Available online 29 June 2025, 151500

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are frequently employed in the management of biliary disease. With growing utilization in the pediatric population mirroring the rise in gallstone-related disease, it is important to have improved access to pediatric-specific advanced endoscopic care. Multi-center collaborations have now provided more robust data on the safety and efficacy of ERCP in pediatric patients. EUS remains primarily diagnostic in evaluating biliary pathology but is slowly emerging as a therapeutic modality following the adult experience with biliary drainage procedures. Access to pediatric-specific endoscopic equipment remains a challenge in this population. In this review, we provide an overview of endoscopic treatment options for biliary disease in children, discussing the most relevant recent literature while providing approaches to some of the most encountered complex biliary diseases.

The spectrum of biliary disease in children is broad with several key differences from the adult population. Malignant disease and related biliary obstruction are proportionately rarer in children compared to adults. Conversely, congenital anomalies of the pancreaticobiliary system often present in infancy or early childhood with signs of obstruction and may require endoscopic intervention. Hemolytic disease including sickle cell hemoglobinopathies or hereditary spherocytosis historically

ERCP was initially developed in the 1960s primarily for diagnostic indications via transpapillary cholangiography but has evolved over decades towards primarily therapeutic indications. Open surgical approaches for diseases like choledocholithiasis were largely replaced by an endoscopic approach 4. Children who required ERCP were historically treated primarily by adult gastroenterologists or surgeons. However, with increased pediatric utilization over the last 20 years, access to

Choledocholithiasis typically results from the migration of stones within the gallbladder into the biliary tree. Most stones in adults and children are derived from cholesterol which is thought to develop from supersaturated bile and subsequent crystal formation and growth within the biliary lumen. The remainder of stones are black/pigmented stones from excessive bilirubin secretion typically as a result of hemolytic disease, or brown stones related to infection 31.

Given the aforementioned

In this review, we summarize ERCP and EUS approaches to the treatment of biliary disease in children, which have evolved with increased utilization and access to pediatric-specific care. ERCP remains a valuable tool in the management of biliary pathology and particularly choledocholithiasis. EUS remains largely diagnostic, but newer endoscopic drainage procedures may prove useful in the multidisciplinary care of children with complex biliary disease. Multi-center collaborations over the last

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© 2025 Published by Elsevier Inc.