Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

ERCP for pancreatic disease in children

Moises Guelrud, MD
Section Editors
Melvin B Heyman, MD, MPH
Douglas A Howell, MD, FASGE, FACG
Deputy Editor
Alison G Hoppin, MD


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 observed in the pediatric population [1].

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 "ERCP for biliary disease in children" and "ERCP in children: Technique, success and complications".)


Endoscopic retrograde cholangiopancreatography (ERCP) should be considered for all patients with pancreatitis for which an anatomical obstructive etiology is suspected. Potential indications for ERCP in children with pancreatitis are listed in the table (table 1) [2].

Initial evaluation — 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, occasionally celiac disease, and auto immune pancreatitis), drug-induced pancreatitis, and blunt trauma to the pancreas. In recurrent acute or chronic pancreatitis, hereditary causes should be explored through genetic testing for cationic trypsinogen (PRSS1), serine protease inhibitor Kazal type 1 gene (SPINK 1), cystic fibrosis transmembrane conductance regulator (CFTR) and chymotrypsinogen C (CTRC) mutations [3]. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children" and "Hereditary pancreatitis", section on 'Genetic testing' and "Causes and contributing risk factors for chronic pancreatitis in children and adolescents", section on 'Genetic'.)

Imaging with abdominal computerized tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) is important to establish the extent of the pancreatitis. We recommend MRCP prior to consideration of ERCP for most patients with chronic or acute recurrent pancreatitis. ERCP is more invasive and the procedure may trigger or exacerbate pancreatitis. Others have suggested endoscopic ultrasound (EUS) which is particularly useful for diagnosing 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 [4]. On the other hand, ERCP has the advantage of offering therapeutic interventions, such as sphincterotomy, stone removal and stent placement, so it is a valuable therapeutic procedure once a treatable condition has been diagnosed by CT, MRCP, or EUS. (See "Clinical manifestations and diagnosis of chronic and acute recurrent pancreatitis in children", section on 'Initial imaging'.)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 14, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Morinville VD, Barmada MM, Lowe ME. Increasing incidence of acute pancreatitis at an American pediatric tertiary care center: is greater awareness among physicians responsible? Pancreas 2010; 39:5.
  2. Fox VL, Werlin SL, Heyman MB. Endoscopic retrograde cholangiopancreatography in children. Subcommittee on Endoscopy and Procedures of the Patient Care Committee of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2000; 30:335.
  3. Schwarzenberg SJ, Bellin M, Husain SZ, et al. Pediatric chronic pancreatitis is associated with genetic risk factors and substantial disease burden. J Pediatr 2015; 166:890.
  4. Varadarajulu S, Wilcox CM, Eloubeidi MA. Impact of EUS in the evaluation of pancreaticobiliary disorders in children. Gastrointest Endosc 2005; 62:239.
  5. Whitcomb D. Hereditary and childhood disorders of the pancreas, including cystic fibrosis. In: Gastrointestinal and Liver Disease, 7th ed, Feldman M, Friedman LS, Sleisenger MH (Eds), Saunders, Philadelphia 2002. p.881.
  6. Brown KO, Goldschmiedt M. Endoscopic therapy of biliary and pancreatic disorders in children. Endoscopy 1994; 26:719.
  7. Buckley A, Connon JJ. The role of ERCP in children and adolescents. Gastrointest Endosc 1990; 36:369.
  8. Cotton PB, Laage NJ. Endoscopic retrograde cholangiopancreatography in children. Arch Dis Child 1982; 57:131.
  9. Dítè P, Vacek E, Stefan H, et al. Endoscopic retrograde cholangiopancreatography in childhood. Hepatogastroenterology 1992; 39:291.
  10. Graham KS, Ingram JD, Steinberg SE, Narkewicz MR. ERCP in the management of pediatric pancreatitis. Gastrointest Endosc 1998; 47:492.
  11. Lemmel T, Hawes R, Sherman S, et al. Endoscopic evaluation and therapy of recurrent pancreatitis and pancreaticobiliary pain in the pediatric population (abstract). Gastrointest Endosc 1994; 40:A54.
  12. Putnam PE, Kocoshis SA, Orenstein SR, Schade RR. Pediatric endoscopic retrograde cholangiopancreatography. Am J Gastroenterol 1991; 86:824.
