Clinical study on the necessity and feasibility of routine MRCP in patients with cholecystolithiasis before LC.

BACKGROUND: In the past quite a long time, intraoperative cholangiography(IOC)was necessary during laparoscopic cholecystectomy (LC). Now magnetic resonance cholangiopancreatography (MRCP) is the main method for diagnosing common bile duct stones (CBDS). Whether MRCP can replace IOC as routine examination before LC is still inconclusive. The aim of this study was to analyze the clinical data of patients undergoing LC for cholecystolithiasis, and to explore the necessity and feasibility of preoperative routine MRCP in patients with cholecystolithiasis. METHODS: According to whether MRCP was performed before operation, 184 patients undergoing LC for cholecystolithiasis in the Department of General Surgery, Beijing Shijitan Hospital, Capital Medical University from January 1, 2017 to December 31, 2018 were divided into non-MRCP group and MRCP group for this retrospective study. The results of preoperative laboratory test, abdominal ultrasound and MRCP, biliary related comorbidities, surgical complications, hospital stay and hospitalization expenses were compared between the two groups. RESULTS: Among the 184 patients, there were 83 patients in non-MRCP group and 101 patients in MRCP group. In MRCP group, the detection rates of cholecystolithiasis combined with CBDS and common bile duct dilatation by MRCP were higher than those by abdominal ultrasound (P < 0.05). The incidence of postoperative complications in non-MRCP group (8.43%) was significantly higher (P < 0.05) than that in MRCP group (0%). There was no significant difference in hospital stay (P > 0.05), but there was significant difference in hospitalization expenses (P < 0.05) between the two groups. According to the stratification of gallbladder stone patients with CBDS, hospital stay and hospitalization expenses were compared, and there was no significant difference between the two groups (P > 0.05). CONCLUSIONS: The preoperative MRCP can detect CBDS, cystic duct stones and anatomical variants of biliary tract that cannot be diagnosed by abdominal ultrasound, which is helpful to plan the surgical methods and reduce the surgical complications. From the perspective of health economics, routine MRCP in patients with cholecystolithiasis before LC does not increase hospitalization costs, and is necessary and feasible.

Imaging Diagnosis and Management of Fistulas in Pancreatitis.

Pancreatic fistula is a highly morbid complication of pancreatitis. External pancreatic fistulas result when pancreatic secretions leak externally into the percutaneous drains or external wound (following surgery) due to the communication of the peripancreatic collection with the main pancreatic duct (MPD). Internal pancreatic fistulas include communication of the pancreatic duct (directly or via intervening collection) with the pleura, pericardium, mediastinum, peritoneal cavity, or gastrointestinal tract. Cross-sectional imaging plays an essential role in the management of pancreatic fistulas. With the help of multiplanar imaging, fistulous tracts can be delineated clearly. Thin computed tomography sections and magnetic resonance cholangiopancreatography images may demonstrate the communication between MPD and pancreatic fluid collections or body cavities. Endoscopic retrograde cholangiography (ERCP) is diagnostic as well as therapeutic. In this review, we discuss the imaging diagnosis and management of various types of pancreatic fistulas with the aim to sensitize radiologists to timely diagnosis of this critical complication of pancreatitis.

Immune checkpoint inhibitor-related cholangiopathy: Novel clinicopathological description of a multi-centre cohort.

BACKGROUND AND AIMS: Cholestatic liver dysfunction is common in immune-related hepatitis (irH) during treatment with immune checkpoint inhibitors (CPI) for malignancy. We investigated the spectrum of bile duct injury and associated natural history in this cohort. METHOD: Clinical, laboratory, radiological and histopathological data in patients with evidence of bile duct injury during CPI treatment from 2018 to 2020 was collected in three tertiary hospitals. RESULTS: In this study, ten patients with confirmed bile duct disease were identified. Pembrolizumab was most commonly implicated (8/10). Median CPI cycles prior to bile duct injury was 6. Median alanine aminotransferase and alkaline phosphatase were 225 U/L and 1549 U/L respectively. Clinical jaundice was seen in 6/10 and radiological evidence of bile duct pathology in 8/10. Of five patients, who had liver biopsy, three cases (including two cases with normal MRCP) showed primary sclerosing cholangitis (PSC) like changes with periductal fibrosis. All patients were treated first-line with prednisolone following cessation of CPI, three with mycophenolate mofetil and one with tacrolimus, with clinical response in four patients. Five patients died after a mean follow-up of 27 weeks; cause of death was primarily related to progression of malignancy. CONCLUSION: Within this heterogeneous cohort, we identified that CPI-related cholangiopathy responded poorly to immunosuppression and potentially progressed to bile duct loss. Thorough radiological and histological assessment is recommended, as identification of the cholangiopathy-associated phenotype may permit more informed advice regarding prognosis. Further data is required to determine detailed immunological characterisation in order to identify individuals at an increased risk of developing cholangiopathy.

Magnetic resonance cholangiopancreatography versus endoscopic ultrasound for diagnosis of choledocholithiasis: an updated systematic review and meta-analysis.

