Endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic disease in children

INTRODUCTION — Endoscopic retrograde cholangiopancreatography (ERCP) has changed the approach to the diagnosis and management of pancreatic disorders in adults. It remains a less common procedure in children, despite accumulating experience since the mid-1980s in the use of ERCP for a variety of indications. In the last two decades, an increased incidence of acute and chronic pancreatitis has been recognized in the pediatric population [1]. ERCP in children and infants requires a high level of expertise and specialized training. It is now routinely used for therapeutic purposes where the special expertise for performing the procedure in children is available.

The pancreatic disorders that can be evaluated by ERCP are described here. The use of ERCP for biliary disorders in children and the technique, success, and complications of ERCP in children are discussed separately. (See "Endoscopic retrograde cholangiopancreatography (ERCP) for biliary disease in children" and "Endoscopic retrograde cholangiopancreatography (ERCP) in children: Technique, success, and adverse events".)

UNEXPLAINED ACUTE AND RECURRENT PANCREATITIS — ERCP should be considered in selected patients with clinically significant pancreatitis for which an anatomical (including obstructive) etiology is suspected. Potential indications for ERCP in children with pancreatitis are listed in the table (table 1) [2].

Initial evaluation

●Exclude nonanatomical causes – Prior to considering ERCP, specific nonanatomical causes of pancreatitis should be explored. These include infections, systemic diseases (including systemic inflammatory conditions such as systemic lupus erythematosus, hypertriglyceridemia, hypercalcemia, inflammatory bowel disease affecting the area of the major papilla, and, occasionally, celiac disease and autoimmune pancreatitis), drug-induced pancreatitis, and blunt trauma to the pancreas.

●Genetic testing – In acute recurrent or chronic pancreatitis, genetic causes should be explored through genetic testing, typically offered as a "pancreatitis panel", including tests for PRSS1 (cationic trypsinogen), SPINK1 (serine protease inhibitor Kazal type 1), CFTR (cystic fibrosis transmembrane conductance regulator), and CTRC (chymotrypsinogen C) gene mutations [3,4]. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children" and "Causes and contributing risk factors for chronic pancreatitis in children and adolescents", section on 'Genetic' and "Pancreatitis associated with genetic risk factors", section on 'Genetic testing'.)

●Imaging – Pancreatic imaging is important to evaluate the pancreatic duct and pancreatic parenchyma, rule out anatomical conditions that may lead to pancreatitis, and evaluate for pancreatic/peripancreatic fluid collections. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children", section on 'Initial imaging'.)

•Magnetic resonance cholangiopancreatography (MRCP) should be performed prior to consideration of ERCP for most patients with chronic or acute recurrent pancreatitis. MRCP has high diagnostic yield for treatable pancreatic conditions and is noninvasive. Abdominal computed tomography (CT) is also reasonably sensitive but has the disadvantage of radiation exposure.

•EUS is increasingly used if MRCP is not revealing. As examples, EUS may identify gallbladder sludge, pancreas divisum, congenital biliary anomalies, duodenal duplication cyst, small biliary or pancreatic stones that may have been missed with other imaging modalities, and chronic pancreatitis [5-8]. The findings on an EUS examination may also obviate the need for ERCP, potentially sparing the patient the risk of post-ERCP pancreatitis. (See "Endoscopic ultrasound in chronic pancreatitis".)

If these noninvasive tests identify a relevant condition such as biliary obstruction, we proceed to therapeutic ERCP [2].

Indications for ERCP — Indications for ERCP in children were initially extrapolated from the adult literature but are supported by increasing clinical experience with ERCP in the pediatric age groups, as summarized in consensus guidelines [9,10]. ERCP is now considered to be mainly a therapeutic procedure and is rarely used for diagnostic purposes alone.

Special expertise in performing ERCP in infants and children is not widely available. In centers in which this expertise is available, ERCP is often appropriate for treating patients with anatomic pancreatic disorders (table 2), as outlined below. However, the risks and benefits of ERCP depend on individual patient characteristics, including age and associated medical comorbidities, and whether an anatomical abnormality identified on noninvasive testing is likely to be treatable with therapeutic ERCP. Thus, the indications described below apply to centers in which expertise in pediatric ERCP is available and may vary with individual patient characteristics.

●First attack of pancreatitis – After a first attack of pancreatitis, the first step is noninvasive testing consisting of laboratory tests and imaging, as outlined above. (See 'Initial evaluation' above.)