  13. Poddar U, Thapa BR, Bhasin DK, et al. Endoscopic retrograde cholangiopancreatography in the management of pancreaticobiliary disorders in children. J Gastroenterol Hepatol 2001; 16:927.
  14. Blustein PK, Gaskin K, Filler R, et al. Endoscopic retrograde cholangiopancreatography in pancreatitis in children and adolescents. Pediatrics 1981; 68:387.
  15. Forbes A, Leung JW, Cotton PB. Relapsing acute and chronic pancreatitis. Arch Dis Child 1984; 59:927.
  16. Guelrud M, Mujica C, Jaen D, et al. The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents. Gastrointest Endosc 1994; 40:428.
  17. Lucidi V, Alghisi F, Dall'Oglio L, et al. The etiology of acute recurrent pancreatitis in children: a challenge for pediatricians. Pancreas 2011; 40:517.
  18. Brown CW, Werlin SL, Geenen JE, Schmalz M. The diagnostic and therapeutic role of endoscopic retrograde cholangiopancreatography in children. J Pediatr Gastroenterol Nutr 1993; 17:19.
  19. Mori K, Nagakawa T, Ohta T, et al. Pancreatitis and anomalous union of the pancreaticobiliary ductal system in childhood. J Pediatr Surg 1993; 28:67.
  20. Guelrud M, Morera C, Rodriguez M, et al. Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept. Gastrointest Endosc 1999; 50:194.
  21. Misra SP, Dwivedi M. Pancreaticobiliary ductal union. Gut 1990; 31:1144.
  22. Sugiyama M, Haradome H, Takahara T, et al. Biliopancreatic reflux via anomalous pancreaticobiliary junction. Surgery 2004; 135:457.
  23. Sugiyama M, Atomi Y, Kuroda A. Pancreatic disorders associated with anomalous pancreaticobiliary junction. Surgery 1999; 126:492.
  24. Guelrud M, C-LD, Fox VL. ERCP in pediatric practice: Diagnosis and treatment, Isis Medical Media Ltd, Oxford, UK 1997.
  25. Greene FL, Brown JJ, Rubinstein P, Anderson MC. Choledochocele and recurrent pancreatitis. Diagnosis and surgical management. Am J Surg 1985; 149:306.
  26. Weisser M, Bennek J, Hörmann D. Choledochocele--a rare cause of necrotising pancreatitis in childhood. Eur J Pediatr Surg 2000; 10:258.
  27. Siegel JH, Harding GT, Chateau F. Endoscopic incision of choledochal cysts (choledochocele). Endoscopy 1981; 13:200.
  28. Stimec B, Bulajić M, Korneti V, et al. Ductal morphometry of ventral pancreas in pancreas divisum. Comparison between clinical and anatomical results. Ital J Gastroenterol 1996; 28:76.
  29. Portwood G, Maniatis A, Jowell PS, et al. Diagnostic and therapeutic ERCP in children: Safe with a high success rate in experienced hands (abstract). Gastrointest Endosc 1995; 41:A342.
  30. Manegold BC, Gottstein T, Pescatore P. Diagnostic and therapeutic ERCP in children under 14 years (abstract). Gastrointest Endosc 1996; 43:A328.
  31. Guelrud M. The incidence of pancreas divisum in children. Gastrointest Endosc 1996; 43:83.
  32. Hsu RK, Draganov P, Leung JW, et al. Therapeutic ERCP in the management of pancreatitis in children. Gastrointest Endosc 2000; 51:396.
  33. Lehman GA, O'Connor KW. Coexistence of annular pancreas and pancreas divisum--ERCP diagnosis. Gastrointest Endosc 1985; 31:25.
  34. Yogi Y, Shibue T, Hashimoto S. Annular pancreas detected in adults, diagnosed by endoscopic retrograde cholangiopancreatography: report of four cases. Gastroenterol Jpn 1987; 22:92.
  35. Rosenstock E, Achkar E. A "short pancreas". Gastrointest Endosc 1986; 32:296.
  36. Holstege A, Barner S, Brambs HJ, et al. Relapsing pancreatitis associated with duodenal wall cysts. Diagnostic approach and treatment. Gastroenterology 1985; 88:814.
  37. Lavine JE, Harrison M, Heyman MB. Gastrointestinal duplications causing relapsing pancreatitis in children. Gastroenterology 1989; 97:1556.
  38. Johanson JF, Geenen JE, Hogan WJ, Huibregtse K. Endoscopic therapy of a duodenal duplication cyst. Gastrointest Endosc 1992; 38:60.
  39. Davis JJ, Heyman MB, Ferrell L, et al. Sclerosing cholangitis associated with chronic cryptosporidiosis in a child with a congenital immunodeficiency disorder. Am J Gastroenterol 1987; 82:1196.
  40. Godwin TA. Cryptosporidiosis in the acquired immunodeficiency syndrome: a study of 15 autopsy cases. Hum Pathol 1991; 22:1215.
  41. Krige JE, Lewis G, Bornman PC. Recurrent pancreatitis caused by a calcified ascaris in the duct of Wirsung. Am J Gastroenterol 1987; 82:256.
  42. Maddern GJ, Dennison AR, Blumgart LH. Fatal ascaris pancreatitis: an uncommon problem in the west. Gut 1992; 33:402.
  43. Guelrud M. Endoscopic retrograde cholangiopancreatography in the infant. In: Advanced therapeutic endoscopy, Barkin J (Ed), Raven Press, New York 1990. p.335.
  44. Guelrud M, Mendoza S, Rossiter G, Villegas MI. Sphincter of Oddi manometry in healthy volunteers. Dig Dis Sci 1990; 35:38.