INTRODUCTION: Both endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are used for the diagnosis of choledocholithiasis (CDL). Previous studies have shown conflicting results regarding the optimal diagnostic strategy for suspected CDL; hence, this meta-analysis was conducted. METHODS: A comprehensive search of literature from 1990 till April 2022 was done of three databases for studies comparing EUS and MRCP to diagnose CDL. RESULTS: A total of 12 studies were identified. The pooled sensitivity and specificity for EUS were 0.96 [95% confidence interval (CI) 0.92-0.98], and 0.92 (95% CI 0.85-0.96), respectively. The pooled sensitivity and specificity for MRCP were 0.85 (95% CI 0.78-0.90) and 0.90 (95% CI 0.79-0.96), respectively. EUS had a higher relative sensitivity [Relative risk (RR) 1.12, 95% CI 1.05-1.19], a higher diagnostic accuracy (Odds ratio 1.98, 95% CI 1.35-2.90) but comparable specificity (RR 1.02, 95% CI 0.96-1.08) with MRCP. CONCLUSION: There is little difference concerning specificity, although EUS likely provides a higher sensitivity and accuracy for diagnosing CDL, compared to MRCP.

Magnetic resonance cholangiopancreatography using T2 preparation pulse: quantitative and qualitative analyses.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) may exhibit ghosting and blurring artifacts due to irregular breathing cycles, which can be overcome by shortening the shot duration. T2 preparation pulse enables heavy T2 contrast even with a shorter TE by use of the shortened shot duration; therefore, a technique using T2 preparation pulse combined with 3D turbo spin-echo MRCP (TPT-MRCP) was constructed. PURPOSE: To evaluate the clinical usefulness of TPT-MRCP in both navigation and breath-hold sequences compared to the conventional method. MATERIAL AND METHODS: We obtained navigation MRCP, which were TPT and conventional 3D turbo spin-echo in 37 patients, and breath-hold MRCP in 31 patients, which were TPT and gradient and spin echo. The quantitative evaluation included signal-to-noise ratio, contrast ratio, contrast-to-noise ratio and sharpness of the common bile duct in all sequences. Two radiologists visually evaluated image quality using a five-point grading method, assessing overall image quality and each of the six areas: common bile duct, right hepatic duct, left hepatic duct, main pancreatic duct, cystic duct and motion artifact. RESULTS: TPT-MRCP was significantly superior to conventional MRCP in all quantitative evaluations, except for signal-to-noise ratio in the navigation sequence. In the visual evaluation, TPT-MRCP provided higher image quality than the conventional technique in nearly all areas. The kappa (k) coefficient of the overall image quality was good for all sequences (κ = 0.61-0.8). CONCLUSION: TPT-MRCP provides higher image quality than conventional techniques in both navigation and breath-hold sequences. The present study demonstrates the greater clinical usefulness of TPT-MRCP.

Pancreatic cancer detection with a non-contrast MR protocol: is it reliable?

PURPOSE: The pancreatic cancer (PC) is the 4th leading cancer-related death, becoming the second one by 2030, with a 5 year survival rate of 8%. Considering its increased incidence in high-risk categories compared to the general population, we aimed to validate a non-contrast MR protocol, to detect PC in its earliest phase, which could be suitable as a screening tool in high-risk patients. MATERIALS AND METHODS: In this retrospective study, we selected 200 patients (> 40 years) from our radiological database, which performed upper abdominal MRI between 2012 and 2017. 100 were negative for pancreatic lesions and 100 positive for pancreatic lesion (< 30 mm). The latter group included: 40 PDAC (pancreatic adenocarcinoma), 42 BD-IPMN (Branch Duct- Intraductal Papillary Mucinous Neoplasm), 10 PNET(pancreatic neuroendocrine tumor), 4 SCN(serous cystic neoplasm), 3 IPS(intrapancreatic spleen), 1 MCN(mucinous cystic neoplasm). Three readers (R1, R2 and R3) with a high, medium and low experience, respectively, analysed, first, the non-contrast MR sequences (single-shot T2w breath-hold, GE T1w FS, DWI and 2D/3D MRCP), and then the standard MR protocol, independently, randomly and anonymously. Readers identified or excluded the presence of pancreatic lesion, in both reading sessions. These results were compared with the histopathological diagnosis, and then divided into 3 different classes of lesions: all lesions, pancreatic adenocarcinoma and solid lesion. Mcnemar's test was used to compare the results. The inter-observer agreement was determined according to the kappa statistic in both protocols, and then the inter-protocol agreement was calculated. RESULTS: The non-contrast MR protocol has reached statistical parameters values ranging between 83% in SE (sensitivity) by R3 and 99% in NPV (negative predictive value) by R1. The standard MR protocol has reported slight increasing statistical parameters compared to those of the proposed one. However, there are not significant statistical differences between the both protocols. The proposed non-contrast MR protocol has reported the highest NPVs in the PDAC group detection (R1: 99%, R2: 99%, R3: 98%). In all groups of lesions, the agreement between the two protocols was excellent for each Reader ranging from 96 to 98%. CONCLUSION: The proposed non-contrast MR protocol showed high PC detection values and a time execution ≤ 20 min. Therefore, it can be proposed as a screening tool in high-risk patients.

Diagnostic value of endoscopic ultrasonography in periampullary duodenal tumours.

Introduction: The objective of this study was to investigate the diagnostic value of endoscopic ultrasonography (EUS) for tumours around the duodenal ampullary. Patients and Methods: A retrospective analysis was performed on cases diagnosed and treated in our hospital from October 2016 to August 2021 due to the lesions around the duodenal ampulla. All patients received EUS, abdominal enhanced computed tomography (CT) and magnetic resonance imaging combined with magnetic resonance cholangiopancreatography (MRI-MRCP). Pathological diagnosis was used to verify the accuracy of the imaging findings. The detection rates of periampullary tumours by EUS, abdominal enhanced CT and MRI-MRCP were determined and compared. