Acurácia do protocolo abreviado de colangioressonância magnética no diagnóstico de coledocolitíase / Accuracy of abbreviated protocol of magnetic resonance cholangio-pancreatography in the diagnosis of choledocholithiasis

ABSTRACT Background: Abbreviated magnetic resonance imaging protocols have emerged to reduce the examination time of the long protocols eliminating unnecessary pulse sequences to answer a targeted clinical question, without compromising diagnostic information. Objective: The objective of this study was to evaluate the diagnostic accuracy of an abbreviated magnetic resonance cholangiopancreatography (A-MRCP) protocol in patients with suspected choledocholithiasis. Methods: This retrospective study evaluated patients (ages 10 + years) that performed consecutive MRCP examination from October 2019 to June 2020, with the clinical suspicion of choledocholithiasis. Readers first evaluated the biliary tree using a four-sequence A-MRCP protocol and later reviewed the entire conventional eleven-sequence MRCP. Presence of choledocholithiasis, stone size, common bile duct caliber, and additional findings were evaluated. Results: A total of 148 patients with MRCP were included (62.8% female, mean 50.9 years). The prevalence of choledocholithiasis was 32.2%. The accuracy of the abbreviated MRCP protocol for choledocholithiasis was 98.7%. There was no difference between the performance of the abbreviated and conventional MRCP image sets for detection of choledocholithiasis (kappa=0.970), with a sensitivity of 98% and a specificity of 99%. There was excellent inter-reader agreement evaluating for choledocholithiasis on both imaging sets of MRCP protocols (kappa values were 0.970). Conclusion: An abbreviated MRCP protocol to evaluate for choledocholithiasis provides similar diagnostic over the conventional MRCP protocol, offering potential for decreased scanning time and improved patient tolerability.

RESUMO Contexto: Protocolos abreviados de ressonância magnética (RM) surgiram a fim de reduzir o tempo de exame, eliminando sequências de pulso desnecessárias para responder a uma questão clínica específica, sem comprometer o diagnóstico. Objetivo: O objetivo do estudo foi avaliar a acurácia diagnóstica de um protocolo abreviado de colangiopancreatografia por ressonância magnética (colangioRM) em pacientes com suspeita de coledocolitíase. Métodos Estudo retrospectivo, com pacientes acima de 10 anos que realizaram exame de colangioRM, entre outubro de 2019 a junho de 2020, com suspeita clínica de coledocolitíase. Os observadores, radiologistas especialistas, primeiro avaliaram a árvore biliar usando um protocolo abreviado de colangioRM composto por quatro sequências de pulso e, posteriormente, revisaram o protocolo convencional de colangioRM de 11 sequências. A presença de coledocolitíase, o tamanho do cálculo, o calibre do ducto hepático comum e achados adicionais foram avaliados. Resultados Um total de 148 pacientes foram incluídos, sendo 62,8% do sexo feminino, com média de 50,9 anos de idade. A prevalência de coledocolitíase foi de 32,2%. A acurácia do protocolo abreviado de colangioRM para coledocolitíase foi de 98,7%. Não houve diferença entre o desempenho dos protocolos abreviado e convencional de colangioRM para a detecção de coledocolitíase (k=0,970), com uma sensibilidade de 98% e uma especificidade de 99%. Além disso, observou-se excelente concordância entre observadores na avaliação de coledocolitíase em ambos os protocolos de colangioRM (k=0,925). Conclusão O protocolo abreviado de colangioRM apresentou excelente acurácia para o diagnóstico de coledocolitíase quando comparado ao protocolo convencional.

