Veronique Morinville, MDCM, on EUS and ERCP for Evaluating and Treating Children With Chronic Pancreatitis

In this podcast, Veronique Morinville, MDCM, from Montreal Children's Hospital, talks about the latest NASPGHAN position paper on roles of endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation and treatment of chronic pancreatitis in children.

Additional Resources:

• Liu QY, Gugig R, Troendle DM, et al. The roles of EUS and ERCP in the evaluation and treatment of chronic pancreatitis in children: a position paper from the NASPGHAN Pancreas Committee [published online February 19, 2020] J Pediatr Gastroenterol Nutr. https://doi.org/10.1097/mpg.0000000000002664 
• Lowe ME, Greer JB, Srinath A. The National Pancreas Foundation. Chronic Pancreatitis in Children. Accessed April 1, 2020. https://pancreasfoundation.org/patient-information/childrenpediatric-pancreatitis/chronic-pancreatitis-in-children/.

Veronique D. Morinville, MDCM, is an associate professor of pediatrics at McGill University, and is a pediatric gastroenterologist and the medical director of pancreas care at Montreal Children's Hospital—a teaching hospital part of the McGill University Health Centre in Montreal, Quebec, Canada. She is also prior chair of the NASPGHAN Pancreas Committee.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator Amanda Balbi with Consultant360 Specialty Network.

Chronic pancreatitis is rare in children, and there currently is no guidance for diagnosing or treating chronic pancreatitis in children. However, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (or NASPGHAN) recently released a position paper to help physicians better understand the use of endoscopic ultrasound and ERCP for diagnosing and treating chronic pancreatitis in children.

Today I’ll be speaking with the prior chair of the NASPGHAN Pancreas Committee and senior author for the position paper, Dr Veronique D. Morinville, MDCM, who is an associate professor of pediatrics at McGill University, and is a pediatric gastroenterologist and the medical director of pancreas care at Montreal Children's Hospital—a teaching hospital part of the McGill University Health Centre in Montreal, Quebec, Canada.

Thank you for joining me today, Dr Morinville.

Veronique Morinville: Thank you so much for inviting me to participate in this.

Amanda Balbi: To start, can you give us some background on the NASPGHAN position paper and why it is important to have published now?

Veronique Morinville: NASPGHAN society, which is the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, approached me in 2014 to form a Pancreas Committee are realizing that there was a lack of information regarding the pancreas care of children.

Related to this, the pancreas committee has developed a number of projects to increase the understanding of what pancreatitis is, pancreatic insufficiency, and how to manage children who have pancreatitis. One of the big learning deficits that we acknowledged at that point was that people did not know how to deal with children with chronic pancreatitis.

We have been learning in the last few decades that children are increasingly being diagnosed with acute recurrent and chronic pancreatitis. Most of our management has actually stemmed from what is done in adults, but it's become clear that even for conditions such as acute pancreatitis, because the causes of pancreatitis are different, the management is different, and children are not just little adults.

Similarly, chronic pancreatitis can have a great deal of health care burden, as children often have pain or not thriving appropriately with their nutrition and may have recurrent attacks that lead them into the hospital. Over time, we decided that we needed to address how to help gastroenterologists and pediatricians who would be dealing with children who have chronic pancreatitis, and so we embarked on a series of 3 projects that would help physicians to manage children with chronic pancreatitis.

These three subjects are going to be endoscopy management or endoscopic ultrasound and ERCP, which is the topic of this first project that has been published. And the other 2 projects that are still to come will relate to the surgical management of chronic pancreatitis and the medical management of chronic pancreatitis, including pain.

It was felt that it was important to get some documentation out, because there is nothing out there to help pediatric specialists help children with chronic pancreatitis. We know it's a field that's evolving and we don't have the answers, but we wanted to start off with some help. At this point in 2020.

Amanda Balbi: Absolutely. Can you talk a little bit about the recommendations you and the panel made in the position paper and how the recommendations came about?

Veronique Morinville: So, I think it would be helpful for me to go through or methodology for this manuscript. As I was mentioning, the NASPGHAN Pancreatitis Committee determined that this was a need for people to have a better understanding of what EUS and ERCP could do for children with chronic pancreatitis, both in management workup and managing complications.