•If the noninvasive tests and imaging reveal a cause that is potentially treatable via ERCP, it is appropriate to proceed to therapeutic ERCP. Biliary pancreatitis (due to choledocholithiasis or sludge) is a common indication. (See 'Biliary pancreatitis' below.)

•If the noninvasive imaging is unrevealing, we generally do not proceed to ERCP after a first attack of pancreatitis.

●Recurrent pancreatitis – Approximately 17 percent of children with acute pancreatitis will have recurrences [11]. Depending on the age of first episode and underlying etiology, a significant number of patients with acute recurrent pancreatitis will go on to develop chronic pancreatitis [12].

If noninvasive testing (CT or MRCP) and genetic testing is unrevealing, we occasionally proceed to ERCP in selected patients, but the diagnostic yield is low and must be balanced against the risk of complications. Post-ERCP pancreatitis occurs in 3 to 12 percent of pediatric ERCPs and is more common in those who undergo pancreatic duct injection or pancreatic sphincterotomy [13]. (See "Endoscopic retrograde cholangiopancreatography (ERCP) in children: Technique, success, and adverse events", section on 'Adverse events'.)

ERCP findings and interventions by cause — Various anatomical conditions have been associated with recurrent pancreatitis, which can be categorized as congenital or acquired (table 2). The major diagnoses within these categories will be reviewed below.

Congenital anomalies — Several congenital biliary and pancreatic anomalies have been associated with pancreatitis in children, some of which are potentially amenable to therapeutic intervention during ERCP.

●Biliary cysts and abnormal pancreaticobiliary junction – Biliary cysts are cystic dilatations that may occur singly or in multiples throughout the intra- and extrahepatic bile ducts. They originally were termed choledochal cysts (involving the extrahepatic bile duct), but the clinical classification was revised in 1977 to include intrahepatic cysts. (See "Biliary cysts" and "Endoscopic retrograde cholangiopancreatography (ERCP) for biliary disease in children".)

A biliary cyst is identified in 6 to 20 percent of cases of acute pancreatitis in children [14-16]. Most children with biliary cysts and pancreatitis have an anomalous pancreaticobiliary junction (APBJ; also known as an anomalous pancreaticobiliary union) in which the pancreaticobiliary union is located outside the duodenal wall (figure 1A-B). The incidence of ABPJ is approximately 1:100,000 in the Western world, compared with 1:1000 in Japan [17]. The predisposition of patients with APBJ to pancreatitis is probably related to retrograde flow of bile into the pancreatic duct but has also been attributed to sphincter of Oddi dysfunction (SOD) [18-22].

Therapeutic ERCP is helpful for most patients with biliary cysts and pancreatitis. Children with a choledochocele (in which the cyst is located within the duodenal wall, also known as type III biliary cyst) may also benefit from sphincterotomy (picture 1 and image 1A-B) [23-26]. In other patients with biliary cysts, pancreatitis may be due to pancreatic stones or plugs, which can be removed endoscopically. The approach to management depends on the cyst type. Most biliary cysts should also be surgically removed due to long-term risk of malignancy. (See "Biliary cysts".)

A type "long Y" APBJ is not associated with a biliary cyst, but these patients need a cholecystectomy due to an association with gallbladder cancer. (See "Biliary cysts", section on 'Abnormal pancreatobiliary junction and cancer'.)

●Pancreas divisum – Pancreas divisum is the most common congenital variant of the pancreas and is caused by failure of fusion of the dorsal and ventral endodermal buds. As a result, each duct drains via its own orifice. The major papilla of Vater drains the ventral duct of Wirsung, while the minor accessory papilla drains the dorsal duct of Santorini (figure 2). Pancreas divisum occurs in approximately 7 percent of individuals in autopsy series [27]. (See "Pancreas divisum: Clinical manifestations and diagnosis".)

The association between pancreas divisum and pancreatitis is controversial since many patients with pancreas divisum (identified during ERCP for indications other than pancreatitis or in autopsy studies) do not have a history of pancreatitis. Indeed, only approximately 5 percent of individuals with pancreas divisum develop pancreatic symptoms (see "Pancreas divisum: Clinical manifestations and diagnosis", section on 'Clinical manifestations'). However, the rate of pancreas divisum is somewhat higher among patients with recurrent pancreatitis than in the general population. As an example, pancreas divisum has been found in approximately 11 percent of 296 children with recurrent pancreatitis reported in the published literature [14,23,28-35]. In our own experience with 272 consecutive successful ERCPs performed for a variety of indications, pancreas divisum was found in nine (3.3 percent) [36]. The prevalence was considerably higher (12 percent) among the 50 children older than one year who had recurrent pancreatitis. These observations suggest but do not prove that pancreas divisum is associated with recurrent pancreatitis in children, but they also confirm that most patients with pancreas divisum do not develop pancreatic disease.

