Is There a Role for ERCP in the Management of Gallstone Pancreatitis in Children? A Western Pediatric Surgery Research Consortium Study
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Updated: Sep 10, 2025
Laparoscopic Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults
Published on: February 28, 2025
Utsav M Patwardhan1, Gretchen Floan Sachs1, Romeo L Ignacio1
1Division of Pediatric Surgery, Rady Children's Hospital San Diego, La Jolla, CA, USA.
Insights
In pediatric gallstone pancreatitis, common predictors like high bilirubin and dilated bile ducts do not reliably indicate stones. Magnetic resonance cholangiopancreatography (MRCP) showing stones is the best predictor for choledocholithiasis (CDL).
Area of Science:
- Pediatric Gastroenterology
- Hepatobiliary Surgery
- Diagnostic Imaging
Background:
- Gallstone pancreatitis (GP) guidelines for adults recommend ERCP for biliary obstruction.
- Pediatric studies on GP are limited by small sample sizes.
- Predictors of choledocholithiasis (CDL) in pediatric GP require further investigation.
Purpose of the Study:
- To explore factors predicting choledocholithiasis (CDL) in pediatric gallstone pancreatitis (GP).
- To correlate predictive factors with endoscopic retrograde cholangiopancreatography (ERCP) findings in pediatric GP.
- To evaluate the utility of MRCP in predicting CDL in pediatric GP.
Main Methods:
- Retrospective analysis of pediatric GP patients undergoing cholecystectomy (2016-2019).
- Exclusion of patients with incomplete records or cholangitis.
- Comparative analysis between ERCP and non-ERCP groups, defining absence of CDL by negative or unperformed ERCP.
Main Results:
- Of 125 pediatric GP patients, 30 (24%) had preoperative ERCP.
- ERCP patients showed higher mean bilirubin and CBD diameter, and more visualized stones on MRCP.
- Hyperbilirubinemia or dilated CBD did not reliably predict CDL; 71% lacked CDL.
- Visualized stones on MRCP best predicted CDL, though 40% of these had negative ERCP.
- ERCP was not linked to increased length of stay or readmissions.
Conclusions:
- Hyperbilirubinemia and CBD dilation are unreliable predictors of CDL in pediatric GP.
- Magnetic resonance cholangiopancreatography (MRCP) with visualized stones is the strongest predictor of CDL.
- Using MRCP before ERCP may reduce unnecessary procedures, radiation, and anesthesia in pediatric GP.
Background:
Guidelines for adult gallstone pancreatitis (GP) in adults recommend endoscopic retrograde cholangiopancreatography (ERCP) for ongoing biliary obstruction. Studies in children are limited by small sample sizes. We sought to explore whether factors predictive of choledocholithiasis (CDL) are correlated with ERCP findings of stones in pediatric GP.
Methods:
We analyzed a subgroup of GP patients from a retrospective pediatric cohort undergoing cholecystectomy across ten hospitals from 2016 to 2019. Those with incomplete records and cholangitis were excluded. The absence of CDL was defined as ERCP that was either negative or not performed because of the resolution of obstruction. Comparative analyses were made between ERCP and non-ERCP patients.
Results:
Among 1601 children undergoing cholecystectomy, 125 with GP were identified of which 30 (24 %) underwent preoperative ERCP. ERCP patients had a greater mean bilirubin (4.1 vs. 2.4, p = 0.02), median CBD diameter (9 vs. 5 mm, p <0 .001), and visualized stone on MRCP (36.7 vs. 4.2 %, p < 0.001). However, among patients with hyperbilirubinemia (≥1.8 mg/dL) or a dilated CBD (≥6 mm), 71 % of patients did not have CDL. In contrast, only 40 % of patients with a visualized stone on MRCP had a negative ERCP. ERCP was not associated with prolonged length of stay (LOS) or readmissions.
Conclusion:
In children with GP, hyperbilirubinemia and CBD dilation were not reliable predictors of a positive ERCP, potentially leading to unnecessary radiation and/or anesthesia. MRCP with visualized stone was the best predictor of CDL. Although ERCP did not result in greater LOS or readmissions, the use of MRCP prior to ERCP may reduce unnecessary procedures for children with gallstone pancreatitis.
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