The diagnostic work-up and outcomes of 'presumed' idiopathic acute pancreatitis: A post-hoc analysis of a multicentre observational cohort.

INTRODUCTION: After standard diagnostic work-up, the aetiology of acute pancreatitis remains unknown in 16-27% of cases, a condition referred to as idiopathic acute pancreatitis (IAP). Determining the aetiology of pancreatitis is essential, as it may direct treatment in the acute phase and guides interventions to prevent recurrent pancreatitis. METHODS: Between 2008 and 2015, patients with acute pancreatitis were registered prospectively in 19 Dutch hospitals. Patients who had a negative initial diagnostic work-up with regard to the underlying aetiology of their pancreatitis were labelled 'presumed' IAP. The aim of this study was to assess the use of diagnostic modalities and their yield to establish an aetiology in 'presumed' IAP, and to assess recurrence rates both with and without treatment. RESULTS: Out of the 1632 registered patients, 191 patients had a first episode of 'presumed' IAP, of whom 176 (92%) underwent additional diagnostic testing: CT (n = 124, diagnostic yield 8%), EUS (n = 62, yield 35%), MRI/MRCP (n = 56, yield 33%), repeat ultrasound (n = 97, yield 21%), IgG4 (n = 54, yield 9%) and ERCP (n = 15, yield 47%). In 64 of 176 patients (36%) an aetiological diagnosis was established, mostly biliary (n = 39). In 13 out of 176 of patients (7%) a neoplasm was diagnosed. If additional diagnostic workup revealed an aetiology, the recurrence rate was lower in the treated patients than in the patients without a definite aetiology (15% versus 43%, p = 0.014). CONCLUSION: Additional diagnostic testing revealed an aetiology in one-third of 'presumed' IAP patients. The aetiology found was mostly biliary, but occasionally neoplasms were found. Identification of an aetiology with subsequent treatment reduced the rate of recurrence.

Hilar cholangiocarcinoma: Value of high-resolution enhanced magnetic resonance imaging for preoperative evaluation.

OBJECTIVES: The objective is to assess the accuracy of high-resolution (HR) enhanced magnetic resonance imaging (MRI) images in the preoperative evaluation of biliary and vascular invasion in hilar cholangiocarcinomas. METHODS: This retrospective study included 36 patients with hilar cholangiocarcinoma who underwent enhanced HR-MRI with an effective section thickness of 1.2 mm at 3.0 T before surgery. Combined HR-MRI and magnetic resonance cholangiopancreatography (MRCP) images were compared with MRCP in evaluating the extent of biliary infiltration according to the Bismuth-Corlette classification. To determine the suitable criterion for HR-MRI in predicting vessel invasion, Labeling 180 and 90 of circumferential contact of the tumor with the vessel were used to predict the invasion. The correlation between imaging findings and surgical and histopathological records was statistically analyzed. RESULTS: The accuracy in detecting biliary neoplastic invasion was higher for combined HR-MRI images (97.2%) than MRCP images (86.1%). HR-MRI images increased the accuracy in delineation of the tumor biliary extent (P < 0.05). The accuracy of Labeling 90 (98.6% in portal venous system and 98.0% in hepatic arterial system) was higher than that of Labeling 180 (96.5% in portal venous system and 94.6% in hepatic arterial system). However, there was no significant statistic difference between them (P > 0.05). Interobserver agreement was high with respect to biliary tract, portal venous, and hepatic arterial system involvement. CONCLUSIONS: Enhanced HR-MRI images showed excellent capability for assessing tumor extent and vascular invasion in hilar cholangiocarcinomas. More than 90° of circumferential contact of the tumor with the vessel on HR-MRI may be an appropriate criterion for predicting invasion.

The southwestern surgical congress multi-center trial on suspected common duct stones.