Endoscopic treatment of pancreas divisum is generally reserved for patients whose symptoms are recurrent and disabling. The treatment typically consists of sphincterotomy of the minor papilla, with temporary placement of a stent. Clinical improvement with such treatment has been observed in up to 75 percent of patients [23,32,37]. The results are less favorable in children with evidence of chronic pancreatitis in the dorsal pancreas. Individuals with pancreas divisum but no dilation of the dorsal duct (image 2) are less likely to respond to endoscopic therapy than those with pancreas divisum and a dilated dorsal duct (image 3 and picture 2). (See "Treatment of pancreas divisum".)

A study from the INSPPIRE consortium (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) reported that pancreas divisum was present in 52 of 359 subjects (14.5 percent) with acute recurrent or chronic pancreatitis, acting independently from genetic risk factors [38]. ERCP was most helpful if obstructing stones were present in the dorsal pancreatic duct.

●Annular pancreas – Case reports have described an association between annular pancreas (image 4) and recurrent pancreatitis in children [23,39,40]. However, whether there is a causal relationship remains uncertain since many of the reported cases of annular pancreas (in adults and children) had coexistent pancreas divisum [39].

●Other pancreatic congenital anomalies – Several other anomalies have been described in association with pancreatitis including:

•Agenesis of the dorsal pancreas (also known as "short pancreas") (image 5).

•Cystic dilation of the pancreatic duct (pancreatocele) (image 6) [23,41].

•Duodenal duplication cyst – These are rare; the association with pancreatitis is presumably due to intermittent obstruction of the pancreatic duct [42-44]. ERCP can be helpful for establishing the diagnosis and for definitive treatment [45,46]. The appearance of a duplication cyst on EUS is described separately. (See "Endoscopic ultrasound for the characterization of subepithelial lesions of the upper gastrointestinal tract".)

Biliary pancreatitis — Biliary pancreatitis is a common indication for ERCP in children. ERCP is indicated for children with biliary pancreatitis with cholangitis or with obstruction of the common bile duct, as reflected in expert consensus guidelines [9,10]. If the pancreatitis is severe, the procedure should be performed within 24 hours. For biliary pancreatitis without cholangitis, ERCP is generally indicated for stone extraction but is not urgent.

Other acquired diseases — In addition to biliary pancreatitis, other acquired disorders associated with pancreatitis are viral or parasitic infections, certain medications, systemic inflammatory conditions, and, possibly, SOD:

●Parasitic infestation – Pancreatitis is occasionally seen as a complication of infestation with Ascaris lumbricoides (image 7) or other parasites among children living in endemic areas. Cryptosporidiosis can invade the biliary and pancreatic ducts from the intestine in immunodeficient patients, leading to pancreatitis (and biliary duct disease) [47,48]. In most cases, the pancreatitis is caused by migration of the worm into the bile duct, causing transient obstruction of the papilla of Vater. Less commonly, the worm migrates into the main pancreatic duct, causing recurrent pancreatitis [49] or, rarely, necrotizing pancreatitis [50]. Worms can sometimes be removed endoscopically [51]. (See "Ascariasis".)

●HIV infection – Few publications are available on pancreatic involvement in children with acquired immunodeficiency syndrome (AIDS). Pancreatitis is a recognized complication of human immunodeficiency virus (HIV) infection in children and adults. Most cases are associated with use of didanosine (a nucleoside reverse-transcriptase inhibitor in use in the United States for over 30 years) or other medications [52-54]. Opportunistic infections may involve the pancreas [52]. The most common are Cytomegalovirus and Cryptosporidium, followed by Pneumocystis jirovecii (carinii), Toxoplasma gondii, and Mycobacterium avium. ERCP may permit ductal decompression in children who have developed strictures due to infections [55].