We developed a working group that included mostly members from the Pancreas Committee, including authorship that themselves perform EUS and/or ERCP and our pediatric trait. We additionally added some colleagues from the NASPGHAN Endoscopy and Procedures Committee, who also were experts in EUS and ERCP.

With this, we did a quite thorough literature review, looking at both adult and pediatric data regarding EUS and ERCP but tried to focus particularly on articles that was children—so 18 years and younger. With this, the author has developed some summaries of the different topics that we had wanted to cover, and we had a video conference where we reviewed the literature and the strength of evidence for the literature.

At that time, we determined that the quality of literature would not allow us to do what's called a GRADE system for recommendations, and instead we developed summary recommendations that we would vote upon to make sure that we were all in agreement with what we were proposing as suggestions, mostly expert suggestions, but suggestions based on the medical literature.

And our topics dealt with a number of subjects. Our first area of interest was who should be getting EUS and ERCP and in what scenario. And I think one important thing is that both EUS and ERCP are invasive procedures, and thus, they're not first line if a child has chronic abdominal pain. These are really to be used when there is a high suspicion that there would be chronic pancreatitis as a diagnosis.

And one very important thing is that you need someone who's appropriately trained endoscopist to perform these procedures. Depending on the site where someone is working, this may be an adult gastroenterology endoscopist, who has comfort and has been speaking with the pediatric team and does the procedure on behalf of the pediatric team. Or in some specialized centers, there are some pediatric trained endoscopists that do EUS and ERCP. And it's very important for the person performing the procedure to feel comfortable doing it in children.

The second part that we wanted to review is how small can children have these procedures done. And I think that's one of the stumbling blocks is that people do not realize that even younger children could probably undergo these procedures.

With the review of the literature, we set out that ERCP typically can be performed in children who are greater than 10 kg using the typical equipment. If someone is smaller, you need more-specialized equipment. And endoscopic ultrasound (or EUS) needs a slightly larger size, actually greater than 15 kg. And again, if someone is smaller, one might need to use alternative equipment that's not specifically designed for use in the gastrointestinal tract.

The second part is one should be using these procedures. Well, endoscopic ultrasound can be used in evaluating to see if someone would have chronic pancreatitis, especially if you're not getting an answer through a cross-sectional imaging, such as ultrasound or MRI or less-ideal CT scan because of radiation, so it can be utilized to make a diagnosis.

By comparison, ERCP normally would not be recommended to be used to make a diagnosis because of the use of thoracoscopy, and it is more invasive, and I will get into the fact of potential adverse events with it. The very important thing is actually the criteria to make a diagnosis of chronic pancreatitis, to this day in 2020, are adult based.

So typically for endoscopic ultrasound, adults will resort to what are called the Rosemont criteria or conventional criteria, but these are adult based. And I think that's important to realize that there may be limitations to do this. Similarly, ERCP criteria are also adult based. So, someone has to be weary of the fact that maybe not all criteria are readily usable in children.

With respect to what can be done once someone has chronic pancreatitis, and that there may be a complication, one of the uses of endoscopic ultrasound is to assess fluid collections that can happen in chronic pancreatitis, and there may be some interventions that can be made to try to drain the fluid collections. And actually, it's more preferable to consider noninvasive means such as EUS before considering a surgery, for example, which would be a lot more of an open and invasive procedure.

Similarly, ERCP, although it's not used for diagnosis of CP, it can be used if someone believes there will be a need for endo therapy. ERCP can be very useful to manage ductal strictures and stones that would be found within the pancreatic duct. And it can be used with fluid collections if somehow endoscopic ultrasound would not be possible, suboptimal, or it's not seen to be sufficient or in conjunction. So, both EUS and ERCP can be useful measures to manage complications before one would consider an open, more invasive surgery.

Both procedures are used in children. And it's important to know that both procedures have certain risks. One would certainly consider endoscopic ultrasound the lesser-risky procedure, and the rate of complications is probably likely to doing an esophageal gastroduodenoscopy in adults. There is not enough data to clearly state what it is in children, but it felt to be similar.

