Hydrops Gallbladder Caused by Cystic Duct Fibrosis Leading to Mirizzi Syndrome: A Case Report.

Mirizzi syndrome (MS) is a rare complication of cholelithiasis, resulting from the extrinsic compression of the common hepatic duct or common bile duct by impacted gallstones in the cystic duct or Hartmann's pouch. MS is most commonly observed in the elderly with a long-standing history of gallstones. We present the case of MS type I diagnosed following magnetic resonance cholangiopancreatography (MRCP). Surgical management was performed with laparoscopic cholecystectomy. MS should be considered as a differential diagnosis in elderly patients presenting with asymptomatic obstructive jaundice. Imaging studies such as MRCP and endoscopic retrograde cholangiopancreatography (ERCP) are essential for diagnosing. We present this case to highlight the importance of recognizing hydrops gallbladder caused by cystic duct fibrosis leading to MS.

Incidentally detected pancreatic duct dilatation on ultrasound and role of MRI.

OBJECTIVE: The clinical significance of incidentally detected pancreatic duct (PD) dilatation at ultrasound (US) without a visualized underlying cause is unclear. We aimed to assess the role of subsequent MRI (including MRCP) and to identify US imaging and laboratory findings predictive of underlying pancreaticobiliary malignancy at the time of initial US. MATERIALS AND METHODS: Patients with incidentally detected PD dilatation at ultrasound from 2011 to 2019 that had an ensuing MRI were included. Based on MRI results patients were divided into three groups: malignant pancreaticobiliary causes, benign causes and idiopathic PD dilatation. Subsequently the diagnostic ability of MRI was assessed. Initial ultrasound findings and laboratory results were compared between groups to identify predictors of underlying pancreaticobiliary pathology. A p-value < .05 was considered statistically significant. RESULTS: In 37/59 (63%) patients PD dilatation was confirmed on MRI. MRI demonstrated malignant 7/59 (12%) and benign 10/59 (17%) causes of PD dilatation detected at initial ultrasound. Sensitivity, specificity, negative predictive value, positive predictive value and accuracy of MRI to ascertain the cause of PD dilatation was 89%, 100%, 95%, 100% and 97% respectively. Patients with a larger magnitude of PD dilatation, concomitant CBD dilatation and elevated lipase values were more likely to have underlying pancreaticobiliary malignancy (p < 0.05). No patient with initial negative MRI had pancreaticobiliary malignancy on subsequent work-up. CONCLUSION: Incidentally detected PD dilatation on ultrasound is an important finding and should prompt referral to MRI. MRI is an accurate, noninvasive method for identifying the underlying cause of PD dilatation in these patients and in excluding pancreaticobiliary malignancy.

The effect on gastrointestinal peristalsis for magnetic resonance cholangiopancreatography during breath-holding methods.

The breath-hold (BH) 3D magnetic resonance cholangiopancreatography method has been reported to suppress "respiratory artifacts"; however, the influence of gastrointestinal peristalsis around the target organs has not been discussed. In contrast, the autonomic nervous system has been reported to affect gastrointestinal peristalsis and BH imaging has been reported to influence venous blood flow signal (BFS) through its involvement with the autonomic nervous system. We examined the impact of BH imaging on gastrointestinal peristalsis. Seven healthy volunteers participated. Three respiratory patterns-free breathing (FB), BH at maximum inspiration (Insp-BH), and BH at maximum expiration (Exp-BH)-were used. Gastrointestinal peristalsis was measured using cine MRI. Cine MRI data were analyzed using the normalized interframe difference method, focusing on the duodenum and gastric body. Hemodynamic changes resulting from BH methods were evaluated using 2D phase contrast, targeting the inferior vena cava (IVC). The BFS was examined for all phases of each respiratory pattern. Peristalsis variation in the duodenum showed no significant differences among FB, Exp-BH, and Insp-BH. In the gastric body, no significant differences were observed between FB and Exp-BH or between Exp-BH and Insp-BH. However, a significant difference emerged between FB and Insp-BH. Regarding BFS, in the IVC, significant differences were observed between Exp-BH and Insp-BH and between FB and Insp-BH (both, p < 0.01), with no significant difference between FB and Exp-BH. Insp-BH reduces venous blood flow and suppresses the influence of peristalsis variation.

