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©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jun 10, 2016; 8(11): 425-432
Published online Jun 10, 2016. doi: 10.4253/wjge.v8.i11.425
Endoscopic retrograde cholangiography for pediatric choledocholithiasis: Assessing the need for endoscopic intervention
Douglas S Fishman, Bruno P Chumpitazi, Isaac Raijman, Cynthia Man-Wai Tsai, E O’Brian Smith, Mark V Mazziotti, Mark A Gilger
Douglas S Fishman, Bruno P Chumpitazi, Cynthia Man-Wai Tsai, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX 77030, United States
Isaac Raijman, Digestive Associates of Houston, Houston, TX 77098, United States
E O’Brian Smith, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States
Mark V Mazziotti, Michael E Debakey, Department of Surgery, Section of Pediatric Surgery, Baylor College of Medicine, Houston, TX 77030, United States
Mark A Gilger, Department of Pediatrics, Baylor College of Medicine, Children’s Hospital of San Antonio, San Antonio, TX 78207, United States
Author contributions: Fishman DS designed and performed the research and wrote the manuscript; Chumpitazi BP designed and performed the research, wrote the manuscript and edited and approved the final manuscript; Raijman I designed the research, supervised the report, contributed to the analysis, edited and approved the final manuscript; Smith EO performed the statistical analysis and supervised the report; Tsai CMW and Mazziotti MV contributed to the analysis, edited and approved the final manuscript; Gilger MA designed and performed the research, supervised the report and contributed to the analysis and final editing and approval of the manuscript.
Institutional review board statement: This study was approved by the Baylor College of Medicine Institutional Review Board.
Informed consent statement: A waiver for informed consent was approved by the Baylor College of Medicine Institutional Review Board. Patients were not required to give informed consent to the study because subjects had previously received standard of care; the study could not be completed without the waiver; and all precautions were taken to prevent loss of private health information.
Conflict-of-interest statement: Dr. Douglas Fishman is on an advisory board for Norgine Pharmaceuticals, and has served as a consultant for Cook Medical. Dr. Raijman is a speaker and consultant for Boston Scientific. Dr. Chumpitazi has received research support from QOL Medical, Inc. and is a consultant for Mead Johnson Nutrition.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Douglas S Fishman, MD, Associate Professor, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children’s Hospital, Clinical Care Center 1010, 6621 Fannin Street, Houston, TX 77030, United States.
dougfishman@gmail.com
Fax: +1-832-8253633
Received: November 13, 2015
Peer-review started: November 16, 2015
First decision: January 4, 2016
Revised: February 16, 2016
Accepted: March 7, 2016
Article in press: March 9, 2016
Published online: June 10, 2016
Processing time: 205 Days and 21.2 Hours
AIM: To assess pediatric patients for choledocholithiasis. We applied current adult guidelines to identify predictive factors in children.
METHODS: A single-center retrospective analysis was performed at a tertiary children’s hospital. We evaluated 44 consecutive pediatric patients who underwent endoscopic retrograde cholangiography (ERCP) for suspected choledocholithiasis. Patients were stratified into those with common bile duct stones (CBDS) at ERCP vs those that did not using the American Society of Gastrointestinal Endoscopy (ASGE) guidelines (Very Strong and Strong criteria) for suspected CBDS.
RESULTS: CBDS were identified in 84% at the time of ERCP. Abdominal ultrasound identified CBDS in 36% of patients. Conjugated bilirubin ≥ 0.5 mg/dL was an independent risk factor for CBDS (P = 0.003). The Very Strong (59.5%) and Strong (48.6%) ASGE criteria identified the majority of patients (P = 0.0001). A modified score using conjugated bilirubin had a higher sensitivity (81.2% vs 59.5%) and more likely to identify a stone than the standard criteria, odds ratio of 25.7 compared to 8.8. Alanine aminotransferase and gamma-glutamyl transferase values identified significant differences in a subset of patients with odds ratio of 4.1 and 3.25, respectively.
CONCLUSION: Current adult guidelines identified the majority of pediatric patients with CBDS, but specific pediatric guidelines may improve detection, thus decreasing risks and unnecessary procedures.
Core tip: In pediatric patients with gallstones, biliary obstruction has been reported in up to 30% of patients with limited data to predict need for endoscopic retrograde cholangiography for choledocholithiasis. In this single-center retrospective study we evaluated 44 consecutive pediatric patients and used the American Society of Gastrointestinal Endoscopy guidelines for suspected choledocholithiasis. We found that the Very Strong and Strong criteria identified the majority of patients. Conjugated bilirubin was also identified as an important predictor. Current adult guidelines can be used in the majority of patients, but specific pediatric guidelines may improve detection, thus decreasing risks.
