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Endoscopic retrograde cholangiopancreatography in infantile cholestasis
M L Wilkinson1, G Mieli-Vergani, C Ball
1Gastroenterology Unit, United Medical Guy's Hospital, London.
Insights
Diagnosing conjugated hyperbilirubinaemia in infants can be challenging. Endoscopic retrograde cholangiopancreatography (ERCP) using prototype pediatric duodenoscopes offers a valuable tool to improve diagnostic accuracy and avoid unnecessary surgeries.
Area of Science:
- Pediatric Gastroenterology
- Diagnostic Imaging
- Hepatobiliary Surgery
Background:
- Distinguishing surgically correctable causes of conjugated hyperbilirubinaemia in infants is difficult.
- Standard diagnostic methods can yield equivocal results, leading to delayed or unnecessary surgical interventions.
- Accurate diagnosis is crucial for timely management of infant cholestatic conditions.
Purpose of the Study:
- To evaluate the utility of prototype pediatric duodenoscopes for endoscopic retrograde cholangiopancreatography (ERCP) in infants with conjugated hyperbilirubinaemia.
- To assess the diagnostic accuracy of ERCP in cases where standard methods were inconclusive.
- To determine if ERCP can help avoid unnecessary laparotomies.
Main Methods:
- ERCP was performed using prototype pediatric duodenoscopes (PJF 7.5 and XPJF 8.0) in infants with conjugated hyperbilirubinaemia.
- A total of 159 infants were evaluated, with 11 referred for ERCP, and the procedure was successfully completed in nine.
- Diagnostic outcomes were compared with subsequent clinical management and surgical findings.
Main Results:
- ERCP successfully visualized bile ducts in four infants, avoiding the need for laparotomy.
- In one infant with uncertain visualization, operative cholangiography confirmed patent bile ducts.
- In infants where bile ducts were not visualized, ERCP findings helped differentiate extrahepatic biliary atresia from other conditions.
Conclusions:
- ERCP performed with pediatric duodenoscopes in experienced hands can provide crucial diagnostic information in selected infants with conjugated hyperbilirubinaemia.
- This technique may help improve diagnostic accuracy and guide surgical decisions, potentially reducing unnecessary laparotomies.
- While generally safe, potential complications like gallbladder perforation and air overinflation were noted, highlighting the need for careful technique and appropriate equipment.
Abstract:
The difficulty of distinguishing surgically correctable causes of conjugated hyperbilirubinaemia in infants from other causes means that some infants may undergo laparotomy and intraoperative cholangiography unnecessarily, and others may be referred for surgery too late. In an attempt to improve the diagnostic accuracy in infants with conjugated hyperbilirubinaemia when standard methods produced equivocal results, we have been using prototype paediatric duodenoscopes (PJF 7.5 and XPJF 8.0; Olympus) to perform endoscopic retrograde cholangiopancreatography (ERCP). From 159 infants with conjugated hyperbilirubinaemia, 11 were referred for ERCP, which was performed in nine. In four in whom bile ducts were definitely visualised laparotomy was avoided. Operative cholangiography confirmed patent bile ducts in one in whom visualisation had been uncertain. Three of four in whom bile ducts were not seen had extrahepatic biliary atresia. Visible bile drainage in the fourth excluded atresia. No major complications ensued but there was radiological evidence of gall bladder perforation in one (common hepatic duct block) and overinflation with air was a problem until finer cannulae (Wilson-Cook) were introduced. In appropriately selected patients with conjugated hyperbilirubinaemia, ERCP with paediatric duodenoscopes in experienced hands may provide useful diagnostic information.