BACKGROUND: Choledocholithiasis is present in up to 15% of cholecystectomy patients. Treatment can be surgical, endoscopic, or via interventional radiology. We hypothesized significant heterogeneity between hospitals exists in the approach to suspected common duct stones. METHODS: A retrospective review of patients that had a preoperative MRCP, endoscopic ultrasound, endoscopic retrograde cholangiopancreatogram (ERCP), or intra-operative cholangiogram was performed. Comparisons were by Wilcoxon-Mann-Whitney tests with significance of p < 0.05 for paired variables and p < 0.017 for multiple comparisons. RESULTS: Twelve participating institutions identified 1263 patients (409 men and 854 women) with a median age of 49 years (IQR: 31-94). Liver function tests (LFT's) were elevated in 939 patients (75%), median bilirubin level 1.75 mg/dl (IQ: 0.8-3.7 mg/dl) and median common duct size 7 mm (IQR 5-10 mm). The most common initial procedure was cholecystectomy with IOC at seven institutions, endoscopy at four and MRCP at one. CONCLUSION: Significant variation exists within the surgical community regarding suspected common duct stones. These results underscore the need for a protocol for common duct stones to minimize multiple, redundant interventions.

Evolving Practice and Changing Phenotype in Pediatric Autoimmune Liver Disease: Outcomes From an Australian Center.

OBJECTIVES: Autoimmune liver disease (AILD) incorporates primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH), and autoimmune sclerosing cholangitis (ASC). ASC is a condition that includes overlap of AIH and PSC. We investigate changes in practice in relation to diagnosis and phenotype over 2 time periods. METHODS: Retrospective chart review was conducted from January 2000 to 2016. Data were divided into two 8-year cohorts, CI and C2. RESULTS: Data were collected in 75 children, 29 in 2000-2007 (C1) and 46 in 2008-2016 (C2). Presenting AILD type was AIH in 59%, ASC in 10%, and PSC in 31%. Final AILD type was AIH in 53%, ASC in 16%, and PSC in 31%. When comparing C1 to C2, those with AIH decreased (65% vs 45%) and those with ASC increased (14% vs 18%). Use of magnetic resonance cholangio-pancreatography increased from 34% in C1 to 65% in C2. Advanced liver disease on biopsy was noted in 53% of all children at presentation. Only 5 female children progressed to liver transplant (3 ASC-IBD [inflammatory bowel disease]; 1 PSC-IBD; 1 AIH). Colonoscopy performance increased from 48% in C1 to 63% in C2 with diagnosis of AILD-IBD increasing from 31% to 52%. Right-sided disease was present in 46% and macroscopic rectal sparing in 36% of those with ulcerative colitis (UC). Colectomy was required in 3 children with large duct PSC-IBD. CONCLUSIONS: PSC and ASC are increasing in relevance along with IBD and reflect increasing performance of magnetic resonance cholangio-pancreatography and colonoscopy. Large duct PSC and ASC with IBD are risk factors for colectomy and along with female gender, for liver transplant.

Prevalence of Sclerosing Cholangitis Detected by Magnetic Resonance Cholangiography in Patients With Long-term Inflammatory Bowel Disease.

BACKGROUND & AIMS: The prevalence of primary sclerosing cholangitis (PSC) among patients with inflammatory bowel disease (IBD) is unclear. Patients with IBD might be screened for PSC using magnetic resonance cholangiography (MRC). We aimed to estimate the frequency and distribution of MRC-detected lesions that indicate PSC in patients with IBD 20 years after their initial diagnosis and to identify clinical characteristics associated with these findings. METHODS: We performed a follow-up analysis of a population-based cohort of 756 patients in South-Eastern Norway diagnosed with IBD from January 1, 1990 through December 31, 1993. Of these subjects, 470 attended a follow-up evaluation 20 years later in which they were offered routine clinical blood testing and ileocolonoscopy; 322 were screened by MRC (222 with ulcerative colitis and 100 with Crohn's disease). Two radiologists independently evaluated results from the MRC examinations. RESULTS: In the MRC examination, 24 patients (7.5%) were found to have PSC-like lesions; only 7 of these patients (2.2%) were known to have PSC. One patient was initially missed and 1 had small-duct PSC, so the final prevalence of PSC was 8.1%. Extensive colitis, a high prevalence of colectomy, and chronic and continuous symptoms of IBD occurred in significantly more patients with suspected PSC than without PSC (P = .029, P = .002, and P = .012, respectively). Among patients with subclinical features of PSC, the MRC progression score for PSC increased when they were re-examined after a median 3.2 years (P = .046). CONCLUSIONS: Using MRC analysis of patients with long-term IBD, we found the prevalence of PSC to be around 3-fold higher than that detected based on symptoms. Sixty-five percent of patients had subclinical PSC associated with progressive IBD, with no biochemical abnormalities and mild disease, based on radiology findings. PSC appears to progress in patients with subclinical disease, but long-term outcomes are not known.

