffusely scattered throughout the pancreatic duct. The common bile duct was partially visualized (Fig. 9).
Operation and autopsy disclosed
a
tumorous lesion involving the duct system, which
was histopathologically a Burkitt's lymphoma growing from the retroperitoneum (Fig. 10).
Discussion
Our experiences on 3 children show that ERCP can be performed in the same way
and by the same technique as in adults. Especially in cases of congenital choledochal
cysts this method is superior to all other
Drip infusion cholangiography, tomography. The common hepatic duct and the intrahepatic bile duct are dilated remarkably. Fig. 5
procedure to clarify exactly the extention of the dilatation, the situation of the distal part of the common bile duct and the relation between biliary and pancreatic duct systems. Intravenous cholangiography can not give exact information about the distal common
bile duct. Percutaneous transhepatic cholangiography (PTC) does not allow to judge
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fusion cholangiography the common hepatic duct as well as the intrahepatic bile duct were grossly
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ERCP Performed in Children
Fig. 6
Celiac angiogram. The pancreatic duodenal arcade appears to be widened and displaced laterally.
Fig. 7
ERCP in left side position. Both extrahepatic and intrahepatic bile duct are grossly
Fig. 8 ERCP in supine position. A cystic structure of the common bile duct is demonstrated.
dilated.
The distal common bile duct is narrowed.
Y. Urakami et al.: ERCP Performed in Children
Fig. 9
ERCP with combination of drip infusion pyelography. Numerous areas of narrowing and dilatation are diffusely scattered throughout the pancreatic duct. The common bile duct is partially visualized. A filling defect at the left kidney is also demonstrated by DIP.
Fig. 10
Histological figure of biopsy specimen showing "starry sky" pattern (HE stain, x400).
the relation with the pancreatic duct. Only
To exclude the patient's fear, in children
by ERCP an accurate diagnosis and the relation between both ducts are possible
ERCP may be performed under general
prior to operation. Therefore, in our opinion ERCP is indicated in every suspected case of choledochal cyst. The study of abnormal
thesia also prevents a compression of the bronchial system from the fiberscope. The
connection of both ducts will be useful to solve the pathogenesis of congenital choledochal cyst and to determine the method of operation.
anesthesia. In young children general anesexamination, however, has to be done carefully and exposure to X-ray must be limited to minimum. When ERCP in children will become more
popular thinner duodenofiberscope has to be
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developed. Experiences of ERCP in newborns are extremely limited. The youngest child we know was a 6-week-old boy with
diagnosis and differentiation of congenital
congenital atresia of the common bile
Admowledgement
duct (1). In this case using the normal JF-B, only the pancreatic duct was opacified. In newborn the location of the papilla is high in the duodenum and the short distance be-
The authors wish to thank Prof. E. Seifert (West
vents an exact management of the cannula (1). An improvement of special designed duodenofiberscope for children may open the
new field of ERCP also in newborn for the
Germany), Prof. N. Komi (1st Department of Surgery, Tokushima Univ.) and Prof. H. Otsuka (2nd Department of Pathology, Tokushima Univ.) for their help and advice.
References 1 Seifert, E.: Personal communication 2 Urakami, Y. et al.: Congenital choledochal cyst in children diagnosed by endoscopic retrograde cholangiopancreatography. Gastroent. Endoscopy 18 (1976) 609
Dr. Y. Urakami, 2nd Dept. of Inteinal Med., School of Med., Tokushima University, Kuramotocho, Tokushima City, 770, Japan
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tween the instrument and the papilla pre-
atresia of the common bile duct.