  45. Guelrud M, Siegel JH. Hypertensive pancreatic duct sphincter as a cause of pancreatitis. Successful treatment with hydrostatic balloon dilatation. Dig Dis Sci 1984; 29:225.
  46. Varadarajulu S, Wilcox CM. Endoscopic management of sphincter of Oddi dysfunction in children. J Pediatr Gastroenterol Nutr 2006; 42:526.
  47. Jang JY, Yoon CH, Kim KM. Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children. World J Gastroenterol 2010; 16:490.
  48. Cheng CL, Fogel EL, Sherman S, et al. Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography in children: a large series report. J Pediatr Gastroenterol Nutr 2005; 41:445.
  49. Miller TL, Winter HS, Luginbuhl LM, et al. Pancreatitis in pediatric human immunodeficiency virus infection. J Pediatr 1992; 120:223.
  50. Butler KM, Venzon D, Henry N, et al. Pancreatitis in human immunodeficiency virus-infected children receiving dideoxyinosine. Pediatrics 1993; 91:747.
  51. Van Dyke RB, Wang L, Williams PL, Pediatric AIDS Clinical Trials Group 219C Team. Toxicities associated with dual nucleoside reverse-transcriptase inhibitor regimens in HIV-infected children. J Infect Dis 2008; 198:1599.
  52. Yabut B, Werlin SL, Havens P, et al. Endoscopic retrograde cholangiopancreatography in children with HIV infection. J Pediatr Gastroenterol Nutr 1996; 23:624.
  53. Finkelberg DL, Sahani D, Deshpande V, Brugge WR. Autoimmune pancreatitis. N Engl J Med 2006; 355:2670.
  54. Fujii LL, Chari ST, El-Youssef M, et al. Pediatric pancreatic EUS-guided trucut biopsy for evaluation of autoimmune pancreatitis. Gastrointest Endosc 2013; 77:824.
  55. Gargouri L, Ponsot P, Viala J, et al. Recurrent autoimmune pancreatitis in a 10-year-old boy. J Pediatr Gastroenterol Nutr 2009; 48:374.
  56. Güitrón A, Adalid R, Barinagarrementería R, et al. [Endoscopic cholangiopancreatography (ERCP) in pediatric patients]. Rev Gastroenterol Mex 1998; 63:211.
  57. Oracz G, Pertkiewicz J, Kierkus J, et al. Efficiency of pancreatic duct stenting therapy in children with chronic pancreatitis. Gastrointest Endosc 2014; 80:1022.
  58. Troendle DM, Fishman DS, Barth BA, et al. Therapeutic Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients With Acute Recurrent and Chronic Pancreatitis: Data From the INSPPIRE (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) Study. Pancreas 2017; 46:764.
  59. Iqbal CW, Moir CR, Ishitani MB. Management of chronic pancreatitis in the pediatric patient: endoscopic retrograde cholangiopancreatography vs operative therapy. J Pediatr Surg 2009; 44:139.
  60. Ford K, Paul A, Harrison P, Davenport M. Surgical Success in Chronic Pancreatitis: Sequential Endoscopic Retrograde Cholangiopancreatography and Surgical Longitudinal Pancreatojejunostomy (Puestow Procedure). Eur J Pediatr Surg 2016; 26:232.
  61. Beebe DS, Bubrick MP, Onstad GR, Hitchcock CR. Management of pancreatic pseudocysts. Surg Gynecol Obstet 1984; 159:562.
  62. Kozarek RA, Christie D, Barclay G. Endoscopic therapy of pancreatitis in the pediatric population. Gastrointest Endosc 1993; 39:665.
  63. Sharma SS, Maharshi S. Endoscopic management of pancreatic pseudocyst in children-a long-term follow-up. J Pediatr Surg 2008; 43:1636.
  64. Haluszka O, Campbell A, Horvath K. Endoscopic management of pancreatic pseudocyst in children. Gastrointest Endosc 2002; 55:128.
  65. Theodoros D, Nikolaides P, Petousis G. Ultrasound-guided endoscopic transgastric drainage of a post-traumatic pancreatic pseudocyst in a child. Afr J Paediatr Surg 2010; 7:194.
  66. Scheers I, Ergun M, Aouattah T, et al. Diagnostic and Therapeutic Roles of Endoscopic Ultrasound in Pediatric Pancreaticobiliary Disorders. J Pediatr Gastroenterol Nutr 2015; 61:238.
  67. Makin E, Harrison PM, Patel S, Davenport M. Pancreatic pseudocysts in children: treatment by endoscopic cyst gastrostomy. J Pediatr Gastroenterol Nutr 2012; 55:556.
  68. Rescorla FJ, Plumley DA, Sherman S, et al. The efficacy of early ERCP in pediatric pancreatic trauma. J Pediatr Surg 1995; 30:336.
  69. Canty TG Sr, Weinman D. Treatment of pancreatic duct disruption in children by an endoscopically placed stent. J Pediatr Surg 2001; 36:345.
  70. Westgarth-Taylor C, Loveland J. Paediatric pancreatic trauma: a review of the literature and results of a multicentre survey on patient management. S Afr Med J 2014; 104:803.
  71. Bhasin DK, Rana SS, Rao C, et al. Endoscopic management of pancreatic injury due to abdominal trauma. JOP 2012; 13:187.