Surg Endosc (2011) 25:25362540
DOI 10.1007/s00464-011-1582-8
An appraisal of endoscopic retrograde cholangiopancreatography
(ERCP) for pancreaticobiliary disease in children:
our institutional experience in 231 cases
Alana K. Otto Matthew D. Neal Adam N. Slivka
Timothy D. Kane
Received: 12 July 2010 / Accepted: 10 January 2011 / Published online: 27 February 2011
Springer Science+Business Media, LLC 2011
Abstract
Background Endoscopic retrograde cholangiopancrea-
tography (ERCP) is an important tool used by clinicians in
the diagnosis and management of pancreaticobiliary dis-
ease. The safety and utility of ERCP for adults has been
well documented. However, experience with ERCP for
pediatric patients remains limited. This study aimed to
examine the utility and safety of ERCP for diagnosis and
therapy in pediatric surgical conditions.
Methods An institutional review boardapproved retro-
spective chart review of all children younger than 21 years
who underwent ERCP at a single childrens hospital
between 1992 and 2008 was performed. Age, sex, medical
history, presenting symptoms, laboratory values, and dis-
charge diagnoses were recorded. The ERCP findings,
interventions performed, complications, and associated
surgical procedures also were recorded.
Results A total of 231 ERCPs were performed for 167
children (98 girls and 69 boys) ages 62 days to 21 years.
The mean patient age was 11.4 years, with 11% (n = 18)
A. K. Otto
M. D. Neal
Division of Pediatric General and Thoracic Surgery, University
of Pittsburgh Medical Center, Childrens Hospital of Pittsburgh
of UPMC, 4401 Penn Avenue, 15224 Pittsburgh, PA, USA
A. N. Slivka
Division of Gastroenterology, Hepatology & Nutrition,
Department of Medicine, University of Pittsburgh Medical
Center, 200 Lothrop Street, 15213 Pittsburgh, PA, USA
T. D. Kane (&)
Division of Pediatric General and Thoracic Surgery, Childrens
National Medical Center, 111 Michigan Avenue NW,
20010 Washington, DC, USA
e-mail: tkane@cnmc.org
123
of the ERCPs performed for children younger than 2 years.
Common indications for ERCP included chronic or recur-
rent pancreatitis (n = 106), acute pancreatitis (n = 42),
and choledocholithiasis (n = 26). Additional indications
included choledochal cyst (n = 2), congenital biliary
obstruction (n = 2), and malignant biliary obstruction
(n = 1). Therapeutic interventions were performed in 159
cases (69%) including sphincterotomy (n = 96), stone
extraction (n = 55), and stent insertion (n = 52). Com-
plications occurred for only 11 patients (4.76%), including
7 cases of post-ERCP pancreatitis. The use of ERCP for
imaging resulted in surgical procedures in 58 cases.
Conclusion Endoscopic retrograde cholangiopancreatog-
raphy was used most commonly for children with pancre-
atitis and gallstone disease. It was used frequently for
infants with a low complication rate. The majority of
patients required therapeutic intervention, suggesting an
important role for ERCP in the management of pancreati-
cobiliary disease in infants and children.
Keywords Endoscopic cholangiopancreatography

ERCP
Pediatrics
Endoscopic retrograde cholangiopancreatography (ERCP)
is an important tool used by clinicians in the diagnosis and
management of pancreaticobiliary disease. The safety and
utility of ERCP in the diagnosis and treatment of adult
disease has been well documented [1]. However, docu-
mented experience with ERCP for pediatric patients
remains limited for several reasons. Notable issues include
the relative rarity of pancreaticobiliary diseases requiring
surgery among children, the relatively recent advent of the
pediatric duodenoscope, and the lack of safety information
and accepted indications for ERCP in children [2].
Surg Endosc (2011) 25:25362540
Importantly, rates for complications after ERCP in
children have not been well established, in part because
most published case series have been limited by small
sample sizes [3]. To address this issue and the paucity of
evidence-based guidelines for the use of ERCP, we
examined the utility and safety of ERCP in the diagnosis
and therapy of common pediatric surgical conditions at a
large, university-based childrens hospital.