Diagnostic yield of endoscopic ultrasound in dilated common bile duct with non-diagnostic cross-sectional imaging.

BACKGROUND: Biliary dilatation without obvious etiology on cross sectional imaging warrants further investigation. This study aimed to assess yield of endoscopic ultrasound in providing etiologic diagnosis in such situation. METHODS: Prospective cohort of consecutive patients with biliary dilatation & non diagnostic computed tomography (CT) and /or magnetic resonance imaging (MRI) underwent endoscopic ultrasound (EUS) with/without fine needle aspiration cytology (FNAC) and were followed clinically, biochemically with/without radiology for up to six months. The findings of EUS were corroborated with histopathology of surgical specimens and endoscopic retrograde cholangiography (ERCP) findings in relevant cases. RESULTS: Median age of 121 patients completing follow up was 55 years. 98.2% patients were symptomatic and median common bile duct (CBD) diameter was 13 mm. EUS was able to identify lesions attributable for biliary dilatation in (67 out of 121) 55.4% cases with ampullary neoplasm being the commonest (29 out of 67 i.e. 43%). Multivariate logistic regression analysis identified jaundice as the predictor of positive diagnosis on EUS, of finding ampullary lesion and pancreatic lesion on EUS. EUS had sensitivity, specificity, positive predictive value and diagnostic accuracy of 95.65%, 94.23%, 95.65% and 95.04% respectively in providing etiologic diagnosis. Threshold value for baseline bilirubin of 10 mg%, for baseline CA 19.9 of 225 u/L and for largest CBD diameter of 16 mm were determined to have specificity of 98%, 95%, 92.5% respectively of finding a positive diagnosis on EUS. CONCLUSION: EUS provides considerable diagnostic yield with high accuracy in biliary dilatation when cross sectional imaging fails to provide etiologic diagnosis.

Bile duct injury following laparoscopic cholecystectomy in a patient with a trifurcated hepatic duct: A case report.

INTRODUCTION AND IMPORTANCE: Iatrogenic bile duct injury is a serious complication of laparoscopic cholecystectomy, often due to misinterpretation of biliary tree anatomy. Anatomical variations, patient condition, gallbladder pathology, and surgeon-related factors are key risk factors for bile duct injury. CASE PRESENTATION: A 68-year-old male with a history of hypertension and type 2 diabetes mellitus underwent Laparoscopic cholecystectomy for symptomatic gallstones. One-month post-surgery, he developed right upper quadrant pain, jaundice, and elevated liver enzymes. Magnetic resonance cholangiopancreatography (MRCP) showed a hilar confluence stricture affecting the right posterior and left hepatic ducts, with mild-to-moderate dilation of upstream intrahepatic bile ducts. CLINICAL DISCUSSION: Trifurcation of the hepatic duct is a rare but clinically significant anatomical variation that can predispose patients to common bile duct injuries. Preoperative MRCP can identify such variations, aiding in surgical planning. However, intraoperative recognition and management of these anatomical differences are crucial to prevent bile duct injuries. This is particularly important in low-resource settings where routine preoperative imaging may not be feasible. CONCLUSION: Accurate intraoperative identification of biliary tree anatomical variations is essential to prevent iatrogenic injuries during surgery. Preoperative imaging, when available, can provide valuable information to assist in surgical planning. Additionally, the use of intra-operative cholangiogram (IOC) should be considered to help identify and manage anatomical variations, thereby reducing the risk of bile duct injuries.

Comparative Efficacy of Magnetic Resonance Cholangiopancreatography vs. Percutaneous Transhepatic Cholangiography With Percutaneous Transhepatic Biliary Drainage Stenting in Evaluating Obstructive Jaundice: A Prospective Study in South India.