Anomalía de la unión biliopancreática: una entidad infrecuente en Occidente / Pancreaticobiliary maljunction: a rare entity in the West

Resumen La anomalía de la unión biliopancreática (AUBP) es una malformación congénita en la que los conductos pancreáticos y biliares se unen anatómicamente fuera de la pared duodenal. Debido a la excesiva longitud del canal común, la acción del esfínter no afecta la unión pancreatobiliar, lo que permite el reflujo del jugo pancreático hacia la vía biliar. Se asocia con quistes del colédoco y sus manifestaciones incluyen cáncer de la vía biliar, pancreatitis, coledocolitiasis y colangitis. Es una rara patología, especialmente en países occidentales. La colangiopancreatografía por resonancia magnética (CPRM) se ha convertido en el método más utilizado por no ser invasivo, teniendo en cuenta que la colangiopancreatografía retrógrada endoscópica (CPRE) se encuentra contraindicada en casos de pancreatitis aguda y colangitis, además del riesgo de pancreatitis posterior al procedimiento. La distancia entre la unión biliopancreática y la pared duodenal debe ser superior a 9 mm de longitud para diagnosticar AUBP mediante CPRM. En caso de que mida entre 6 y 9 mm y la acción del esfínter afecte la unión pancreatobiliar, se lo denomina unión biliopancreática alta (UBPA) y se debe confirmar mediante CPRE. Describimos los hallazgos en imágenes de siete pacientes jóvenes con clínica abdominal y diagnóstico de AUBP o UBPA por CPRM, y además revisamos la literatura sobre el tema.

Abstract Pancreaticobiliary maljunction (PBM) is a congenital malformation in which the pancreatic and biliary ducts are anatomically joined outside the duodenal wall. Due to the excessive length of the common channel, the action of the sphincter does not affect the pancreaticobiliary junction, allowing the reflux of pancreatic juice into the bile duct. It is associated with cysts of the common bile duct and its manifestations include cancer of the bile duct, pancreatitis, choledocholithiasis and cholangitis. It is a rare pathology, especially in Western countries. Magnetic resonance cholangiopancreatography (MRCP) has become the most used method because it is non-invasive, taking into account that endoscopic retrograde cholangiopancreatography (ERCP) is contraindicated in cases of acute pancreatitis and cholangitis, in addition to the risk of pancreatitis after the procedure. The distance between the biliopancreatic junction and the duodenal wall must be greater than 9 mm in length to diagnose PBM by MRCP. If it is between 6 to 9 mm and the action of the sphincter affects the pancreaticobiliary junction, it is called high confluence of pancreaticobiliary ducts (HCPBD) and should be confirmed by ERCP. We describe the imaging findings of 7 young patients with abdominal symptoms and diagnosis of PBM or HCPBD by MRCP, and also review the literature on the subject.

Colangitis esclerosante primaria / Primary sclerosing cholangitis

La colangitis esclerosante primaria (CEP) se define por la inflamación, fibrosis y estenosis de los conductos biliares intra o extrahepáticos que no pueden ser explicadas por otras causas. La prevalencia de CEP está estimada entre 0 a 16,2 por 100.000 habitantes, mientras que la incidencia está entre 0 y 1,3 casos por cada 100.000 personas por año. Las causas siguen siendo difíciles de dilucidar y en muchos casos se establece como de origen idiopático. Sin embargo, se han propuesto factores genéticos, ambientales e isquémicos asociados, además de un componente autoinmune. Existe además una fuerte asociación entre la enfermedad inflamatoria intestinal y la CEP. Los síntomas suelen ser inespecíficos, 50% de los pacientes son asintomáticos, presentando únicamente alteración en el perfil hepático de patrón colestásico, con predominio de elevación de la fosfatasa alcalina. La ictericia es un signo de mal pronóstico que con frecuencia se asocia a colangiocarcinoma. La confirmación diagnóstica se hace por colangiopancreatografía retrógrada endoscópica (CPRE) e imágenes por resonancia magnética. Aún no existe un tratamiento establecido, y en la mayoría de los casos coexiste con otras patologías. El tratamiento es multimodal con fármacos, terapia endoscópica y trasplante hepático.