Methods
After approval of the Institutional Review Board at the
Childrens Hospital of Pittsburgh of the University of Pitts-
burgh Medical Center (UPMC) (PA), the electronic medical
record was queried for children from birth through 21 years
of age who underwent ERCP between 1992 and 2008. Cases
were identified by the International Statistical Classification
of Diseases and Health-Related Problems, Ninth Revision,
(ICD-9) procedure codes 51.10 (ERCP), 51.11 (endoscopic
retrograde cholangiography), 52.13 (endoscopic retrograde
pancreatography), 51.84 (endoscopic dilation of the ampulla
and the biliary duct), 51.85 (endoscopic sphincterotomy and
papillotomy), 51.86 (endoscopic insertion of a nasobiliary
drainage tube), 51.87 (endoscopic insertion of a stent [tube]
into bile duct), and 51.88 (endoscopic removal of stone or
stones from the biliary tract).
Of the 171 patients identified, 167 had complete medical
records available. Charts were individually reviewed for
age, sex, medical history, presenting symptoms, laboratory
values, ERCP findings, ERCP interventions performed,
ERCP complications, other associated surgical procedures,
other imaging studies, and discharge diagnoses. All ERCPs
were performed at the Childrens Hospital of Pittsburgh of
UPMC and UPMC Presbyterian Hospital by adult endos-
copists with training and experience in ERCP for adults
and children.
Results
Patient demographics
A total of 231 ERCPs were performed for 167 children (98
girls and 69 boys) ages 62 days to 21 years. The mean
patient age at the time of ERCP was 11.4 5.1years. At
the time of their procedures, 11% (n = 18) of the patients
were 2 years of age or younger.
Indications and interventions
The most common indication for ERCP was chronic or
recurrent pancreatitis (Fig. 1). For 68 patients with
2537
Fig. 1 Etiology of pancreatitis in children undergoing endoscopic
retrograde cholangiopancreatography (ERCP). The most common
indication for ERCP in this series was chronic or recurrent
pancreatitis, representing nearly half of all the ERCPs performed.
In 72% of the cases, ERCP was successful in identifying a source for
recurrent pancreatitis, and nearly half of the patients with an identified
anatomic abnormality went on to surgical intervention. Acute
pancreatitis was a less common indication, with the most common
cause being biliary in nature
recurrent pancreatitis, 106 ERCPs were performed. A total
of 20 ERCPs were performed for 13 patients found to have
recurrent pancreatitis of anatomic or structural etiology,
including pancreas divisum in 5 patients, choledochal cyst
in 2 patients, choledochocele in 2 patients, and biliary
atresia in 1 patient. The ERCP procedure was performed
for 11 patients with chronic pancreatitis caused by
sphincter of Oddi dysfunction, and 6 patients underwent 15
ERCPs for recurrent pancreatitis related to cystic fibrosis.
One patient with familial chronic pancreatitis underwent
two ERCPs. No cause was established for 27 patients who
underwent a total of 30 ERCPs recurrent pancreatitis. For
cases of isolated acute pancreatitis, 42 ERCPs were per-
formed. The most common indication for ERCP for acute
pancreatitis was gallstone pancreatitis (n = 15).
Common biliary indications for ERCP included cho-
ledocholithiasis (n = 26), cholangitis (n = 21), and cho-
lelithiasis (n = 20). Additional indications included biliary
cirrhosis (n = 4), biliary atresia (n = 1), and malignant
biliary obstruction (n = 1).
Therapeutic interventions were performed in 159 cases
(69%), including sphincterotomy in 96 cases (42%), stone
extraction in 55 cases (24%), and stent insertion in 52 cases
(23%). One patient was unable to undergo planned
sphincterotomy and stent insertion due to an increased risk
of bleeding secondary to thrombocytopenia. Two patients
were unable to undergo planned sphincterotomy and stent
insertion, respectively, due to inflammation secondary to
active pancreatitis.
123
2538
Associated procedures
The use of ERCP for diagnostic imaging resulted in 58
surgical procedures. After ERCP, 41 patients underwent
laparoscopic (n = 35) or open (n = 6) cholecystectomy.
The cholecystectomies included 17 performed for patients
who had cholelithiasis without pancreatitis, including 2
cholecystectomies for patients younger than 10 years. The
other indications for cholecystectomy after ERCP were
acute gallstone pancreatitis (n = 10), choledocholithiasis
(n = 8), chronic idiopathic pancreatitis (n = 4), chronic
cholecystitis (n = 1), and biliary atresia (n = 1).
Six patients required exploratory laparotomy after
ERCP: five for drainage or debridement of pancreatic
pseudocysts and one for excision of a choledochal cyst. Six
patients underwent Roux-en-Y hepaticojejunostomy after
ERCP for bile duct obstruction: three for pancreatic pseu-
docyst and one each for choledochal cyst, cholangitis, and
biliary atresia. Distal pancreatectomy was performed in
three cases: for traumatic pancreatitis in two cases and for
acute pancreatitis with pseudocyst in one case.
Complications
Complications related to ERCP were seen in 11 cases
(4.76% of all procedures) (Table 1). The most common
complication was post-ERCP pancreatitis (n = 7, 3%),
defined clinically as abdominal pain and elevated serum
amylase requiring a hospital stay of at least 24 h after
ERCP [4]. All seven cases were graded as mild or as
requiring hospitalization or prolongation of hospitalization
for 3 days or less based on the consensus classifications of
post-ERCP pancreatitis by Cotton et al. [5].
Postsphincterotomy bleeding occurred in two cases
(0.87%). One case required treatment with transfusion of
packed red blood cells and fresh frozen plasma, which
resulted in the formation of a submucosal hematoma at the
sphincterotomy site. The second case of bleeding was mild
and resolved spontaneously. Other complications included
fever and retained common bile duct stones.
Table 1 Complications related to ERCP
Complication No. of Percentage
patients of total ERCPs
Post-ERCP pancreatitis 7 3.03
Bleeding after sphincterotomy 2 0.87
Fever 1 0.43
Retained stones 1 0.43
Total 11 4.76
ERCP endoscopic retrograde cholangiopancreatography
123
Surg Endosc (2011) 25:25362540
Discussion
In this retrospective review, the use of ERCP for children
was found to be safe and useful in the management of a
variety of pancreaticobiliary conditions, especially chronic
or recurrent pancreatitis. In our series, one of the largest in
the literature to date, the rate of complications after ERCP
was less than 5%, with post-ERCP pancreatitis as the most
common complication. No complications were seen in
infants. One-fourth of all ERCPs performed led to surgical
interventions, most commonly cholecystectomy, empha-
sizing an important role for ERCP in the surgical man-
agement of pediatric pancreaticobiliary patients.
The common indications seen in our patients were
similar to those described for adults [1, 6]. Acute gallstone
pancreatitis was a relatively uncommon indication for
ERCP in our study, comprising 6.5% of all cases. Chole-
lithiasis or choledocholithiasis without pancreatitis were
more common, but gallstones were an indication for only
26% of all ERCPs, reflecting the observation that gall-
stones in preprepubescent children are rare, especially
compared with their incidence in adults [7]. Nonetheless,
recent reports that the incidence of gallstone disease among
children is increasing [7] suggest the potential for expan-
sion of the role for ERCP in pediatric gallstone disease. In
our study, ERCP led to the successful removal of stones in
55 of 56 attempts, indicating that ERCP is a valuable tool
in the treatment of children with gallstone disease.
The largest role for ERCP in our study was the evalu-
ation of chronic or recurrent pancreatitis. Of 68 patients
with recurrent pancreatitis, 27 received a diagnosis of idi-
opathic recurrent acute pancreatitis because organic etiol-
ogies were not found. However, despite a lack of consensus
on the role of ERCP in the evaluation of idiopathic
recurrent abdominal pain or pancreatitis [3, 8, 9], etiologies
were identified in 41 of 68 patients (60%) in our study who
underwent ERCP for recurrent pancreatitis. Sphincter of
Oddi dysfunction was diagnosed for 11 of these patients,
established by sphincter of Oddi manometry during ERCP
[10], underscoring the importance of the role of ERCP in
children with recurrent biliary or pancreatic abdominal
pain.
Unlike adults, among whom most cases of chronic
pancreatitis are related to alcohol use, children are more
likely to have chronic pancreatitis of obstructive causes,
including congenital or anatomic causes [11], which may
be visualized, diagnosed, and often improved by ERCP
[1214]. Importantly, anatomic abnormalities were seen in
20 ERCPs performed on 13 patients for chronic pancrea-
titis, which led to surgical therapy for anatomic causes of
pancreatitis in 6 of these patients.
Pancreatic pseudocysts were seen in 10 patients who
underwent 13 ERCPs for acute or chronic pancreatitis.
Surg Endosc (2011) 25:25362540
Seven of these patients underwent subsequent laparotomy
(n = 5), distal pancreatectomy (n = 3), surgical drainage
(n = 2), and/or pancreatic resection (n = 2). Although
pancreatic pseudocyst has been established as a good
indication for ERCP in adults [1, 6], our study did not
appear to demonstrate a high success rate for the man-
agement of pseudocyst with ERCP. However, our study
was not designed specifically to assess this outcome.
Nonetheless, all seven cases of pseudocyst treated with
surgical interventions occurred between 1992 and 1999,
when techniques for and experience with endoscopic
drainage of pancreatic pseudocysts still were evolving.
A recent case series demonstrated the safety and efficacy
of endoscopic management of pancreatic pseudocysts in
children [15]. However, our preference most recently has
been for laparoscopically assisted creation of pancreatic
pseudocyst gastrostomy for internal drainage of chronic
pancreatic pseudocysts.
An analysis of lawsuits subsequent to ERCP found that
most malpractice cases after ERCP allege that ERCP was
not indicated [16], emphasizing the need to establish
guidelines on the use of ERCP for pediatric pancreaticob-
iliary disease. In our study, the most common indications
for ERCP were similar to accepted adult indications and
those reported in other similar case series [3, 17].
In our study, 69% of ERCPs included one or more
interventions, a rate similar to that seen for adults [18],
suggesting that ERCP may offer an advantage over other
imaging modalities for children with pancreaticobil-
iary disease. The sensitivity and specificity of magnetic
resonance cholangiopancreatography (MRCP) in the
diagnosis of adult choledocholithiasis, bile duct obstruc-
tion, and pancreatitis are found to be comparable with
ERCP in many cases [1923]. However, a separate
ERCP is required for the performance of any necessary
interventions.
The complication rate after ERCP in children is not
well established. The reported incidence of ERCP-related
morbidity in children ranges from 0% to 28.5%, with
pancreatitis being the most common complication [3, 13,
17, 2427]. Strikingly, in our study, both the overall
complication rate of 4.76% and the post-ERCP pancreatitis
rate of 3% were lower than or similar to the respective
adult rates of 6% to 10% and 3% reported in a systematic
review [28] and lower than the rates of 8% and 4% reported
by a prospective multicenter study [28, 29]. No compli-
cations were seen in infants younger than 1 year, sup-
porting a previous series demonstrating the safety of ERCP
for infants [24].
In adult ERCP, the rates for complications are lower for
endoscopists who have performed more than 100 ERCPs
and those who perform more than 40 ERCPs per year [30]
or 1 per week [31]. The low complication rate and the large
2539
case volume in our study suggest that the incidence of
ERCP morbidity also is lower among endoscopists who
frequently perform pediatric ERCP. Only two complica-
tions occurred between 1999 and 2008, further suggesting
that complication rates may decrease over time with
increased experience in pediatric ERCP. Additionally, a
large, multicenter prospective cohort study of complica-
tions after ERCP sphincterotomy found that the incidence
of complications is primarily determined by the volume of
procedures performed by endoscopists rather than patient
age or medical condition [31].
The rate of post-ERCP pancreatitis for children is
reported to be higher for children with existing recurrent
pancreatitis than for those without chronic pancreatitis [25,
32]. In our study, less than half of the cases of post-ERCP
pancreatitis (n = 3) involved children with chronic pan-
creatitis. It is possible that the actual rate of post-ERCP
pancreatitis among the patients with recurrent pancreatitis
in our study was higher, with some cases mistaken for
existing pancreatitis and therefore unrecognized. However,
this was unavoidable due to the retrospective nature of our
analysis.
In adults, the rate of complications after ERCP is higher
when ERCP includes a therapeutic intervention, especially
sphincterotomy, than when it is used for imaging alone [18,
3335]. Of 11 complications in our study, 7 occurred in
children who underwent one or more therapeutic inter-
ventions. All seven included sphincterotomy. Further
evaluation is needed to determine whether sphincterotomy
is an independent risk factor for complications in pediatric
ERCP.
Our study had several limitations. First, it was a retro-
spective analysis and thus subject to all the inherent limi-
tations of this type of study. Assessment of complications
was based on the written medical record, although we did
review post-ERCP amylase and lipase levels when they
were available to confirm the written record. Although our
study followed some children over several years for various
clinical conditions, data on the long-term effects or com-
plications of ERCP were not recorded. Further investiga-
tion into the long-term consequences of ERCP and
sphincterotomy for children are needed to address the
current paucity of literature in this area [3].
In summary, ERCP is safe and useful for the diagnosis
and management of pancreaticobiliary disease, especially
chronic or recurrent pancreatitis, in pediatric patients. The
complication rates are similar to or lower than those seen
for adults, with post-ERCP pancreatitis the most common
complication.
Acknowledgements Disclosures Alana K. Otto, Matthew D.
Neal, Adam N. Slivka, and Timothy D. Kane have no conflicts of
interest or financial ties to disclose.
123
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