Introduction Obstructive jaundice due to proximal biliary obstruction presents significant diagnostic and therapeutic challenges. Accurate and timely diagnosis is essential for effective management. Objective/aim This study aimed to evaluate and compare the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and percutaneous transhepatic cholangiography (PTC) along with percutaneous transhepatic biliary drainage (PTBD) stenting in obstructive jaundice, while also incorporating the comparison of ultrasonography (USG) and computed tomography (CT) findings. Materials and methods A prospective study was conducted at a tertiary healthcare center in South India from January 2020 to June 2022. Comprehensive diagnostic evaluations were performed using USG, contrast-enhanced computed tomography (CECT), MRCP, and PTC. The diagnostic outcomes from USG and CECT were initially assessed, followed by MRCP for every patient. These results were then compared with PTC, focusing on identifying the causes and levels of biliary obstruction. Results Fifty patients with suspected obstructive jaundice were included in the study. The study predominantly involved patients aged between the fourth and eighth decades (80%). Choledocholithiasis was identified as the leading cause (30%). MRCP demonstrated superior sensitivity in identifying both the cause (80%) and level (88%) of obstruction. It was particularly effective in detecting hilar masses with 100% sensitivity. Conversely, PTC, while less sensitive in detection, offered the advantage of simultaneous therapeutic intervention through stenting, with a sensitivity rate of 93% in detecting hilar masses. Conclusion MRCP outperforms PTC in diagnostic sensitivity for obstructive jaundice caused by proximal biliary obstruction. However, the advantage of PTC lies in its capacity for immediate therapeutic intervention via stent placement, addressing both diagnostic and treatment needs.

Clinical outcomes and reintervention after endoscopic retrograde cholangiopancreatography in primary sclerosing cholangitis in absence of cholangitis.

BACKGROUND AND AIM: Endoscopic retrograde cholangiopancreatography (ERCP) may help detect cholangiocarcinoma in patients with primary sclerosing cholangitis (PSC), but it may be associated with complications. This study was aimed at determining the prognostic impact of ERCP on patients with PSC without cholangitis. METHODS: Patients with PSC without cholangitis were divided into two groups: those who underwent ERCP within three years after diagnosis (ERCP-performed group) and those who did not (non-ERCP group). These groups were compared in terms of clinical outcomes (liver-related death or liver transplantation, endoscopic treatment requirement and repeated cholangitis) and the composite outcome. RESULTS: Of 99 patients with PSC with detailed medical history, 49 were included in the ERCP-performed group and 21 in the non-ERCP group. In Kaplan-Meier analysis, the non-ERCP group was less likely to achieve the three outcomes and the composite outcome, showing statistical significance (endoscopic treatment requirement; p = 0.017 and composite outcome; p = 0.014). A Cox proportional hazards model indicated that ERCP in the asymptomatic state was a significant predictor of endoscopic treatment requirement (hazard ratio [HR]: 4.37, 95% confidence interval [CI]: 1.03-18.59) and the composite outcome (HR: 4.54, 95% CI: 1.07-19.28). CONCLUSION: ERCP in patients with PSC without cholangitis is likely to require further endoscopic treatment and may be associated with poor prognosis.

Utility of Radiological Follow Up of Main-Duct Intraductal Papillary Mucinous Neoplasms and Mixed-Type Intraductal Papillary Mucinous Neoplasms.

BACKGROUND: Intraductal papillary mucinous neoplasms (IPMNs) have the potential to evolve into pancreatic adenocarcinoma (PDAC). While main-duct IPMNs (MD-IPMNs), involving the main pancreatic duct (MPD), are less common than side-branch IPMNs (SB-IPMNs) or mixed-type IPMNs (mixed-IPMNs), their malignant transformation potential is far greater. Controversy exists between different guidelines in terms of recommended management strategies. This study was aimed at assessing the utility of the radiological follow up of MD-IPMNs and mixed-type IPMNs, including prevalence of worrisome radiological findings as well as clinical and laboratory parameters, and their correlation with the development of progression or pancreatic adenocarcinoma. METHODS: Eighty-four patients with MD-IPMNs or mixed-type IPMNs who underwent at least one magnetic resonance cholangiopancreatography (MRCP) were included. Clinical and laboratory data were obtained retrospectively. A cross-sectional analysis was carried out to establish clinical and laboratory parameters associated with development of PDAC. A retrospective cohort analysis was performed on 44 patients who had at least six months of follow up, trying to identify factors correlating with worrisome radiological features. RESULTS: Nine cases (10.7%) of PDAC were recorded in this cohort. The laboratory and imaging factors associated with cyst size progression greater than 5 mm during follow up were elevated alanine transaminase (ALT) levels, the maximal cyst size, and the MPD diameter. Cross-sectional analysis indicated that PDAC was associated with nausea (p = 0.01), as well as increased levels of aspartate aminotransferase (AST) (p = 0.05), gamma glutamyl transpeptidase (GGT) (p = 0.01), and alkaline phosphatase (ALP) (p = 0.01). CONCLUSIONS: Elevated levels of liver enzymes were associated with IPMN progression and, subsequently, the development of PDAC. ALT levels, maximal cyst size, and MPD diameter are associated with the progression of cyst size. These data may aid in risk-stratifying patients when determining the follow up approach for IPMNs.