But one should definitely have a good discussion with families before a procedure like this should be done, because indeed it's not something that's done that frequently in children.

Endoscopic retrograde cholangiopancreatography (or ERCP) has actually a higher complication rate than endoscopic ultrasound, and the risks are including perforation and bleeding, infections, radiation exposures, one could have allergic reactions to the contrast, one can have post-ERCP pancreatitis, and one might need several procedures. So, it's important again to have a good discussion with families to make sure that they understand why the procedure is being proposed, the potential benefits, and potential adverse events and what could happen if the procedure’s successful or not and how it lies in the scheme of the management plan for that child.

And so, with these needs, we hope that people will better understand what EUS and ERCP can and cannot do in the realm of both diagnosing and managing chronic pancreatitis in children.

Amanda Balbi: Absolutely. As you mentioned before, knowledge and use of endoscopic ultrasound and ERCP is limited among pediatric gastroenterologists. What implications or challenges might practitioners face when trying to use the recommendations outlined in the position paper?

Veronique Morinville: Yes, so thank you.  And firstly, I'd like to stress, we're not able to call this a guideline because there's little literature from which we can derive a recommendation. So this is one of the reasons why we're calling it a position paper but along the pathway of developing evidence in medicine, we need to start somewhere, and we strongly felt that it was important to have a starting point, even if it was mostly expert-based rather than a guideline at this point.

I think the biggest difficulty for most providers is twofold. One is they don't really understand what chronic pancreatitis is in children. I think there is still a growing understanding that children get chronic pancreatitis, and providers are still not very comfortable all the time managing children with chronic pancreatitis. So, this kind of document may help them feel more empowered of potential things that could be done.

The second part is, unfortunately, not every center has access to a pediatric endoscopist, although most centers somehow have an adult endoscopy service that would have adult ERCP and EUS specialists. And I think this kind of document can help a pediatric specialist start a conversation with their adult colleagues about what they might be comfortable doing and not doing. Whereas the adult endoscopy specialist is very comfortable with EUS and ERCP in adults, they might not be quite as comfortable with a pediatric patient. And having that knowledge of what can be done and what they're comfortable with may help decide what can be done for that child in that center and/or whether a child might benefit from a transfer to a different hospital center, should these technologies not be available locally.

So, I think it empowers the treating pediatric gastroenterologist to try to obtain the best care for their patients with chronic pancreatitis. But definitely, I think the local access to these technologies and access to pediatric trained endoscopists is definitely a limitation in 2020.

Amanda Balbi: Absolutely. What else should gastroenterologists know about the position paper?

Veronique Morinville: What I think is important to understand from this is chronic pancreatitis is increasingly being diagnosed, its present, one has to consider it.

ERCP and EUS can be helpful in the diagnosis—so that would be primarily EUS—and in the management, both EUS and ERCP, as alternatives and more-favorable alternatives to considering open procedures, surgical procedures.

And they can be done in children that are quite small, so even toddler size in most scenarios. And I think that's important to understand—that these technologies can be used in small children—and I think that's been something that many specialists, even pediatric specialists, are not quite comfortable understanding.

Now, I do think it's a starting block. I think having publications like these will help people feel more empowered to have these procedures done in their pediatric patients, which will obviously hopefully generate more literature so that subsequently, down the road, we could relook at the literature and maybe come up with even evidence-based guidelines that would really be with a pediatric focus with respect to publications with youth in children. So, I think these kinds of documents help improve the care of children.

This is meant, as I was mentioning at the beginning, as one of 3 parts to help with children's management that have chronic pancreatitis. I think it's an important first step. I think it's important for pediatric gastroenterologists, that will at some point in their career manage children with chronic pancreatitis, understand the benefits, the limitations, and what can be done with EUS and ERCP.

Amanda Balbi: Great. Thank you so much for speaking with me today about this important position paper.

Veronique Morinville: Thank you so much for inviting me to participate in this. It's been a very important work to participate in the development of this management position paper, and I hope that our readers will find it useful in their clinical care of children with chronic pancreatitis.