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PCRE Terapeutica en Pancreatitis Pediatrica

PCRE Terapeutica en Pancreatitis Pediatrica

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396
GASTROINTESTINAL ENDOSCOPYVOLUME 51,NO.4,PART 1,200
ERCP is an established modality for the diagnosisand treatment of pancreaticobiliary diseases inadults.
1,2
Reported experience with diagnostic andtherapeutic ERCP in pediatric patients is limited.
3,4
This is due to the relatively low incidence of pancre-aticobiliary diseases (e.g.,calculi or neoplasia),limi-tations in the size of duodenoscopes,the need forgeneral anesthesia,and the lack of highly trainedand experienced endoscopists familiar with thesespecial procedures in pediatric patients.With therefinement of technique and improvement in endo-scope design,several studies have been reportedwith excellent results in the pediatric population,
3-15
especially the management of biliary diseases (bil-iary sphincterotomy to facilitate drainage or stoneextraction,
4,5
stent placement,
6,7
or stricture dila-tion).
7
Experience with pancreatic therapy is limit-ed.
15-17
We report our experience with ERCP in themanagement of pancreatitis in pediatric patients.
PATIENTS AND METHODS
Patients in this study included children who haveundergone ERCP examination for the management of pan-creatitis at two medical centers over a 32-month period(April 1994 to December 1996).The diagnosis of pancreati-tis was made on the basis of clinical presentation,serumamylase/lipase levels,abdominal sonography,or CT find-ings.The demographic information,clinical data,ERCPfindings,and complications were entered into a computerdatabase system (GI Trac,Akron Systems Development,Charleston,S.C.).All available medical records werereviewed to verify the clinical history,results of laboratory
Therapeutic ERCP in the management of pancreatitis inchildren
Ronald K.Hsu,MD,FACG,FACP,Peter Draganov,MD,Joseph W.Leung,MD,FRCP,Paul R.Tarnasky,MD,Andy S.Yu,MD,Robert H.Hawes,MD,John T.Cunningham,MD,Peter B.Cotton,MD,FRCP
Sacramento and Pleasant Hill, California, and Charleston, South Carolina 
Background: 
The use of diagnostic and therapeutic endoscopic retrograde cholangiopancre-atography (ERCP) is increasing in the management of pancreatobiliary diseases in children.
Methods: 
Over a 32-month period,we performed 34 ERCP procedures for the treatment of pan-creatitis in 22 children at two university hospitals.Demographics and clinical data and ERCP find-ings were documented.Clinical status was assessed 6 months before the first ERCP and 6 monthsafter the last ERCP,according to general condition,severity and frequency of pain,and health careencounters (emergency department visits,clinic visits,and hospital admissions related to thepancreatitis).
Results: 
Mean age of the patients was 10.7 years (range 1.5 to 17 years).Abdominal pain was themain presenting symptoms with hyperamylasemia and hyperlipasemia.Clinical diagnoses includ-ed acute pancreatitis (6),recurrent pancreatitis (5),and chronic pancreatitis (11).The mean follow-up was 16.4 months.Nine patients had sphincter manometry,with abnormal results leading to bil-iary sphincterotomy in 4.Fifteen patients underwent a total of 23 therapeutic ERCP proceduresunrelated to sphincter dysfunction.There were 2 complications of 34 procedures (6%),both beingmild pancreatitis after sphincter manometry.There were no deaths.There was a significant reduc-tion in frequency (
< 0.01) and severity of pain (
< 0.01) after intervention.Patients without pan-creatographic changes of chronic pancreatitis had the most marked clinical improvement (
<0.05).In those with ductal changes of chronic pancreatitis,clinical improvement was not predict-ed by the extent of ductal changes.There was a significant decrease in health care encounters(
< 0.05) and improvement in general condition (
< 0.01) after endoscopic therapy,especially inthose with a normal pancreatogram.
Conclusions: 
Therapeutic ERCP is safe in pediatric patients with pancreatitis.Significant clinicalimprovement is achieved in patients with biliary or pancreatic stone disease.Prospective studieswith long-term follow-up are needed to determine the impact of endoscopic therapy in patients withchronic pancreatitis and sphincter of Oddi dysfunction.(Gastrointest Endosc 2000;51:396-400.)
Received February 17,1999.For revision May 18,1999.AccepteSeptember 29,1999.From the University of California Davis Medical Center,Sacramento,California;Digestive Disease Center,MedicaUniversity of South Carolina,Charleston,South Carolina; Section of Gastroenterology,VA Northern California,Health Care System,Pleasant Hill,California.Presented at the Digestive Diseases Week,May 1997,Washington,D.C.(Gastrointest Endosc 1997;45:146).Reprint requests:Ronald Hsu,MD,FACG,FACP,University oCalifornia,Davis Medical Center,PSSB Room 3500,4150 V St.,Sacramento,CA 95817;e-mail:rkhsu@ucdavis.edu.
37/1/103335
doi:10.1067/mge.2000.103335 
 