Trend in predictive factors of choledocholithiasis: the key to the management of pediatric patients with suspected gallstones. / Tendencia en los factores predictivos de coledocolitiasis: la clave para el manejo de pacientes pediátricos con sospecha de cálculos en la vía biliar.

OBJECTIVES: To reduce the overuse of magnetic resonance cholangiopancreatography and the rates of non-therapeutic endoscopic retrograde cholangiopancreatography in pediatric patients suspected of choledocholithiasis. MATERIALS AND METHODS: Retrospective study of patients suspected of choledocholithiasis between January 2010 and June 2023. Patients with cholangitis or two or more of the following predictive factors of choledocholithiasis in initial laboratory tests and ultrasound were categorized as high-risk group: total bilirubin level ≥ 2 mg/dl, common bile duct > 6 millimeters on ultrasound; and detection of choledocholithiasis by ultrasound. Patients were recategorized according to the results of the second set of laboratory and ultrasound analysis. Confirmatory modalities (magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, and/or intraoperative cholangiography) were used to evaluate the presence of choledocholithiasis. Finally, we assessed the predictive capability of both the initial high-risk group and the group after recategorization. RESULTS: A total of 129 patients were included. After initial studies, 72 (55.8%) patients were classified into the high-risk group. After recategorization, only 29 (22.5%) patients were included in this group. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the initial high-risk group were 89.3%, 53.5%, 34.7%, 94.7%, and 61.2%, respectively, while after recategorization, they were 82.1%, 94.1%, 79.3%, 95.0%, and 91.5%, respectively. CONCLUSIONS: Recategorization of the risk of choledocholithiasis would significantly improve the diagnostic accuracy of choledocholithiasis and help reduce the overuse of more complex and unnecessary studies/procedures.

OBJETIVOS: Disminuir la sobre indicación de la colangiorresonancia y las tasas de colangiopancreatografía retrógrada endoscópica o terapéuticas en pacientes pediátricos con sospecha de coledocolitiasis. MATERIAL Y METODOS: Estudio retrospectivo de pacientes con sospecha de coledocolitiasis entre enero de 2010 y junio de 2023. Los pacientes con colangitis o dos o más de los siguientes factores predictivos de coledocolitiasis en las pruebas de laboratorio y ecografía iniciales, se categorizaron como grupo de alto riesgo: nivel de bilirrubina total ≥ 2 mg/dl, colédoco > 6 milímetros en ecografía; y la detección de coledocolitiasis por ecografía. Los pacientes fueron recategorizados de acuerdo a los resultados del segundo conjunto de análisis de laboratorio y ecografía. Para evaluar la presencia de coledocolitiasis se utilizaron modalidades confirmatorias (colangiorresonancia, colangiopancreatografía retrógrada endoscópica y/o colangiografía intraoperatoria). Finalmente, evaluamos la capacidad predictiva tanto del grupo de alto riesgo inicial como del grupo después de la recategorización. RESULTADOS: Se incluyeron 129 pacientes. Luego de los estudios iniciales, 72 (55,8%) pacientes se clasificaron en el grupo de alto riesgo. Luego de la recategorización, solo 29 (22,5%) pacientes fueron incluidos dentro de este grupo. La sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y precisión diagnóstica del grupo de alto riesgo inicial fueron de 89,3%, 53,5%, 34,7%, 94,7% y 61,2%, mientras que luego de la recategorización fueron de 82,1%, 94,1%, 79,3%, 95,0% y 91,5%, respectivamente. CONCLUSIONES: La recategorización del riesgo de coledocolitiasis, mejoraría significativamente la precisión diagnóstica de coledocolitiasis y ayudaría a disminuir la sobre indicación de estudios/procedimientos complejos e innecesarios.

Early detection of pancreatic cancer.