Primary sclerosing cholangitis (PSC) is defined by inflammation, fibrosis, and stenosis of the intra or extrahepatic bile ducts that cannot be explained by other causes. The prevalence of PSC is estimated between 0 to 16.2 per 100,000 inhabitants, while the incidence is between 0 and 1.3 cases per 100,000 persons-year. The causes remain elusive and, in many cases, it is established as idiopathic in origin. However, genetic, environmental and ischemic factors have been proposed in addition to an autoimmune component. There is also a strong association between inflammatory bowel disease and PSC. Symptoms are usually nonspecific, 50% of the patients are asymptomatic, presenting only an alteration in the liver profile with a cholestatic pattern, and predominance of elevated alkaline phosphatase. Jaundice is a poor prognostic sign and is frequently associated with cholangiocarcinoma. Diagnostic confirmation is made by endoscopic retrograde cholangiopancreatography and magnetic resonance imaging. There is still no established treatment, and in most cases, the disease coexists with other pathologies. Treatment is multimodal with drugs, endoscopic therapy and liver transplantation.

Magnetic resonance cholangiopancreatography identification of pancreaticobiliary maljunction in the colombian pediatric population. / Unión biliopancreática anómala por colangiorresonancia en población pediátrica colombiana.

OVERVIEW: Pancreaticobiliary maljunction (PBM) is a congenital malformation characterized by a long common pancreaticobiliary channel which causes sphincter of Oddi malfunction. In children, it is typically diagnosed using magnetic resonance cholangiopancreatography (MRCP). It is associated with congenital biliary dilatation, pancreatitis, and gallbladder and bile duct tumors at adulthood. Studies in the western population are rare. Given its morbidity rate, it should be searched for in the western pediatric population. The objective of this study was to look for and identify the presence of pancreaticobiliary maljunction through MRCP in pediatric patients with biliary or pancreatic disease, as well as to find out other associated factors. METHODS: MRCP was used to measure common channel length, pancreatic duct length, and bile duct diameter in 41 pediatric patients with biliary or pancreatic disease. RESULTS: The common channel could only be measured in 17.6% of cases, 50% of which were >8 mm long. All patients were female and had congenital biliary dilatation. No age-related differences were found in terms of bile duct length. CONCLUSIONS: PBM is present in the western pediatric population, but prevalence and morbidity are unknown. Larger studies are required to identify morbidity and mortality, as well as prevalence among patients.

OBJETIVO: La unión biliopancreática anómala (UBPA) es una malformación congénita caracterizada por un canal común pancreatobiliar largo que impide el adecuado funcionamiento del esfínter de Oddi. Su diagnóstico en niños se realiza comúnmente mediante colangiopancreatografía por resonancia magnética (CPRM). Se asocia a dilatación biliar congénita, pancreatitis y tumores de la vesícula y la vía biliar en la edad adulta. Los estudios en población occidental son escasos; debido a su morbilidad resulta de relevancia la búsqueda en población pediátrica occidental. Este estudio pretende buscar e identificar la presencia de unión biliopancreática anómala mediante CPRM de pacientes pediátricos con enfermedad de la vía biliar o pancreática, al igual que identificar otros factores asociados. METODOS: Se midió por CPRM la longitud del canal común, el conducto pancreático y el diámetro de la vía biliar de 41 pacientes pediátricos con patología biliar o pancreática. RESULTADOS: El canal común solo pudo ser medido en el 17,6% de los casos, de los cuales el 50% tuvo una longitud >8 mm, siendo todos ellos pacientes femeninos con dilatación biliar congénita; no se encontraron diferencias en la longitud de la vía biliar relacionado con la edad. CONCLUSIONES: La UBPA es una malformación que se encuentra presente en población pediátrica occidental con prevalencia y morbilidad desconocida; se requieren estudios a mayor escala para identificar morbimortalidad y prevalencia de pacientes con esta malformación.