Therapeutic ERCP in the management of pancreatitis in childrenR Hsu,P Draganov,J Leung,et al.VOLUME 51,NO.4,PART 1,2000GASTROINTESTINAL ENDOSCOP
397
tests and radiologic imaging.A total of 34 ERCPs were per-formed on 22 patients.The mean age was 10.7 years (range1.5 to 17 years).Abdominal pain was the main presentingsymptom in all patients.The clinical diagnoses includedacute pancreatitis in 6 cases,recurrent pancreatitis in 6,and chronic pancreatitis in 10.The following parameterswere assessed for the period of 6 months before the firstERCP and 6 months after the last ERCP:general condition(Likert scale:0 = terrible,1 = poor,2 = fair,3 = good,4 =excellent),severity of pain (0 = no pain,10 = unbearable),frequency of pain (0 = never,l = yearly,2 = monthly,3 =weekly,4 = daily,5 = continuously),and number of healthcare encounters:(1) emergency room visits,(2) clinic visits,(3) admissions to the hospital.At the time of this report,the patients had been followed for a mean of 16.4 months(range 6 to 33 months).Informed consent was obtained after the risks and ben-efits of the procedure and alternative treatments wereexplained to the patient and key family members,in dis-cussions which included the pediatrician,endoscopist,andsurgeon where appropriate.Intravenous conscious sedation using a combination ofmidazolam,fentanyl,and droperidol was used in 7patients (22%,age range 11 to 13 years) and general anes-thesia was used in the remaining 15 patients (68%,agerange 1.5 to 17 years).General anesthesia or conscioussedation was chosen at the discretion of the endoscopist.Blood pressure,pulse,and oxygen saturation were closelymonitored during the examination.All ERCPs were per-formed using the standard “adult”videoduodenoscopes(JF-100,TJF-100;Olympus America,Inc.,Melville,N.Y.)with standard (5F to 7F) accessories.Sphincterotomy wasperformed using standard instruments (Wilson-CookMedical Inc.,Winston-Salem,N.C.).Strictures were dilat-ed using 4 to 6 mm diameter balloons (Max force;Microvasive Inc.,Natick,Mass.) and stones were extract-ed with standard baskets (22Q or 23Q,Olympus).Biliaryand/or pancreatic manometry was performed using thetechnique described by Sherman et al.
18
with specialcatheters (Wilson-Cook);a basal pressure greater than 40mm Hg was considered abnormal.Radiation exposure waskept to a minimum.The pancreatographic changes of chronic pancreatitiswere defined using the Cambridge classification.
19
Mildpancreatitis is defined as a normal main duct and morethan 3 abnormal side branches;moderate pancreatitis hasirregularities of the main duct and more than 3 abnormalside branches;severe pancreatitis has strictures and dila-tion involving the main pancreatic duct with or withoutstones or pseudocysts.The effects of therapeutic intervention on general con-dition and severity and frequency of pain score wereassessed with analysis of variance by rank.Logisticregression was used to determine the predictors for clini-cal improvement.
RESULTS
A total of 34 ERCPs were attempted on 22patients.We achieved successful cannulation of thedesired duct in all cases.Five patients had mild,2 moderate,and 4 severe pancreatitis changes bypancreatography;11 had a normal pancreatogram.The causes of pancreatitis were categorized aspancreatic or biliary.Fourteen patients had pancreat-ic causes:6 pancreas divisum,3 familial pancreatitis,4 idiopathic pancreatitis,and 1 lymphomatous infil-tration of the head of pancreas.Among the 6 patientswith pancreas divisum,2 had concomitant cysticfibrosis (ages 18 months and 13 years) and 1 had bil-iary sphincter hypertension.Of the 8 patients withbiliary causes,4 had choledochal cysts,3 of whom(75%) had associated bile duct stones.Two patientshad sphincter of Oddi dysfunction,confirmed by bil-iary manometry,and 2 had cholelithiasis.Fifteen patients underwent a total of 23 therapeu-tic ERCP procedures (range 1 to 3 per patient) unre-lated to sphincter of Oddi dysfunction.There were 3biliary sphincterotomies and 6 pancreatic sphinctero-tomies (2 major and 4 minor).Stone extraction wasperformed in 7 patients (4 biliary and 3 pancreatic).In 2 patients,pancreatic stones were extracted via
Table 1.Impact of therapeutic ERCP
ScoreScoreChangebefore ERCPafter ERCPin scores
ValueGeneral condition1.23.0+1.80.004Severity9.52.6-6.80.002Frequency3.31.0-2.30.002Emergency department visit1.20-1.40.02Clinic visit3.41.2-2.20.03Admission to hospital2.51.1-1.40.02Positive score indicates improvement in general condition;negative score indicates decreasein number of health care encounters or a decrease in the severity and frequency of attacks.Parameters are graded with Likert scales;all parameters reached statistical significance.General condition score:0 = terrible,l = poor,2 = fair,3 = good,4 = excellent;severity of painrange 0 to 10:0 = no pain,10 = unbearable;frequency of pain:0 = never,l = yearly,2 = monthly,3 = weekly,4 = daily,5 = continuously.Number of health care encounters include:(1) emergencydepartment visits,(2) clinic visits,(3) admissions to the hospital.
 