The diagnosis of pancreatic cancer associates an appalling significance. Detection of preinvasive stage of pancreatic cancer will ameliorate the survival of this deadly disease. Premalignant lesions such as Intraductal Papillary Mucinous Neoplasms or Mucinous Cystic Neoplasms of the pancreas are detectable on imaging exams and this permits their management prior their invasive development. Pancreatic intraepithelial neoplasms (PanIN) are the most frequent precursors of pancreatic adenocarcinoma (PDAC), and its particular type PanIN high-grade represents the malignant non-invasive form of PDAC. Unfortunately, PanINs are not detectable on radiologic exams. Nevertheless, they can associate indirect imaging signs which would rise the diagnostic suspicion. When this suspicion is established, the patient will be enrolled in a follow-up strategy that includes performing of blood test and serial imaging test such as computed tomography or magnetic resonance imaging, which will cost in the best-case scenario a burden of healthcare systems, and potential mortality in the worst-case scenario when the patient underwent resection surgery, worthless when there is no moderate or high grade dysplasia in the final histopathology. This issue will be avoid having at its disposal a diagnostic technique capable of detecting high-grade PanIN lesions, such is the cytology of pancreatic juice obtained by nasopancreatic intubation. Herein, we review the possibility of detection of early malignant lesions before they become invasive PADC.

Beyond the Usual Suspects: A Pictorial Case Report of Lemmel Syndrome Emphasizing the Role of Multimodality Imaging.

Lemmel syndrome, characterized by biliary and pancreatic duct obstruction secondary to a periampullary duodenal diverticulum (PAD), remains a rare and often overlooked diagnosis. Although duodenal diverticula are found in approximately 23% of the population, only about 5% of these cases lead to complications such as obstructions. A new case of Lemmel syndrome is demonstrated in the article about a middle-aged woman with chronic epigastric pain and right upper abdominal quadrant initially misdiagnosed as cholelithiasis. The accuracy of diagnosis was made possible by multimodal imaging methods, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), and computed tomography (CT) with oral contrast when a diffuse common bile duct was compressed by a PAD. Additionally, it highlights the necessity of including Lemmel syndrome in cases where patients have dilated bile ducts without calculi or mass lesions while emphasizing advanced imaging techniques for the revelation of structural malformations that underlay these conditions. The endoscopic intervention was minimally invasive but effective in relieving symptoms through sphincterotomy followed by laparoscopic cholecystectomy and biliary stent placement, thus making a point of the need for multiple disciplinary approaches toward treatment rare phenomenon like this one. This case report not only sheds light on the diagnostic and therapeutic avenues for Lemmel syndrome but also serves as a valuable educational resource for healthcare professionals. It emphasizes the need for heightened clinical vigilance and the adept use of imaging modalities in cases of biliary obstruction with obscure etiology. By contributing to the growing knowledge of this rare condition, we aim to facilitate timely diagnosis and optimize patient outcomes.

Magnetic resonance imaging features of progressive familial intrahepatic cholestasis type 3.

PURPOSE: Progressive familial intrahepatic cholestasis type 3 (PFIC-3) is a rare autosomal recessive cholestatic liver disorder. This study aimed to present the clinical and magnetic resonance imaging (MRI) features of three patients with PFIC­3. METHODS: The study included three patients with cholestasis and pathogenic variants in the ABCB4 gene identified by next-generation sequencing of a targeted-gene panel or by whole-exome sequencing. The clinical, laboratory, histological, molecular, and MRI features of the patients were collected. RESULTS: Three patients (one male and two females) were enrolled. The age when clinical signs and symptoms were first noted was 21, 14, and 39 years, respectively, and the signs and symptoms included pruritus and splenomegaly (in all three patients). Parenchymatous lace-like fibrosis was associated with periportal hyperintensity and periportal halo sign in three patients. Segmental atrophy was observed in two patients, diffuse atrophy was observed in one patient, and liver surface irregularity caused by regenerating nodules was observed in three patients. Magnetic resonance cholangiopancreatography (MRCP) images showed irregular bile duct changes in three patients, focal hilar bile duct stenosis, and local intrahepatic bile duct dilatation. CONCLUSIONS: Imaging studies using MRI and MRCP can support the clinical and laboratory results in cases of PFIC­3 and can also be used as a noninvasive diagnostic option.

Lateral Pancreaticojejunostomy in a Rare Case of Chronic Calcific Pancreatitis With Peripancreatic Pseudocyst in an 18-Year-Old Male: A Case Report.

