ERCP: Pancreatic Disease

ERCP was introduced in the 1970s as a purely diagnostic modality

ERCP has evolved from a diagnostic to a more therapeutic modality over time

Advances in radiology have enabled non-invasive identification of abnormalities, contributing to ERCP's shift toward therapeutic use

CT provides value in complex cases and complex patients for pancreatic imaging

Severe scoliotic curvature and spinal hardware make it difficult to get a good ultrasound

Fluid collection replacing a large chunk of pancreas with no preserved pancreatic tissue around it indicates an area of necrosis or walled off necrosis

Once you have a lay of the land with CT, you can use ultrasound to target and look at areas of interest in complex cases

If ultrasound findings change dramatically or you're not getting a good sense of things, you may need to go back to cross-sectional imaging (CT or MRI)

Ultrasound is a good modality to follow patients serially over time because it's easier on patients and lacks ionizing radiation

Spinal fusion rods make it challenging to identify and visualize normal ductal structures during ERCP

Pancreatic sphincterotomy and pancreatic duct stent placement allow flow of pancreatic juices to the path of least resistance with hopes of resolving duct defects

The decision to proceed with ERCP is based on clinical suspicion for pancreatic duct leak and the type of expertise available at the institution

There is a growing number of pediatric gastroenterologists becoming skilled in performing ERCP

ERCP is invasive and has the potential to exacerbate pancreatitis

The goal of ERCP in this setting is to be therapeutic

Watchful waiting was an extension of the conservative approach already attempted in this case

Continuing conservative management was not acceptable to the family

A patient with an enlarging collection is potentially failing watchful waiting