Magnetic resonance cholangiopancreatography: utilization and usefulness in suspected choledocholithiasis.

BACKGROUND: The aim of this study was to evaluate the role of magnetic resonance cholangiopancreatography in cases of suspected choledocholithiasis. METHODS: Suitable candidates were recruited from a database of all consecutive patients who underwent magnetic resonance cholangiopancreatography between March 2009 and December 2012. Patients were stratified into low, medium and high risk for choledocholithiasis by assessing clinical symptoms, liver function tests and ultrasonography. True negatives and false positives were calculated based on endoscopic retrograde cholangiopancreatography, intraoperative cholangiogram and clinical follow-up. RESULTS: Of 201 magnetic resonance cholangiopancreatography investigations conducted, choledocholithiasis was diagnosed in 37 (18%) patients. In total, there was one false negative and three false positives. Total sensitivity and specificity values were 97% and 98%, respectively. These values were highest among low-risk patients (100% for both sensitivity and specificity). By initially opting for magnetic resonance imaging in suitable moderate- and high-risk patients, unnecessary endoscopic retrograde cholangiopancreatography procedures were avoided in 61% and 65% of patients, respectively. CONCLUSION: Magnetic resonance cholangiopancreatography for patients with suspected choledocholithiasis yields high sensitivity and specificity. Given its reduced risk profile and relative ease of administration, magnetic resonance cholangiopancreatography is a necessary tool for the assessment of choledocholithiasis with the capacity to rival gold standard diagnostic techniques and help reduce the number of unnecessary interventional procedures.

Is preoperative MRCP necessary for patients with gallstones? An analysis of the factors related to missed diagnosis of choledocholithiasis by preoperative ultrasound.

BACKGROUND: The diagnosis of associated choledocholithiasis prior to cholecystectomy for patients with gallstones is important for the surgical decision and treatment efficacy. However, whether ultrasound is sufficient for preoperative diagnosis of choledocholithiasis remains controversial, with different opinions on whether routine magnetic resonance cholangiopancreatography (MRCP) is needed to detect the possible presence of common bile duct (CBD) stones. METHODS: In this study, a total of 413 patients with gallstones who were admitted to the Department of General Surgery of the First Affiliated Hospital of Harbin Medical University in China for a period of 3 years and underwent both ultrasound and MRCP examinations were retrospectively analysed. After reviewing and screening these cases according to the literature, 11 indicators including gender, age, alanine aminotransferase, aspartate aminotransferase, total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, γ-aminotransferase, CBD diameter, and concurrent acute cholecystitis were selected and comparatively analysed. RESULTS: Among the 413 patients, a total of 109 cases showed concurrent gallstones and choledocholithiasis, accounting for 26.39 % of all cases. Among them, 60 cases of choledocholithiasis were revealed by ultrasound examination, accounting for 55.05 %, while 49 cases of choledocholithiasis were not detected by ultrasound examination but were confirmed by MRCP instead (the missed diagnosis rate of ultrasound was 44.95 %). The results of statistical analysis suggested that alanine aminotransferase, acute cholecystitis, and CBD diameter were the three most relevant factors for missed diagnosis by ultrasound. CONCLUSION: The accuracy of preoperative ultrasonography for the diagnosis of associated CBD stones for patients with gallstones is not high. However, elevated alanine aminotransferase, concurrent acute cholecystitis, and CBD diameter were identified as key factors that may affect the accuracy of the diagnosis. Thus, routine preoperative MRCP examination is suggested for patients with gallstones to rule out possible concomitant CBD stones.