Another name for the Puestow surgery is a lateral pancreaticojejunostomy. The primary pancreatic duct, which runs from the head to the tail of the organ, is opened, exposing the pancreas. In order to allow the pancreas to empty straight into the intestines, the opening of the pancreatic duct is subsequently joined to a tiny intestinal loop. For more than 50 years, this process has been used to effectively relieve pain caused by chronic pancreatitis. This technique has a very low mortality rate and a low rate of surgical complications, and a high success rate. The gradual fibrosis of the pancreas resulting in the loss of exocrine and endocrine function is known as chronic pancreatitis. Intense pain is the disease's most typical symptom. It is unclear what causes the discomfort in chronic pancreatitis. Nonetheless, a large number of these patients have dilated ducts that are made up of intervening structures and saccular dilations, a condition known as the "chain of lakes" phenomenon. Radiological investigations can be used for diagnosis in these patients. Lateral pancreaticojejunostomy is the most effective treatment option for these individuals. Preservation of endocrine and exocrine pancreatic function is another benefit of lateral pancreaticojejunostomy. With lateral pancreaticojejunostomy, chronic fibrocalcific pancreatitis that manifests as pancreatic ductal dilatation and persistent discomfort can be effectively treated. Excellent early outcomes have been observed in terms of pain alleviation as well as post-operative morbidity and mortality; however, the patient's overall outcome and long-term follow-up have not been as well defined.

Post-cholecystectomy Clip Migration: A Case Report.

Surgical clip migration into the common bile duct (CBD) with subsequent stone formation is an exceedingly rare complication following both laparoscopic and open cholecystectomy, with fewer than 100 cases reported in the literature. Herein, we present the case of a 78-year-old female who presented with abdominal pain and dark urine six years after an open cholecystectomy. Her abdominal ultrasonography revealed no abnormalities, with only mild derangements noted in liver function tests. However, computed tomography of the abdomen unveiled a single metallic surgical clip lodged within the CBD, surrounded by a bile stone, alongside another clip at the gallbladder fossa. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), during which the clip was successfully removed. The procedure has utilized SpyGlass cholangioscopy. While clip migration into the CBD remains a rare phenomenon, it should be considered in the differential diagnosis of patients presenting with obstructive jaundice or biliary colic post-cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips-related complications but surgical common bile duct exploration may be necessary. This case highlights the importance of vigilance and prompt intervention in managing post-cholecystectomy clip migration (PCCM) but potentially serious postoperative complications.

Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones.

Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.

Modified respiratory-triggered SPACE sequences for magnetic resonance cholangiopancreatography.

Background: Respiratory-triggered (RT) and breath-hold are the most common acquisition modalities for magnetic resonance cholangiopancreatography (MRCP). The present study compared the three different acquisition modalities for optimizing the use of MRCP in patients with diseases of the pancreatic and biliary systems. Materials and methods: Three MRCP acquisition modalities were used in this study: conventional respiratory-triggered sampling perfection with application-optimized contrasts using different flip evolutions (RT-SPACE), modified RT-SPACE, and breath-hold (BH)-SPACE. Fifty-eight patients with clinically suspected pancreatic and biliary system disease were included. All image data were acquired on a 1.5 T MR. Scan time and image quality were compared between the three acquisition modalities. Friedman test, which was followed by post-hoc analysis, was performed among triple-scan protocol. Results: There was a significant difference in the mean acquisition time among conventional RT-SPACE, modified RT-SPACE, and BH-SPACE (167.41±32.11 seconds vs 50.84±73.78 seconds vs 18.00 seconds, P <0.001). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were also significantly different among the three groups (P <0.001). The SNR and CNR were higher in the RT-SPACE group than in the BH-SPACE group (P <0.05). However, there were no statistically significant differences (P >0.05) among the 3 groups regarding quality of overall image, image clarity, background inhibition, and visualization of the pancreatic and biliary system. Conclusions: MRCP acquisition with the modified RT-SPACE sequence greatly shortens the acquisition time with comparable quality images. The MRCP acquisition modality could be designed based on the patient's situation to improve the examination pass rate and obtain excellent images for diagnosis.

An Unusual Case of Microcystic Serous Cystadenoma in a 19-Year-Old Male Patient.

