Risks and Efficacy of ERCP in Infants with Obstructive Jaundice

Abstract

Background: Early differentiation between extrahepatic and intrahepatic causes of cholestasis is essential for the propper management of cholestasis in infancy. Endoscopic retrograde cholangiopancreatography /ERCP/ is the most reliable and useful examination to establish the patency of the bile duct. However, the experience in cholestatic infants is limited and the radiological findings at ERCP vary considerably. Because of its inherent risks we analysed our series in an attepmpt to better define the diagnostic role of ERCP in infants with obstructive jaundice. Methods: All ERCPs performed in our department during a 7 year period in infants were rewiewed retrospectively. All examinations were performed by two endoskopists. An Olympus PJF /PJF 7,5 duodenoscope /Olympus Co. Tokyo/ was used. This 7,5 mm side wieving endoscope has a 2 mm instrumentation channel with cannula elevator. A 4-Fr catheter was used in all patients. Results: We performed ERCP in 69 infants with cholestasis of uncertain etiology, as a diagnostic procedure to establish the patency of extrahepatic bile ducts. The papilla of Vater was identified and cannulated in 66 of 69 patients /95,7%/. A normal gallbladder and bile ducts could be opacified in 18 patients /26,1%/ In 29 patients in whom successful canulation of the papila was possible /42%/ only the pancreatic duct could be visualized /BA type I/ . In 12 patients /17,4%/ only the common bile duct and gallbladder were visualized , without the common hepatic duct /BA type II/.. In 6 patients/8,7%/ choledochal cyst was found, in one case cholelithiasis/1,5%/. In 3 patients was papila not identified/4,3%/ All patients with preoperative diagnosis of BA type I and II underwent laparotomy and the ERCP findings were confirmed at laparotomy\with the exception of 1 infant where ERCP was false positive and surgery found normal findings in hepaticobiliary tree. Three patients where papila of Vater was not identified undervent laparotomy and biliary atresia was found /4,3%/ In three cases a mild asymptomatic elevation of pancreatic enzymes was noted./4,3%/. Conclusion . Our results show, that ERCP can be performed safely in infants with cholestasis of very young age and low weight /lowest weight 1,6 kg/ with unclear diagnosis. We suppose, that is necessary to do ERCP in infants in large endoscopic centers, where skilled endoscopists and pediatric surgeons and peditricians work together closely. A special endoscopic equipment - pediatric side wieving endoscope is for this investigation essential.