Emerging Role of Endoscopic Ultrasound in the Diagnostic Evaluation of Idiopathic Pancreatitis.

BACKGROUND: "Idiopathic pancreatitis" is diagnosed when clinical, laboratory and conventional radiologic methods do not provide a clear etiology for the episode. Given its associated morbidity and mortality, it is important to determine the cause of pancreatitis to provide early treatment and prevent recurrence. METHODS: The aim of this systematic review was to evaluate the utility of endoscopic ultrasound (EUS) in determining an etiology in patients classified as having idiopathic pancreatitis and to assess how EUS performed compared with other modalities. A PubMed search for relevant articles (January 2000-November 2014) was performed using the search terms "(pancreatitis or idiopathic pancreatitis or unexplained pancreatitis) and (EUS or endoscopic ultrasound)." RESULTS: The search yielded a total of 963 articles, and 13 studies were included in the final review. In some studies, the yield of EUS was higher than magnetic resonance cholangiopancreatography in idiopathic pancreatitis. EUS more accurately detected biliary stones, whereas magnetic resonance cholangiopancreatography more often identified pancreatic duct abnormalities. The yield of EUS was lower in patients postcholecystectomy but was not influenced by gender, severity of pancreatitis, or recurrent disease. The most frequent diagnoses by EUS for those with idiopathic pancreatitis were biliary tract disease (41%). Overall, EUS identified additional diagnostic information in 61% of patients with idiopathic pancreatitis. CONCLUSIONS: Given the high incidence of microlithiasis and/or biliary sludge as a cause of idiopathic pancreatitis as well as the safety and high accuracy, EUS should be considered 1st for evaluation of idiopathic pancreatitis if conventional cross-sectional radiography fails to reveal a cause.

Intraductal papillary mucinous neoplasms of the pancreas: evaluation of malignant potential and surgical resectability by using MR imaging with MR cholangiography.

PURPOSE: To evaluate the diagnostic performance of magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) in determining the malignant potential and surgical resectability of pancreas intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS: Institutional review board approval was obtained, and the requirement for informed consent was waived. Ninety-eight patients with pathologically proved pancreas IPMNs who underwent MR imaging with MRCP comprised the study population. MR images were analyzed for findings suggestive of high-risk stigmata or worrisome features, as proposed by the international consensus guidelines 2012. Interobserver agreement between two experienced observers (observers 1 and 2) and one inexperienced observer (observer 3) was assessed. Diagnostic performance of MR imaging in the evaluation of the malignant potential and surgical resectability of IPMNs was analyzed in these three observers by using receiver operating curve analysis. RESULTS: MR imaging with MRCP showed sensitivity of 83% (35/42), 79% (33/42), and 90% (38/42); specificity of 80% (41/51), 51% (26/51), and 24% (12/51); and accuracy of 82% (76/93), 63% (59/93), and 54% (50/93) for observers 1, 2, and 3, respectively, in the evaluation of the malignant potential of pancreas IPMNs when at least one worrisome feature was present. Interobserver agreement in the detection of intramural nodules (κ = 0.349-0.574), enhanced solid components (κ = 0.318-0.574), and measurement of main pancreatic duct diameter (intraclass correlation coefficient = 0.9477) was fair to high. The respective sensitivity, specificity, and accuracy in determination of surgical resectability were 95% (81/85), 99% (84/85), and 88% (75/85); 69% (9/13), 69% (9/13), and 54% (7/13); and 92% (90/98), 95% (93/98), and 84% (82/98) for observers 1, 2, and 3. CONCLUSION: MR imaging with MRCP is a useful modality in the evaluation of the malignant potential and resectability of IPMNs, with high sensitivity and moderate specificity in the experienced radiologists but relatively low specificity in the inexperienced radiology trainee.

Trends in pre-liver transplant screening for cholangiocarcinoma among patients with primary sclerosing cholangitis.

