Influence of ERCP on the diagnosis and treatment of pediatric patients with symp- tomatic pancreatitis and cystic fibrosis: series of case reports William B. Silverman, MD Philip E. Putnam, MD Susan R. Orenstein, MD Jose Fernando del Rosario, MD John Wilson, PhD Samuel A. Kocoshis, MD Patients with cystic fibrosis and symptomatic pancreatitis may suffer recurring symptomatic episodes of pain. In growing children, interruption of oral alimentation as a result of episodes of pancre- atitis may affect their physical development. This retrospective study describes our experience in per- forming pediatric ERCP in children with cystic fibrosis and pancreatitis. Records of ERCP procedures performed between September 1991 and December 1995 were reviewed using a specially written ERCP procedure data- base/report generator, 1 as well as a computerized hospital medical records system, and the conven- tional hospital paper chart. Follow-up phone calls to patients and their families were made when neces- sary. The patients were all diagnosed with cystic fibrosis based on clinical symptoms and abnormal sweat chloride tests. The CF G551 D gene was abnormal in two; testing was not performed in the other two patients. These patients were referred from the cystic fibrosis center. At our pediatric ter- tiary referral center all patients before ERCP underwent CT or ultrasound of the pancreas. ERCP procedures were performed by an attending gas- troenterologist who had received specialty training in therapeutic pancreaticobiliary endoscopy. All were performed using general anesthesia with endo- tracheal intubation. None of the patients had severe pulmonary disease or other significant co-morbid disease. The Olympus JF-100 or TJF-100 video duo- denoscopes (Olympus America, Inc., Melville, N.Y.) were used for the majority of the procedures. Sphincter of Oddi manometry was performed using an aspiration type catheter (Wilson-Cook Medical, Winston-Salem, N.C.), according to the technique described by Sherman et al. 2 Sphincterotomies were performed using blended current as described by Cotton. 3 Prophylactic antibiotics were adminis- tered, generally ticarcillin/clavulinic acid or ciprofloxicin if allergic to penicillin. No glucagon or other medications known to affect the sphincter of Oddi were administered before the completion of sphincter manometry. During this period, 64 ERCPs were performed in 50 pediatric patients. Four of these patients had cys- tic fibrosis and underwent a total of 9 ERCPs. Age ranged from 4 to 16 years; all were white. Two patients were girls; two were boys. Each had at least three symptomatic episodes of pancreatitis before ERCP. CASE REPORTS Case 1 The patient was a 16-year-old white boy with a history of 16 bouts of pancreatitis since age 17 months. ERCP was performed along with major papilla pancreatic sphincter of Oddi manometry. Basal sphincter pressure was abnor- mally elevated to 100 mm Hg (normal < 40 mm Hg). The retrograde pancreatogram was normal. A biliary sphinc- terotomy was performed, ablating the common sphincter segment. At the time these patients were treated, it was not our practice to perform de novo major papilla pancre- atic sphincterotomies, especially in pediatric patients. Rather, a biliary sphincterotomy with incision of the com- mon portion of the sphincter was our standard practice. There have been no further clinical episodes of pancreati- tis during 2 years of follow-up. Case 2 This 9-year-old white girl with recurrent bouts of pan- creatitis had a dilated pancreatic duct on CT. Retrograde pancreatography demonstrated pancreas divisum, and intraductal concretions were seen in the lumen of the dor- sal duct, which was dilated throughout its course, taper- ing downstream near the minor papilla in a “type IV” lesion. 4 Because of the obstructive nature of the findings, a minor papilla sphincterotomy with basket stone extrac- tion and balloon stricture dilation was performed on three separate occasions with significant but incomplete removal of the intraductal concretions. To minimize both repeated exposure to radiation and the risk of pancreatic duct injury, endoscopic treatment was discontinued and the patient underwent a modified pancreaticojejunostomy. She had no further clinical episodes of pancreatitis until 2 years after the surgery when she experienced a mild clin- ical pancreatic flare. Repeat dorsal duct pancreatography demonstrated new pancreatic concretions in the down- stream nondiverted portion (sump) of the dorsal duct. Hydrostatic balloon dilation of the previous minor papilla sphincterotomy with basket extraction of the majority of 534 GASTROINTESTINAL ENDOSCOPY VOLUME 48, NO. 5, 1998 From the Department of Medicine, Division of Gastroenterology and Hepatology, the Department of Pediatrics, Division of Gastroenterology, Childrens Hospital of Pittsburgh, and the Department of Biostatistics, Pittsburgh Cancer Institute, University of Pittsburgh Medical Center. Reprint requests: William B. Silverman, MD, Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, 4553-A JCP, 200 Hawkins Dr., Iowa City IA 52242- 1009. Copyright © 1998 by the American Society for Gastrointestinal Endoscopy 0016-5107/98/$5.00 + 0 37/4/92257