●Autoimmune pancreatitis – Autoimmune pancreatitis is an infrequently recognized disorder of presumed autoimmune etiology that is associated with characteristic clinical, histologic, and morphologic findings [56]. It can occur as a primary pancreatic disorder or in association with other disorders of presumed autoimmune etiology, including inflammatory bowel disease. The disorder is mostly recognized in adults but occasionally reported in children [57,58]. (See "Autoimmune pancreatitis: Clinical manifestations and diagnosis" and "Causes and contributing risk factors for chronic pancreatitis in children and adolescents", section on 'Autoimmune'.)

Autoimmune pancreatitis is highly suspected based on imaging findings (MRCP, CT, and/or EUS) and confirmed by pancreatic biopsy (although this is rarely needed). ERCP is not indicated for diagnosis, but it is occasionally used for temporary biliary stent placement during treatment with corticosteroids (image 8) [58].

●Sphincter of Oddi dysfunction – The hypothesis that SOD may cause acute recurrent pancreatitis in adults is being increasingly questioned, and its role in children with recurrent pancreatitis is even more uncertain. Therefore, interventions designed to evaluate and address this mechanism, including endoscopic manipulations, manometry, and sphincterotomy (biliary and/or pancreatic), should be approached with great caution. Diagnosis and management of SOD dysfunction in adults is discussed separately.

CHRONIC PANCREATITIS — Risk factors for chronic pancreatitis can be grouped according to their pathophysiology (table 3); these contributors are termed "risk factors" rather than "causes" because chronic pancreatitis may be the result of more than one pathophysiologic event. (See "Causes and contributing risk factors for chronic pancreatitis in children and adolescents", section on 'Overview of risk factors'.)

Chronic calcific pancreatitis is identified by an imaging study such as a CT scan. Stones can be localized in the pancreatic parenchyma with normal duct anatomy, can be intraductal, or can be present in both locations. Parenchymal stones are difficult to treat, and extracorporeal shock wave lithotripsy or surgery may be needed if the patient is symptomatic. Ductal stones can be treated with ERCP and retrieval devices including baskets or balloons.

Genetic etiologies of chronic pancreatitis (PRSS1, SPINK, CTRC, and others) affect the acinar cell, leading to premature activation of trypsinogen, which cannot be inactivated, either due to changes in the trypsinogen configuration or a malfunctioning of the inhibitory mechanism. Other mutations such as CFTR affect the ductal system, leading to obstruction and pancreatitis. Early in the clinical presentation, genetic etiologies do not appear to cause a calcific phenotype. As the disease progresses, calcifications can develop and are most frequently seen in patients with PRSS1 mutations. Early-onset pancreatitis is strongly associated with PRSS1 or CTRC mutations, and there is frequently a family history of pancreatitis [59].

Some of the specific causes of chronic pancreatitis can be identified with laboratory evaluation, genetic tests, and noninvasive imaging including magnetic resonance cholangiopancreatography (MRCP). An approach to the evaluation and diagnosis of chronic pancreatitis is discussed separately. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children".)

Diagnostic ERCP — Since the advent of MRCP and endoscopic ultrasound (EUS), ERCP is only rarely performed for diagnostic purposes.

When ERCP is performed for chronic pancreatitis, the earliest changes involve the side branches of the main pancreatic duct and include dilatation, contour irregularity, clubbing, and stenosis [23,28,31,37,60]. These changes may be accompanied by mild dilatation of the main pancreatic duct. As the disease progresses, the involvement of the main pancreatic duct increases, producing more marked dilatation, irregularity of the walls, and areas of stenosis or occlusion with intraluminal calcifications (image 9).

Therapeutic ERCP — Patients with chronic pancreatitis, abdominal pain, and a dilated main pancreatic duct are candidates for a decompression procedure. Decompression can be accomplished by therapeutic ERCP or by a variety of surgical procedures. The role of endoscopic versus surgical intervention has not been well established in either adults or children, and the very limited evidence available suggests that both types of interventions have a role. Larger and randomized studies are needed to determine optimal selection of patients for these interventions. Management in children is based on expert opinion, guided by indirect evidence from adults with chronic pancreatitis and a few small case series in children.

●Endoscopic therapy – A role of endoscopic therapy in the treatment of chronic pancreatitis is evolving. The only established indication for therapeutic ERCP in children with chronic pancreatitis is for treating abdominal pain due to ductal obstruction [61]. ERCP may be used to remove intraductal stones, dilate strictures, place stents, and perform pancreatic sphincterotomy, maneuvers that can improve drainage of the pancreatic duct and lessen the pain (image 10 and image 9). At present, endoscopic therapy should only be performed in specialized centers, preferably in the context of a clinical study.

