0016-5107/92/3804-0450$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy

ERCP and endoscopic sphincterotomy in infants and children with jaundice due to common bile duct stones Moises Guelrud, MD, Sonia Mendoza, MD Domingo Jaen, MD, Jose Plaz, MD Jose Machuca, MD, Pedro Torres, MD Caracas, Venezuela

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. (Gastrointest Endosc 1992;38:450-453)

The increased awareness of factors predisposing to cholelithiasis and the utilization of ultrasonography has led to the increasing diagnosis of cholelithiasis and common bile duct (CBD) stones in children. ERCP is an established procedure for visualization of the biliary tree in adults! and children. 2• 3 However, until now endoscopic sphincterotomy with stone extraction has only been accepted as the treatment of choice in CBD stones in adults. 4 The role and value of ERCP and endoscopic sphincterotomy in children is less clear. This study describes the usefulness of ERCP and endoscopic sphincterotomy in a group of infants and children with CBD stones.

29 and 62 days old, and in eight children, five with hemolytic anemia (two with hereditary spherocytosis and three with sickle cell disease) and three with family gallstone disease (three boys and five girls), 5 to 12 years old (mean, 9.1 years), because of jaundice suspected to be secondary to CBD stones. The 29-day-old neonate with hemolytic anemia had a normal gallbladder ultrasound and ERCP was indicated to look for biliary atresia. The 62-day-old jaundiced infant with hemolytic anemia had cholelithiasis with a normal common duct on ultrasound. ERCP was indicated to look for a CBD stone. Hemolytic anemia was confirmed by laboratory tests. Ultrasonograms were performed in all patients. Informed consent was obtained from the parents of the children after the nature of the procedure was fully explained.

MATERIALS AND METHODS

Patient population

ERCP was performed in two infants with hemolytic anemia due to hereditary spherocytosis (one boy and one girl) Received October 3, 1991. For revision December 3, 1991. Accepted January 16,1992. From the Gastroenterology Department, Hospital General del Oeste, MSAS, Caracas, Venezuela and Gastroenterology Department, Hospital de Ninos J. M. De Los Rios, Caracas, Venezuela. Reprint requests: Moises Guelrud, MD, Policlinica Metropolitana, Urb. Caurimare, Caracas, Venezuela. 450

Procedures

A prototype side-viewing endoscope (PJF endoscope; Olympus Corporation of America, Lake Success, N. Y.) with an external diameter of 8.8 mm s was used in the two infants. An adult Olympus JF1T endoscope was used in the eight children. ERCP was performed in two infants without sedation, and they tolerated the procedure well. In eight children sedation was obtained with intravenous meperidine (3 mg/kg) and diazepam (0.3 mg/kg) immediately before the procedure. All endoscopies were performed in the x-ray GASTROINTESTINAL ENDOSCOPY

department. A cardiorespiratory ambulatory unit was at the bedside. No anti-spasmodic agent was used to assist in cannulation. Buscopan (bromure hyosciane) was given as an antispasmodic during endoscopic sphincterotomy in six children. The duodenoscope was inserted into the second portion of the duodenum with the patient in the left lateral decubitus position. The papilla of Vater was observed, and an Olympus tapered Teflon catheter (3.5 F at the distal end) was introduced in the two neonates, and a standard adult cannula was introduced in the eight children. Filling of the CBD was determined fluoroscopically. Sixty-five percent uromiron (iodamide metiglucaminic) was diluted to 30% and injected manually using a lO-ml syringe. In six children who had previously undergone cholecystectomy, endoscopic sphincterotomy was done with a 5 F sphincterotome (Microvasive, Watertown, Mass.) and the stones were removed using a stone retrieval balloon or a basket (Microvasive).

procedure is less commonly utilized in children primarily because of fewer indications. The introduction of a thinner pediatric duodenoscope may facilitate investigation of cholestasis in neonates and infants. 5 7 The use of this new instrument is mandatory in neonates and in infants younger than 12 months of age. In older children there is no need for special pediatric duodenoscopes. The technique of ERCP is more difficult in neonates and requires well-trained and skilled endoscopists. In older children, the tech-

RESULTS

A summary of the findin~s in patients is given in Table 1. ERCP was successf.dly performed in all patients. There were four patients with gallbladder in situ. Abdominal ultrasound demonstrated gallstones in three patients with normal CBD in all four patients. ERCP showed gallstones and CBD stones in four patients, including one neonate, one young infant, and two children (Figs. 1 and 2). All patients underwent cholecystectomy with CBD stone extraction. In six children who had previously had a cholecystectomy, ultrasonography demonstrated a dilated CBD in two, a CBD stone in one, and a normal CBD in three. ERCP demonstrated common bile duct stones in all six patients who were treated with sphincterotomy and stone extraction without complication (Fig. 3). DISCUSSION

ERCP is an established procedure for visualization of the biliary tree in adults 1 and in children. 2, 3 The

Figure 1. ERCP in a 29-day-old neonate with hemolytic anemia. Note a normal common bile duct with a stone (arrow) at the common hepatic duct and dilated intra-hepatic ducts. The gallbladder is seen with stones.