Coledococele: caso diagnosticado por resonancia magnética / Choledococele: case diagnosed by MRI

Resumen: El coledococele es una dilatación quística del segmento distal del conducto biliar común que sobresale en el lumen duodenal. Estos comprenden menos del 2% de todos los casos reportados de quistes de colédoco (2). Los hallazgos imagenológicos del coledococele y de los quistes de duplicación duodenal son muy similares, ambos presentan además clínica variada e inespecífica, por lo que el diagnóstico definitivo suele ser durante la cirugía. Presentamos un caso de una paciente de 10 años que consulta por dolor abdominal con elevación de transaminasas que, tras estudio con resonancia magnética con colangioresonancia y EDA se diagnostica coledococele.

Abstract: Choledochocele is a cystic dilation of the distal segment of the common bile duct protruding into the duodenal lumen. Is also known as type III choledochal cyst according to Todani's classification. It is usually misdiagnosed as duodenal duplication cyst. Multislice spiral computed tomography and magnetic resonance cholangiopancreatography may be comparable to endoscopic retrograde cholangiography for diagnosis of choledochocele. We present a case of a 10-years-old girl presented with abdominal pain, elevation of transaminases and a magnetic resonance cholangiopancreatography (MRCP) scan that revealed a choledochocele.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia.

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Eficacia de la colangiopancreatografía por resonancia magnética para el diagnóstico de coledocolitiasis de probabilidad intermedia / Efficacy of cholangiopancreatograghy by magnetic resonance in the diagnosis of choledocholithiasis of intermediate probability

Introducción. La coledocolitiasis de probabilidad intermedia es una condición con gran morbilidad por el riesgo de pancreatitis y colangitis, y se requiere el estudio de la vía biliar para su enfoque diagnóstico y terapéutico. Actualmente, el método de referencia para su diagnóstico y tratamiento, es un examen invasivo, la colangiopancreatografía retrógrada endoscópica (CPRE), que no siempre lleva a un diagnóstico positivo de coledocolitiasis, pero sí implica exponer a los pacientes a sus riesgos. Por esta razón, la colangiopancreatografía por resonancia magnética (CPRM) ha tomado importancia en el diagnóstico, ya que es un examen no invasivo y con menor riesgo de complicaciones, por lo que se pretende evaluar su uso en la coledocolitiasis de probabilidad intermedia. Métodos. Se llevó a cabo un estudio de pruebas diagnósticas en una muestra de pacientes con coledocolitiasis de probabilidad intermedia, en la Fundación Salud El Bosque, entre enero de 2012 y agosto de 2015. Resultados. Se incluyeron 151 pacientes con diagnóstico de coledocolitiasis de probabilidad intermedia. Se evaluaron las características de la CPRM, la cual mostró sensibilidad de 88 %, especificidad de 79 %, valor predictivo positivo (VPP) de 88 % y valor predictivo negativo (VPN) de 96 %, con un índice de exactitud de 94,7 %. Conclusiones. La CPRM es un examen con un rendimiento adecuado en la evaluación de los pacientes con coledocolitiasis de probabilidad intermedia. En estos casos permite obviar la CPRE diagnóstica. El impacto de la dilatación de la vía biliar sumada a otras alteraciones del perfil hepático, no se puede establecer con este estudio

Introduction. Patients with intermediate probability of choledocholithiasis exhibit a highly morbid pathology due to the risk of developing pancreatitis and cholangitis; it demands the study of the bile duct for appropriate diagnostic and therapeutic approach. Currently, the gold standard for its diagnosis and treatment is an invasive examination, ERCP, which not always ends with positive diagnosis of choledocholithiasis, exposing the patient to the associated risks. This is why magnetic resonance cholangiopancreatography has acquired importance in the diagnosis, for it is a non-invasive procedure with lesser risk of complications. For this reason we decided to evaluate its use in mid-probability choledocholithiasis. Methods. A study of the diagnostic tests was carried out in a sample of 151 patients with intermediate probability of choledocholithiasis at our center, Fundación Salud El Bosque (Bogotá, Colombia), in the period 2012-2015. Results: A total of 151 patients with the diagnosis of choledocholithiasis of intermediate probability were included, evaluating the characteristics of the MRCP, which showed sensitivity of 88%, specificity 79%, PPV88% and NPV 96%, with an accuracy index of 94.7%. Conclusions. MRCP is a test that exhibits adequate performance in the evaluation of patients with intermediate probability of choledocholithiasis, avoiding the performance of ERCP. It confirms its previous use when faced with mid-chance choledocholithiasis. The diagnostic impact of dilation of the bile duct and other alterations of the liver profile can not be established with this study