Multiple reports in children have suggested that these approaches can be performed safely in expert hands and may relieve symptoms, at least in the short term [2,10,37,62-64], as illustrated by the following studies:

•Among 301 children with acute recurrent pancreatitis or chronic pancreatitis enrolled in the INSPPIRE study (INternational Study group of Pediatric Pancreatitis: In search for a cuRE), 117 (38.9 percent) underwent at least one therapeutic ERCP [65]. The procedure was more commonly performed in children with chronic pancreatitis (66 percent) compared with acute recurrent pancreatitis (13.5 percent). Utility of therapeutic ERCP was similar in both groups (53 versus 56 percent).

•A retrospective single-center case series described ERCPs in 38 children and adolescents, most of whom had chronic pancreatitis [66]. A total of 158 ERCPs were performed with a seven-year follow-up. The post-ERCP complication rate was 3 percent, which is somewhat lower than that reported in most other case series. After the procedure, there were significant decreases in the severity and frequency of abdominal pain, frequency of pancreatitis episodes, and use of analgesia (p<0.001); only one child required subsequent surgery.

These findings suggest that ERCP can be safe and effective for the treatment of chronic pancreatitis in appropriately selected children, where expertise in this technique is available. Complications of ERCP in children are discussed in more detail separately. (See "Endoscopic retrograde cholangiopancreatography (ERCP) in children: Technique, success, and adverse events", section on 'Adverse events'.)

●Surgical therapy – The very limited evidence available suggests that surgical therapy also has a role in the management of children with chronic pancreatitis and abdominal pain:

•Some experts have proposed that ERCP and stenting can be used as a therapeutic trial to assess possible benefit of a surgical duct drainage procedure. A small series of six children described a two-stage management protocol: The patients were first treated with ERCP with pancreatic stenting, and all had relief of pain [67]. Therefore, all of the subjects proceeded to surgical decompression, using longitudinal pancreatojejunostomy (Puestow procedure). All six subjects reported markedly reduced episodes of pain after surgery.

•A small case series suggests a role for surgical intervention in selected children. Among 37 children with chronic pancreatitis, those managed by surgical therapy had a lower rate of recurrent pancreatitis and hospitalization compared with those managed by endoscopic therapy [68]. Some of the patients in this series responded to surgical therapy after failing therapeutic ERCP.

Most experience in surgical procedures for chronic pancreatitis is in adult patients, as described separately. (See "Chronic pancreatitis: Management", section on 'Endoscopic therapy'.)

PANCREATIC AND PERIPANCREATIC FLUID COLLECTIONS — Pancreatic pseudocysts and walled-off necrosis are commonly seen in the setting of acute, acute recurrent, and chronic pancreatitis and in areas of pancreatic trauma. Associated symptoms include abdominal pain and obstructive symptoms from extrinsic gastric or duodenal compression, leading to postprandial vomiting. While most collections resolve spontaneously, symptomatic collections need drainage procedures.

Symptomatic pancreatic and peripancreatic fluid collections have traditionally been drained surgically or percutaneously. Endoscopic methods have developed as a less invasive alternative to surgical and percutaneous drainage, so that surgical drainage is rarely performed. These methods include cystogastrostomy, cystoduodenostomy, and transpapillary drainage (image 11) [61,69]. In adults, successful pseudocyst resolution has been reported in approximately 80 percent of cases. Results have been similar in children, although experience is limited to case reports and case series [70-73]. In a meta-analysis of 187 children, the pooled clinical success rate was 92 percent [74]. (See "Endoscopic interventions for walled-off pancreatic fluid collections".)

PANCREATIC TRAUMA — There is considerable variation in management of patients with traumatic pancreatitis and associated ductal injury. Options range from a conservative approach with observation and supportive management, to ERCP with placement of a pancreatic stent, to an aggressive surgical approach.