the main papilla and in 1 through the minor papilla.Stents were used to facilitate pancreatic sphincter-otomy in 4 patients (1 for major and 3 for minor papil-la sphincterotomy) and for biliary drainage in 2patients.Two patients underwent balloon dilation,one for a stenosed biliary sphincterotomy performedfor stone extraction and one for a stenosed accessorysphincterotomy to facilitate drainage.Some patientsrequired more than one procedure for stent removal,minor sphincterotomy,or assessment of therapy.Manometric studies on both sphincters were per-formed in 9 patients.Four (2 normal pancreas,1severe chronic pancreatitis,1 divisum) were shownto have biliary sphincter hypertension (basal pres-sure > 40 mm Hg) and underwent biliary sphincter-otomy.There was no case of pancreatic sphincterhypertension.
Clinical outcome
Endoscopic intervention resulted in significantimprovements in all 6 outcome parameters (Table1).Overall,there was significant clinical improve-ment in the frequency (
< 0.01) and the severity ofpain (
< 0.01) after therapeutic intervention.Therewas a significant decrease in health care encounters(
< 0.05) and improvement in general condition (
< 0.01) after endoscopic therapy.Patients withoutpancreatographic changes of chronic pancreatitiswere more likely to improve clinically comparedwith those with underlying ductal changes (
<0.05).This was especially true in patients with bil-iary pancreatitis.The most significant predictor for improvementin the severity and frequency of pain was the lack ofpancreatogram changes (Table 2).Patients withoutductal changes had the most significant clinicalimprovement.If changes of chronic pancreatitiswere present,the severity did not correlate withclinical improvement after endoscopic therapy.Improvements were observed irrespective of thecause of pancreatitis,whether biliary or pancreatic.Five of the eight patients (63%) with an underly-ing pancreatic cause had significant clinicalimprovement (3 with pancreatic stones and 2 withpancreas divisum).Of the 6 patients with pancreasdivisum,5 presented with acute/recurrent and 1with chronic relapsing pancreatitis.Minor ductsphincterotomy was performed in 3 patients,all ofwhom improved clinically.The patient with thechronic relapsing presentation had a pancreaticstone,and extraction resulted in a decrease in thefrequency and the severity of attacks.Significant clinical improvement was achieved in6 of 7 patients (86%) with biliary causes for pancre-atitis including the 4 patients with choledochalcysts (3 patients had associated bile duct stones)and 1 patient with cholelithiasis.Three of the four patients with sphincter of Oddidysfunction did not have any improvement in paindespite biliary sphincterotomy.
R Hsu,P Draganov,J Leung,et al.Therapeutic ERCP in the management of pancreatitis in childre
398
GASTROINTESTINAL ENDOSCOPYVOLUME 51,NO.4,PART 1,200
Table 2.Diagnosis,treatment,and outcomes in 22 children with pancreatitis
AgeCambridge classImprovement ofImprovement ofImprovement ofFollow-up(yr)DiagnosisManometryTreatmentpancreatogramgeneral conditionpain severitypain frequency(mo)3CDC,stoneB dil,sto0YesYesYes173CDC,stoneB sph,sto0YesYesYes124CDCB ste0NoYesYes2414CBD stoneBal sto0YesYesYes3114SODAbnormalB sph0YesYesYes91Divisum,CF0YesYesNo89Idiopathic0YesYesYes338LymphomaB ste0NoYesYes911DivisumB sph,P maj sph0YesYesYes3313Divisum,CFmin sph,min ste0YesYesYes1014SODAbnormal*B sph,P major sph1NoNoNo915IdiopathicNormal1YesYesNo115Familialmaj sph,min sph,sto1YesYesYes2214DivisumNormal*min sph,min ste1YesYesYes917SOD,DivisumAbnormalmin dil,min ste 1YesNoYes2517Idiopathic2YesNoNo219IdiopathicNormal2YesYesYes418IdiopathicNormal2YesYesYes46CDC,stoneB sph sto3YesYesYes1412Divisum3NoNoNo2112Pancreatic stoneNormalmin sph,sto3NoNoNo1216SODAbnormalB sph,maj ste3NoNoNo19
CD
,Choledochocyst;
SO
,sphincter of Oddi dysfunction;
CF 
,cystic fibrosis;
,biliary;
di
,dilation;
sph 
,sphincterotomy;
sto 
,stoneextraction;
ste 
,stenting;
,pancreatic;
maj 
,major;
mi
,minor.*Complication from mild pancreatitis.

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