Açai juice as contrast agent in MRCP exams: qualitative and quantitative image evaluation

Abstract This works aims to assess images obtained with administration of açai juice as compared to a manufactured standard iron oxide-based contrast employed as negative oral agents in Magnetic Resonance Cholangiopancreatography (MRCP), employing qualitative and quantitative evaluation. The research was developed with 64 patients submitted to MRCP exams (on 2 days) in a clinic of Curitiba city (Brazil). First (day 1), a manufactured iron oxide-based contrast (A) was offered and later (day 2), açai juice (contrast B) was given to patients. Radiologists (R1 and R2) evaluated the images, classifying them by a score (1-4). In order to have a quantitative assessment, Image J free software was employed generating plots of gray levels against distance of a chosen area of the bile duct interest region. Evaluating images for contrast A, R1 furnished an average score of 3.52 and R2 of 3.27. For contrast B, R1 provided 3.44 and R2 3.38. Both evaluators considered image quality with contrast A adequate for 62 patients. R1 considered adequate for 62 and R2 for 60 patients when using açai juice. By taking same images for all patients with Image J, a quantitative analysis was obtained, resulting correlation coefficient of 0.986 between average curves of contrasts A and B. Thus, açai juice is an adequate alternative as contrast agent in MRCP exams. Image J was employed as a new method for quantitative investigation of image quality, presenting good agreement with medical opinion.

Neoplasia mucinosa papilar intraductal como hallazgo en paciente con pancreatitis / Intraductal papillary mucinous neoplasm as a finding in a patient with pancreatitis

Introducción: La neoplasia mucinosa intraductal papilar (NMIP) del páncreas es una masa quística dependiente del sistema ductal pancreático. Presentación del caso: Paciente de 65 años, femenino, antecedentes mórbidos de diabetes mellitus tipo 2 sin tratamiento e hipertensión arterial esencial en tratamiento. Consulta por cuadro clínico de 9 horas caracterizado por epigastralgia opresiva/urente de inicio súbito, con irradiación en faja a dorso, intensidad EVA 10/10, asociado a náuseas, sin vómitos, diarrea ni fiebre. Ingresa hemodinámicamente estable, afebril, hidratada, sin signos de irritación peritoneal, sin masas palpables y con ruidos hidroaéreos presentes. Destaca en exámenes de laboratorio: amilasa 390 UI/L, lipasa 1760.9 U/L.Se diagnostica pancreatitis aguda y por sospecha de etiología biliar se realiza colangiopancreatografia por resonancia magnética (CPRM). Como hallazgo se describe formación quística de 13mm a nivel de la transición entre cuerpo y cola del páncreas, compatible con NMIP de rama secundaria y se diagnostica pancreatitis aguda leve Balthazar B de etiología litiásica. Se realiza manejo de la pancreatitis y debido a las características del NMIP encontrado el plan es seguimiento tomográfico en 2 a 3 años. Discusión: Las NMIP son hallazgos imagenológicos frecuentemente incidentales, pues la mayoría de los pacientes se mantienen asintomáticos. La característica imagenológica habitual corresponde a una lesión quística multilocular lobulada situada en el proceso unciforme y en contigüidad con el conducto pancreático principal dilatado. Según las características de la lesión, el manejo puede ser quirúrgico o seguimiento. Las tasas de supervivencia global a 5 años se acercan a 61-87%