BACKGROUND: Cholangiocarcinoma (CCA) is the most common hepatobiliary malignancy complicating primary sclerosing cholangitis (PSC). Unfortunately, timely diagnosis of CCA in PSC patients remains challenging. AIM: To investigate the strategies among liver centers regarding pre-transplant screening for CCA in patients with PSC. METHODS: An online survey was returned from 46 US transplant centers, inquiring on the frequency of screening, the use of specific tests, or tactical approaches to high-grade dysplasia (HGD) or CCA. RESULTS: Most centers screen their PSC patients for CCA prior to orthotopic liver transplantation (OLT) (89%). Serum carbohydrate antigen 19-9 and magnetic resonance cholangiopancreatography are first-line screening tools (93 and 84% respectively). Endoscopic retrograde cholangiopancreatography with biliary brushings is routinely performed in only 30% of the centers. In the case of HGD, 61% would choose close monitoring. In the event of non-resectable CCA, 37% have an OLT protocol, 33% resort to palliative treatment and the remaining 30% make an outside referral. Finally, half the participating centers perform CCA surveillance among their listed PSC patients every 6 months. CONCLUSION: Screening for CCA among PSC patients prior to OLT varies greatly among centers. Serum carbohydrate antigen 19-9 and magnetic resonance cholangiopancreatography are widely used. HGD warrants surveillance rather than intervention among most experts. Protocolized chemoradiation followed by OLT has yet to become a widely accepted approach. The very poor survival of PSC patients who develop CCA underlines the importance of an effective and universally accepted screening process that will aid in its earlier detection.

MRCP in patient care: a prospective survey of gastroenterologists.

OBJECTIVE: MRCP is increasingly used to evaluate pancreaticobiliary disease, yet its effect on patient care is unknown. The purpose of this study was to measure the effect of MRCP on referring physicians' initial diagnoses, the physicians' confidence in their diagnoses, and the influence of MRCP results on clinical management. SUBJECTS AND METHODS: We prospectively surveyed gastroenterologists who referred patients for nonurgent MRCP for pancreaticobiliary evaluation. Before MRCP, gastroenterologists reported the working diagnosis, confidence level (high, moderate, low), and next step in clinical management if MRCP was unavailable. MRCP was performed with standard protocols, including secretin enhancement. After reviewing MRCP findings and without referring to their previous assessment, gastroenterologists reported a revised diagnosis, confidence level, and next step in clinical management. They then compared pre- and post-MRCP management plans and rated the influence of MRCP on changing management from 1 (none) to 5 (major). Diagnostic confidence and frequency of common diagnoses and recommendation for an invasive next-step procedure (e.g., ERCP) or endoscopic ultrasound were compared between pre- and post-MRCP assessments. RESULTS: Survey data were analyzed on 171 patients (123 women, 48 men; mean age, 50 [SD, 17] years; range, 19-88 years) undergoing MRCP for unexplained abdominal pain (42.9%), suspected pancreaticobiliary neoplasm (20%), recent acute (17.1%) or suspected chronic (14.9%) pancreatitis, and other indications (5.1%). Recommendations of ERCP and endoscopic ultrasound decreased after MRCP (from 49.1% to 35.1%, p=0.03, and from 26.9% to 13.5%, p≤0.01). After MRCP, high confidence in diagnosis increased (from 72/171 to 100/171, p<0.01), as did recommendations for noninvasive therapy (from 18/171 to 56/171, p<0.01). A major or substantial change in clinical management was made in the care of 67 of 171 patients (39.2%). CONCLUSION: Use of MRCP significantly changes gastroenterologists' treatment of patients with suspected pancreaticobiliary disease by increasing diagnostic confidence and reducing the frequency of invasive follow-up procedures.

Gallbladder patterns in acute pancreatitis: an MRI study.