In patients with traumatic pancreatitis, the first step is noninvasive imaging (eg, magnetic resonance cholangiopancreatography [MRCP] if available with secretin protocol), which has high sensitivity for identifying duct disruptions [2,75]. Subsequently, ERCP can identify the presence and location of duct leakage and may allow endoscopic therapy or identify the need for surgery [72,76,77]. Some experts perform ERCP as early as the first day after the injury, while others reserve it for traumatic pancreatitis that does not show signs of resolving within one week of the injury [77,78]. Patients with a normal pancreatogram can be treated conservatively. Those with duct disruption can be treated with an intrapancreatic stent bridging the disrupted site, thereby reserving surgery for those in whom stenting is unsuccessful [76,79].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)

SUMMARY

●Overview of indications for endoscopic retrograde cholangiopancreatography (ERCP) – ERCP should be considered for patients with pancreatitis for which an anatomical cause is identified radiologically and might be treated endoscopically. Potential indications for ERCP in children with pancreatic disease are listed in the table (table 1).

●Role in acute and recurrent pancreatitis – For patients with unexplained acute or recurrent pancreatitis, the first step in the evaluation is a focused history and laboratory testing to rule out medications, systemic conditions, or genetic mutations that may trigger pancreatitis. We also obtain noninvasive imaging, typically magnetic resonance cholangiopancreatography (MRCP). (See 'Initial evaluation' above.)

•If the imaging reveals a potentially treatable cause (such as biliary or pancreatic obstruction due to a stone or stricture), it is appropriate to proceed to therapeutic ERCP.

•If imaging does not reveal an anatomical cause of the pancreatitis, ERCP is unlikely to be revealing.

(See 'Indications for ERCP' above.)

●Pre-procedure evaluation – Prior to considering ERCP, specific nonanatomical causes of pancreatitis should be excluded. These include infections, metabolic diseases, systemic conditions, drug-induced pancreatitis, and blunt trauma. In recurrent or chronic pancreatitis, genetic etiologies should be explored. Imaging with magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRCP), CT, or endoscopic ultrasound (EUS) is important to evaluate the pancreatic duct and pancreatic parenchyma, rule out anatomical conditions that may lead to pancreatitis, and evaluate for pancreatic/peripancreatic fluid collections. (See 'Initial evaluation' above and "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children".)

●ERCP findings and interventions by cause

•Biliary pancreatitis – ERCP is indicated for children with biliary pancreatitis with cholangitis or with obstruction of the common bile duct but generally not for mild biliary pancreatitis without cholangitis. (See 'Biliary pancreatitis' above.)

•Biliary cysts – A biliary cyst is responsible for 6 to 18 percent of acute pancreatitis in children. Most such children have an anomalous pancreaticobiliary junction (APBJ) in which the pancreaticobiliary union is located outside the duodenal wall (figure 1A-B). Therapeutic ERCP is helpful for most of these patients, but most will also require surgical excision of the cyst. (See 'Congenital anomalies' above.)

•Pancreas divisum – This is more common among children with recurrent pancreatitis than in the general population, but most patients with pancreas divisum do not develop pancreatitis. Endoscopic treatment of pancreas divisum is reserved for patients whose symptoms are recurrent and disabling. (See 'Congenital anomalies' above.)

•Other congenital anomalies – Other congenital anomalies that may be associated with pancreatitis include annular pancreas, agenesis of the dorsal pancreas (also known as "short pancreas"), cystic dilation of the pancreatic duct (pancreatocele), and duodenal duplication cysts. (See 'Congenital anomalies' above.)

●Other indications for ERCP

•Chronic pancreatitis – In children with chronic pancreatitis, the most common indication for therapeutic ERCP is abdominal pain. ERCP may be used to remove intraductal stones, dilate strictures, place pancreatic stents, and perform pancreatic sphincterotomy, maneuvers which can help decompress the pancreatic duct and lessen the abdominal pain. (See 'Chronic pancreatitis' above.)

•Pancreatic trauma or pseudocysts – Endoscopic treatment of symptomatic pancreatic/peripancreatic fluid collections or pancreatic trauma is based on experience in adults. These disorders also are amenable to endoscopic treatment in children. Appropriate patient selection and a high level of expertise in therapeutic ERCP are essential. (See 'Pancreatic and peripancreatic fluid collections' above and 'Pancreatic trauma' above.)

●Complications – The most common complication is post-ERCP pancreatitis, which occurs in approximately 3 to 12 percent of ERCPs in children, and is more common in those who undergo pancreatic duct injection or pancreatic sphincterotomy. Risk factors and types of complications are discussed separately. (See "Endoscopic retrograde cholangiopancreatography (ERCP) in children: Technique, success, and adverse events", section on 'Adverse events'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Moises Guelrud, MD, who contributed to earlier versions of this topic review.