Introduction: Pancreatic intraductal papillary mucinous neoplasm (IPMN) is a cystic mass dependent on the pancreatic ductal system. Case report: Female, 65 years old, with morbid history of type 2 diabetes without treatment and essential hypertension under treatment. Consults by clinical profile of 9 hours characterized by oppressive/ burning epigastralgia of sudden onset, with irradiation in sash to back, intensity EVA 10/10, associated with nausea, without vomiting, diarrhea or fever. Is hemodynamically stable, afebrile, hydrated, with no signs of peritoneal irritation, with no palpable masses and with bowel sounds present. Highlights in laboratory tests: amylase 390 UI / L, lipase 1760.9 U / L. Acute pancreatitis is diagnosed and due the suspicion of biliary etiology a magnetic resonance cholangiopancreatography is performed. A cystic formation of 13mm is described at the transition level between body and tail of the pancreas, compatible with branch duct type IPMN and acute mild pancreatitis Balthazar B of lithiasic etiology is diagnosed. Management of pancreatitis is performed and because of the characteristics of the IPMN found the plan is tomographic follow-up in 2 to 3 years. Discussion: IPMN are frequently incidental imaging findings, as most patients remain asymptomatic. The usual imaging characteristic corresponds to a lobulated multilocular cystic lesion located in the unicular process and in contiguity with the main dilated pancreatic duct. Depending on the characteristics of the lesion, the management may be surgical or follow-up. The 5-year survival rates approach 61-87%.

Apoyo de los métodos de imagen para el Diagnóstico de Áscaris complicado en la vía biliar. Reporte de un caso / Advocacy for imaging methods for the diagnosis of complex Ascaris in the billiary tract: case report

Introducción: El presente caso nos permite revisar la utilidad de los diferentes métodos de imagen en la ascaridiasis en vía biliar a través del ultrasonido abdominal (US), la colangioresonancia (MRCP), la colangiopancreatografía retrógrada endoscópica (CPRE/ERCP) para el diagnóstico y/o tratamiento, para conocer el escenario de esta patología y definir los protocolos de diagnóstico por imagen y abordaje de la misma. La sensibilidad y especificidad de cada uno de los mismos en las diferentes series mundiales. Reporte de Caso: Nos apoyamos en la presentación de un caso clínico de una paciente proveniente del Oriente, que acude con cuadro de dolor abdominal tipo cólico en hipocondrio derecho, ictericia de 15 días de evolución, es transferida al Hospital Carlos Andrade Marín donde se realizaron estudios complementarios dentro de los cuales varios métodos de imagen, se describen los hallazgos en esta patología, así como protocolizar los métodos de imagen. Discusión: El ultrasonido es un método eficaz, accesible, no costoso, en manos expertas tiene elevada sensibilidad, al encontrar hallazgos concluyentes no se requiere el apoyo de otros métodos de imagen adicionales y en caso de ascaridiasis complicada como en nuestra paciente se debe proceder directamente a CPRE con extracción del parásito, en caso de no tener hallazgos concluyentes nos podemos apoyar de métodos como una colangioresonancia.

Introduction: This report let us review the usefulness of different imaging methods in common bile duct ascariasis like abdominal ultrasound, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis and / or treatment, to know the stage of this disease and to define the imaging protocols and addressing it. The sensitivity and specificity of each of them in different world series. Case Report: This is a clinical case of a patient from the Eastern región of Ecuador who was admitted to our hospital with a crampy abdominal pain focused in the right upper quadrant and jaundice that started 15 days before he was transferred to us. Imaging tests performed helped us to find out the problem and prescribe a propper treatment. Discusion: Ultrasound is an effective, accesible and inexpensive tool in expert hands. When the initial findings are not conclusive, other imaging methods can be applied, like Nuclear Magnetic Resonance cholangiopancreatography. Endoscopic retrograde cholangiopancreatography (ERCP) can be used in case of complicated ascariasis, as in our patient, to remove the parasite.