RATIONALE AND OBJECTIVES: The aim of this study was to assess the gallbladder patterns on magnetic resonance imaging (MRI) associated with acute pancreatitis (AP). MATERIALS AND METHODS: There were 197 patients with AP, all of whom had undergone abdominal MRI. AP was categorized as either edematous or necrotizing according to its findings on MRI and graded as mild (0-3 points), moderate (4-6 points), or severe (7-10 points) according to the magnetic resonance severity index. The changes to the walls and dimensions of the gallbladder and common bile duct, in addition to the presence of biliary stones and pericholecystic fluid, were noted and compared with the severity of AP on the basis of the magnetic resonance severity index. RESULTS: Of the 197 patients with AP, 81% were classified as edematous and 19% as necrotizing on MRI. There were 35%, 59%, and 6% of patients with mild, moderate, and severe AP according to the magnetic resonance severity index, respectively. Seventy-six percent of patients had at least one gallbladder abnormality on MRI, including a thickened gallbladder wall (42%), pericholecystic fluid (38%), gallbladder stones (35%), an enlarged gallbladder (24%), dilatation of the common bile duct (16%), and subserosal edema (15%). Eighty-nine percent of patients (34 of 38) with necrotizing AP had gallbladder abnormalities, which was significantly higher than the 72% of patients (115 of 159) with edematous AP (P < .05). The prevalence of gallbladder abnormalities was 64% in patients with mild AP, 81% in those with moderate AP, and 91% in those with severe AP (P < .05 among the three groups). CONCLUSIONS: Most patients with AP have gallbladder abnormalities on MRI, including a thickened gallbladder wall and pericholecystic fluid. The prevalence of gallbladder abnormalities has a positive correlation with the severity of AP on MRI.

Primary sclerosing cholangitis: meta-analysis of diagnostic performance of MR cholangiopancreatography.

PURPOSE: To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) for detection of primary sclerosing cholangitis (PSC) in patients with biochemical cholestasis. MATERIALS AND METHODS: Two reviewers searched MEDLINE, EMBASE, and other electronic databases to identify prospective studies in which MRCP was evaluated and compared with endoscopic retrograde cholangiopancreatography (ERCP), clinical examination, and/or histologic analysis for diagnosis of PSC in cholestasis and control cases. Main study inclusion criteria were (a) use of ERCP or percutaneous transhepatic cholangiography (PTC) as part of the reference standard for the diagnosis of PSC, (b) inclusion of patients with hepatobiliary disease other than PSC (ie, nonhealthy control subjects), (c) blinding of MRCP image readers to reference-standard results, (d) prospective study with ERCP or MRCP performed after subject recruitment into the study, and (e) inclusion of raw data (for true-positive, false-positive, true-negative, and false-negative results) that could be found or calculated from the original study data. Major exclusion criteria were duplicate article (on a primary study) that contained all or some of the original study data and inclusion of fewer than 10 patients with PSC. Methodologic quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies tool. Bivariate random-effects meta-analytic methods were used to estimate summary, sensitivity, specificity, and receiver operating characteristic (ROC) curves. RESULTS: Six manuscripts with 456 subjects (with 623 independent readings)--185 with PSC--met the study inclusion criteria. The summary area under the ROC curve was 0.91. High heterogeneity (inconsistency index, 78%) was found but became moderate (inconsistency index, 36%) with the exclusion of one study in which the diagnostic threshold was set for high sensitivity. There was no evidence of publication bias (P = .27, bias coefficient analysis). Sensitivity and specificity of MRCP for PSC detection across all studies were 0.86 and 0.94, respectively. Positive and negative likelihood ratios with MRCP were 15.3 and 0.15, respectively. In patients with high pretest probabilities, MRCP enabled confirmation of PSC; in patients with low pretest probabilities, MRCP enabled exclusion of PSC. Worst-case-scenario (pretest probability, 50%) posttest probabilities were 94% and 13% for positive and negative MRCP results, respectively. CONCLUSION: MRCP has high sensitivity and very high specificity for diagnosis of PSC. In many cases of suspected PSC, MRCP is sufficient for diagnosis, and, thus, the risks associated with ERCP can be avoided.

Magnetic resonance cholangiopancreatography for the detection of pancreatic duct stones in patients with chronic pancreatitis.