Introduction: Microcystic serous cystadenomas are uncommon, benign neoplasms rarely known to progress to malignancy. They are typically asymptomatic and inadvertently discovered during imaging for another unrelated condition. When discovered, they are commonly found in females over 60 years of age. Case Presentation: In this case report, we examine a unique presentation of a serous cystadenoma discovered when a 19-year-old male presented with symptoms of abdominal pain, nausea, and vomiting. Conclusion: Previous studies on serous cystadenomas in a younger male demographic are rare. Therefore, this study will provide additional insight into the signs, symptoms, diagnosis, and management of cystadenomas in young patients.

High-grade pancreatic intraepithelial neoplasia diagnosed based on changes in magnetic resonance cholangiopancreatography findings: A case report.

BACKGROUND: High-grade pancreatic intraepithelial neoplasia (PanIN) exhibits no mass and is not detected by any examination modalities. However, it can be diagnosed by pancreatic juice cytology from indirect findings. Most previous cases were diagnosed based on findings of a focal stricture of the main pancreatic duct (MPD) and caudal MPD dilatation and subsequent pancreatic juice cytology using endoscopic retrograde cholangiopancreatography (ERCP). We experienced a case of high-grade PanIN with an unclear MPD over a 20-mm range, but without caudal MPD dilatation on magnetic resonance cholangiopancreatography (MRCP). CASE SUMMARY: A 60-year-old female patient underwent computed tomography for a follow-up of uterine cancer post-excision, which revealed pancreatic cysts. MRCP revealed an unclear MPD of the pancreatic body at a 20-mm length without caudal MPD dilatation. Thus, course observation was performed. After 24 mo, MRCP revealed an increased caudal MPD caliber and a larger pancreatic cyst. We performed ERCP and detected atypical cells suspected of adenocarcinoma by serial pancreatic juice aspiration cytology examination. We performed a distal pancreatectomy and obtained a histopathological diagnosis of high-grade PanIN. Pancreatic parenchyma invasion was not observed, and curative resection was achieved. CONCLUSION: High-grade Pan-IN may cause MPD narrowing in a long range without caudal MPD dilatation.

Classification of anatomical morphology of cystic duct and its association with gallstone.

BACKGROUND: Gallstones are common lesions that often require surgical intervention. Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones. Preoperatively, the anatomical morphology of the cystic duct (CD), needs to be accurately recognized, especially when anatomical variations occur in the CD, which is otherwise prone to bile duct injury. However, at present, there is no optimal classification system for CD morphology applicable in clinical practice, and the relationship between anatomical variations in CDs and gallstones remains to be explored. AIM: To create a more comprehensive clinically applicable classification of the morphology of CD and to explore the correlations between anatomic variants of CD and gallstones. METHODS: A total of 300 patients were retrospectively enrolled from October 2021 to January 2022. The patients were divided into two groups: The gallstone group and the nongallstone group. Relevant clinical data and anatomical data of the CD based on magnetic resonance cholangiopancreatography (MRCP) were collected and analyzed to propose a morphological classification system of the CD and to explore its relationship with gallstones. Multivariate analysis was performed using logistic regression analyses to identify the independent risk factors using variables that were significant in the univariate analysis. RESULTS: Of the 300 patients enrolled in this study, 200 (66.7%) had gallstones. The mean age was 48.10 ± 13.30 years, 142 (47.3%) were male, and 158 (52.7%) were female. A total of 55.7% of the patients had a body mass index (BMI) ≥ 24 kg/m2. Based on the MRCP, the CD anatomical typology is divided into four types: Type I: Linear, type II: n-shaped, type III: S-shaped, and type IV: W-shaped. Univariate analysis revealed differences between the gallstone and nongallstone groups in relation to sex, BMI, cholesterol, triglycerides, morphology of CD, site of CD insertion into the extrahepatic bile duct, length of CD, and angle between the common hepatic duct and CD. According to the multivariate analysis, female, BMI (≥ 24 kg/m2), and CD morphology [n-shaped: Odds ratio (OR) = 10.97, 95% confidence interval (95%CI): 5.22-23.07, P < 0.001; S-shaped: OR = 4.43, 95%CI: 1.64-11.95, P = 0.003; W-shaped: OR = 7.74, 95%CI: 1.88-31.78, P = 0.005] were significantly associated with gallstones. CONCLUSION: The present study details the morphological variation in the CD and confirms that CD tortuosity is an independent risk factor for gallstones.