Papel da ranitidina como meio de aprimorar a qualidade do exame de colangiopancreatografia por ressonância magnética / The role of ranitidine in the enhancement of imaging quality in magnetic resonance cholangiopancreatography

OBJETIVO: Avaliar o impacto da ranitidina por via oral na qualidade do exame de colangiopancreatografia por ressonância magnética (CPRM).MATERIAIS E MÉTODOS: Trinta e dois pacientes realizaram CPRM com aquisições 3D e 2D, com três estratégias de supressão do sinal líquido gastrintestinal: a) apenas em jejum; b) 12 horas após ingerir 300 mg de ranitidina; c) após a ingestão de solução de gadolínio. Três observadores avaliaram os estudos, atentos para o grau de visualização da árvore biliopancreática. Foi medida a concordância interobservador com o teste kappa. A diferença entre técnicas e formas de aquisição foi avaliada pela média da soma dos escores de graduação.RESULTADOS: As três estratégias de supressão do sinal líquido gastrintestinal apresentaram elevada reprodutibilidade. A supressão do sinal líquido gastrintestinal com a ranitidina foi semelhante ao jejum e ambas foram piores do que a solução de gadolínio. As aquisições 3D superaram a 2D apenas na visualização do ducto cístico e da vesícula biliar, sendo inferior ou equivalente nos demais segmentos ductais biliopancreáticos.CONCLUSÃO: O uso da ranitidina não parece justificado para aprimorar a avaliação da árvore biliopancreática em exames de CPRM. A CPRM 2D apenas em jejum permite a visualização ductal com elevada qualidade e reprodutibilidade na maioria dos casos.

OBJECTIVE: To assess the impact of oral ranitidine on the imaging quality in magnetic resonance cholangiopancreatography (MRCP).MATERIALS AND METHODS: Thirty-two patients underwent MRCP with 3D and 2D acquisitions, and three strategies for suppression of the gastrointestinal fluid signal: a) only at fasting; b) 12 hours after ingestion of 300 mg ranitidine; c) after oral administration of gadolinium solution. Three observers reviewed the images with a focus on the degree of visualization of the biliopancreatic tree. The interobserver agreement was evaluated with the kappa test. The difference between techniques and acquisition modalities were evaluated by means of average grading scores.RESULTS: The three strategies for suppression of the gastrointestinal fluid signal presented high reproducibility. The results with suppression of the gastrointestinal fluid signal with ranitidine where similar to those obtained with fasting, and both were worse than those obtained with gadolinium solution. The 3D acquisitions surpassed 2D only in terms of visibility of the cystic duct and gallbladder, and were inferior or equivalent in the other biliopancreatic ductal segments.CONCLUSION: The use of ranitidine does not seem justified in the evaluation of the biliopancreatic tree at MRCP, since 2D MRCP with fasting allows the visualization of ductal structures with high quality and reproducibility in the majority of cases.

Conservative management of cholestasis with and without fever in acute biliary pancreatitis.

The presence of cholestasis in both mild and severe forms of acute biliary pancreatitis (ABP) does not justify, of itself, early endoscopic retrograde cholangiography (ERC) or endoscopic sphincterotomy (ES). Clinical support treatment of acute pancreatitis for one to two weeks is usually accompanied by regression of pancreatic edema, of cholestasis and by stone migration to the duodenum in 60%-88% of cases. On the other hand, in cases with both cholestasis and fever, a condition usually characterized as ABP associated with cholangitis, early ES is normally indicated. However, in daily clinical practice, it is practically impossible to guarantee the coexistence of cholangitis and mild or severe acute pancreatitis. Pain, fever and cholestasis, as well as mental confusion and hypotension, may be attributed to inflammatory and necrotic events related to ABP. Under these circumstances, evaluation of the bile duct by endo-ultrasonography (EUS) or magnetic resonance cholangiography (MRC) before performing ERC and ES seems reasonable. Thus, it is necessary to assess the effects of the association between early and opportune access to the treatment of local and systemic inflammatory/infectious effects of ABP with cholestasis and fever, and to characterize the possible scenarios and the subsequent approaches to the common bile duct, directed by less invasive examinations such as MRC or EUS.