AIM: To assess the role of magnetic resonance cholangiopancreatography (MRCP) in detection of pancreatic duct stones (PDS) in patients with chronic pancreatitis (CP). METHODS: Clinical data of 78 CP patients who were treated at the First Affiliated Hospital of Xi'an Jiaotong University (China) between January 2004 and July 2008 were retrospectively analyzed. A predictive model of pancreatic duct stones was established through logistic regression and its effectiveness was verified. Among these patients, MRCP was performed in 60 patients who served as a control group, while 44 patients with a higher predictive value than the entry threshold of the predictive model served as an experimental group. RESULTS: The positive rate of PDS in the 78 patients with CP was 19.2% (15/78). The predictive entry threshold of the predictive model was 5% (P < 0.05). The possibility of existence of PDS could be predicted according to the following 4 indexes: gastrointestinal symptoms, intermittent abdominal pain, diabetes mellitus (DM)/impaired glucose tolerance (IGT) and positive B-mode ultrasound results. The incidence of PDS in the experimental group was higher than that in the control group (P < 0.05). CONCLUSION: MRCP is strongly suggested for the detection of PDS in patients with gastrointestinal symptoms, intermittent abdominal pain, DM/IGT and positive B-mode ultrasound results.

Magnetic resonance cholangiopancreatography: current use and future applications.

Magnetic resonance pancreatography (MRCP) is now established as a robust noninvasive tool for the evaluation of biliary and pancreatic pathology. Its diagnostic performance is comparable with endoscopic retrograde cholangiopancreatography without the associated risks. This article aims to familiarize the reader with the technique, clinical indications, and limitations of the investigation. Common pitfalls in interpretation also are addressed. Emerging applications and techniques are discussed that include recent advances in technology and the development of functional imaging.

Miss rate of pancreas divisum by magnetic resonance cholangiopancreatography in clinical practice.

OBJECTIVES: Pancreas divisum is the most common congenital abnormality of the pancreatic anatomy. Magnetic resonance cholangiopancreatography has emerged as a noninvasive method of examining the pancreatic ductal anatomy. We aim to assess the sensitivity of MRCP for pancreas divisum. METHODS: Patients with pancreas divisum at endoscopic retrograde cholangiopancreatography (ERCP) and who had prior MRCP between January 2001 and February 2006 were identified. Sensitivities were calculated for relevant subgroups with binomial 95% confidence intervals. Fisher exact P values were calculated. RESULTS: Four hundred five patients had divisum at ERCP; of these, 111 (27%) had undergone MRCP before ERCP. Seventy-two (65%) patients had MRCP at outside centers. Twenty-three of the 72 MRCPs at referring centers correctly reported divisum. In contrast, the sensitivity was higher for the 24 MRCPs without secretin at our institution: 16 (67%). The sensitivity in the secretin-stimulated group was 67% (10/15). However, this was not different from that of MRCP without secretin. Of note, 9 (18%) of the 49 negative outside MRCPs had divisum suspected by the gastroenterologist reviewing the MRCP images before ERCP. CONCLUSIONS: Pancreas divisum seems to be often missed on MRCP, even when secretin is used. The absence of secretin, use of suboptimal magnetic resonance techniques, and inexperienced pancreatic MRCP examiners are all possible contributing factors.

Stone detection in MRCP images using controlled region growing.

Stones in the biliary tract are routinely identified using MRCP (magnetic resonance cholangiopancreatography). The noisy nature of the images, as well as varying intensity, size and location of the stones, defeat most automatic detection algorithms, making computer-aided diagnosis difficult. This paper proposes a multi-stage segment-based scheme for semi-automated detection of choledocholithiasis and cholelithiasis in the MRCP images, producing good performance in tests, differentiating them from "normal" MRCP images. With the high success rate of over 90%, refinement of the scheme could be applicable in the clinical environment as a tool in aiding diagnosis, with possible applications in telemedicine.

Prospective study to develop an algorithm for investigation by endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography.