Table 1. Summary of patient findings· Case

Sex

Age

1 2 3

F M F M F F F F M M

29 days 62 days 10 yr 12 yr 6 yr 8 yr 9 yr 12 yr 5 yr 11 yr

4

5 6 7 8 9 10 a

b

Bilirubin (mg/dI) Total

Direct

38.2 63.9 11.3 23.1 16.2 19.1 19.3 8.5 28.3 7.5

18.9 26.2 10.1 16.9 9.9 10.7 8.2 7.6 16.1 6.8

Diagnosis

Ultrasound

HA HA FGD HA HN HA b HA b

G = N, CBD = N Gallstones, CBD = N Gallstones, CBD = N Gallstones, CBD = N CBD=N CBD = dilated CBD = dilated CBD = stone CBD=N CBD=N

FGD b HA b FGD b

Treatment

ERCP Gallstones, Gallstones, Gallstones, Gallstones, CBD stone CBD stone CBD stone CBD stone CBD stone CBD stone

CBD CBD CBD CBD

= = = =

stone stone stone stone

Surgery Surgery Surgery Surgery ES ES ES ES ES ES

HA, hemolytic anemia; G, gallbladder; N, normal; FGD, family gallstone disease; ES, endoscopic sphincterotomy. Previous cholecystectomy.

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nique is no more difficult than in adults. In this study we successfully performed ERCP in all 10 patients. This compares favorable with the experience of Buckley and Connons who successfully cannulated 14 of 15 patients (93%) ranging from 1 to 19 years old with biliary tract disease, and with the series of Allendorph et al. 2 who cannulated the appropriate ductal system in 96% of their procedures (24 of 25 patients).

Figure 2. ERCP in a 62-day-old infant with hemolytic anemia. Note a common bile duct stone (arrow) with a dilated common duct and multiple gallbladder stones.

Significant complications of ERCP, including cholangitis, bacteremia, and pancreatitis, have been rare in children. None of our patients had complications. Other workers have reported similarly low complication rates. 5 , 6, S Ultrasonography is the method of choice for dem0nstration of cholelithiasis. 9 However, the diagnostic approach with respect to the bile ducts is more difficult, and identification of the cause of obstruction is often impossible. In our four children with gallstones, ultrasonography failed to show gallstones in one. In our 10 children with CBD stones, ultrasonography demonstrated a dilated CBD in 2 patients and a CBD stone in only one patient. Endoscopic sphincterotomy is the procedure of choice in the treatment of CBD stones in adults 4 with a success rate of up to 96%.10 In children, sphincterotomy has been performed in infants as young as 2 years old prior to a biliary stent insertion. l l Buckley and Connons successfully performed endoscopic sphincterotomy in five children with stone extraction without significant complications, except for bleeding in one patient who had been given aspirin following the procedure. In our small group of patients, endoscopic sphincterotomy was performed without complications. In adults, the procedure-related short-term complications, such as bleeding, pancreatitis, cholangitis, and retroperitoneal perforation occur in 7 to 10% of patients. 4 ,l0 Our results demonstrate that ERCP is an easy and safe technique which provides opacification of the CBD and gallbladder in infants and children with a

Figure 3. ERCP in a 12-year-old cholecystectomized child with hemolytic anemia. A, Sludge and a common bile duct stone. B, After endoscopic sphincterotomy, the common duct stone is retrieved with a basket. 452

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high degree of accuracy. ERCP can provide valuable information which supplements that from ultrasonography in children with extra-hepatic cholestasis. The procedure is clearly superior to ultrasonography in the diagnosis of CBD stones and should be utilized by expert endoscopists in children with evidence of extrahepatic cholestasis. Our experience also demonstrated the technical feasibility of endoscopic sphincterotomy in a selected group of patients. It should be the treatment of choice in children who have previously undergone cholecystectomy, and who are jaundiced secondary to CBD stones.

REFERENCES 1. Cotton PB. Progress report. Endoscopic retrograde cholangiopancreatography. Gut 1977;18:316-41. 2. Allendorph M, Werlin SL, Geenen JE, et al. Endoscopic retrograde cholangiopancreatography in children. J Pediatr 1987;110:206-7.

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3. Putnam PE, Kocoshis SA, Orenstein SR, Schade RR. Pediatric endoscopic retrograde cholangiopancreatography. Am J GastroenteroI1991;86:824-30. 4. Geenen JE, Vennes JA, Silvis SE. Resume of a seminar on endoscopic retrograde sphincterotomy. Gastrointest Endosc 1981;27:31-8. 5. Guelrud M, Jaen D, Torres P, et al. Endoscopic cholangiopancreatography in the infant: evaluation of a new prototype pediatric duodenoscope. Gastrointest Endosc 1987;33:4-8. 6. Heyman MB, Shapiro HA, Thaler MM. Endoscopic retrograde cholangiography in the diagnosis of biliary malformations in infants. Gastrointest Endosc 1988;34:449-53. 7. Guelrud M, Jaen D, Mendoza S, Plaz J, Torres P. ERCP in the diagnosis of extrahepatic biliary atresia. Gastrointest Endosc 1991;37:522-6. 8. Buckley A, Connon JJ. The role of ERCP in children and adolescents. Gastrointest Endosc 1990;36:369-72. 9. Cooperberg PL, Burhenne HJ. Real-time ultrasonography. Diagnostic technique of choice in a calculous gallbladder disease. N Engl J Med 1980;302:1277-9. 10. Cotton PB. Endoscopic management of bile duct stones. (Apples and oranges). Gut 1984;25:587-97. 11. Guelrud M, Mendoza S, Zager A, Noguera C. Biliary stenting in an infant with malignant obstructive jaundice. Gastrointest Endosc 1989;35:259-61.

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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 pati...
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