BACKGROUND: Identifying cost-efficient and patient-friendly pathways for those who present with suspected pancreatico-biliary disease remains a challenge. Algorithms must be tailored to improve decision-making. We assessed suitable criteria from which an algorithm for selection for endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography could be developed. METHODS: Data on clinical, ultrasound and liver function test findings and outcome were recorded for consecutive patients undergoing ERCP and patients were stratified into different indications and a therapeutic ratio (TR) obtained for each (TR = number of therapeutic ERCP/total number of ERCP). RESULTS: One hundred and twenty ERCP were attempted with 112 cannulations (93.3%). Seventy-one therapeutic procedures were attempted with 64 (90.1%) successes. Forty-two (35%) investigations were normal. Seven (6%) patients suffered complications. Thirteen indications were used. The TR varied according to the indication. The TR for jaundice with biliary dilatation was 0.85. In contrast, asymptomatic patients with deranged liver function test and normal gall bladder on USS had a TR of 0.17. Gallstones with cholestatic liver function test yielded a TR of 0.54. A TR of 0.7 was considered an appropriate 'cut-off' for triage to ERCP or magnetic resonance cholangiopancreatography. An algorithm was generated based on these data. From this cohort, 50 (42%) patients would have been more appropriately investigated by magnetic resonance cholangiopancreatography, although 20 (40%) would have required therapy afterwards. CONCLUSIONS: An algorithm that separates indications by TR (TR > 0.7) may provide a cost-efficient, patient-friendly pathway for investigation and improve the use of resources.

[A meta-analysis of clinical efficiency of two methodologies of cholangiopancreatography].

OBJECTIVE: To compare the efficiency of endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP) in patients with suspected biliary tract or pancreatic diseases. METHODS: Find those prospective comparison trials about the efficiency of ERCP and MRCP in patients with suspected biliary tract or pancreatic diseases from many kinds of database, such as MEDLINE, EMBASE and so on. According to inclusion criteria, two operant choose suitable papers for this study. Collect corresponding original data and make a meta-analysis to compare the sensitivity and specificity of ERCP and MRCP in choledocholithiasis, strictures and malignant tumor. RESULTS: Finally we get 6 articles from 302 ones. To diagnose choledocholithiasis, strictures and malignant tumor, the difference of sensitive between ERCP's and MRCP's is not significant. When it comes to the specificity of ERCP and MRCP in those diseases, ERCP is better than MRCP only in strictures, OR is 6.17 (95% CI 1.35-20.24), P = 0.02. However, we find ERCP is better than MRCP not only in total sensitivity but specificity of biliary tract or pancreatic diseases, OR is 1.72 (95% CI 1.04-2.85) and 4.05 (95% CI 1.32-12.42) respectively, P = 0.04, 0.01. CONCLUSIONS: ERCP is better than MRCP, to biliary tract or pancreatic diseases, in not only sensitivity but specificity. Doctors should think much about patients' situation, tolerance and cost-effectiveness, when they make a decision which examination should patients take.

Value of contrast-enhanced magnetic resonance cholangiography in patients undergoing laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is the preferred treatment of symptomatic gallstone disease. Biliary injury during LC is still a serious problem. Knowledge of anatomic detail is important for not encountering the injury. Magnetic resonance cholangiography (MRC) is a noninvasive method for imaging the biliary ducts. However, MRC has many drawbacks such as not showing anatomic structures in detail and respiratory motion. In this study, contrast-enhanced MRC is used to show cystic ducts that are not seen by MRC. Reasons for patient referral for MRC and contrast-enhanced MRC included suspicion of cholecystolithiasis, adenomyomatosis, and gallbladder polyp. Our results show that routine MRC revealed cystic ducts in 38 patients (77.5%) and contrast-enhanced MRC in 46 patients (93.8%). Intraoperative cholangiography (IOC) was taken as gold standard for all patients. We found that contrast-enhanced MRC can provide a useful supplement to MRC in patients with nonvisualized cystic ducts by MRC. To our knowledge, this is the first study of visualization of cystic duct in patients undergoing LC depicted by both MRC and contrast-enhanced MRC.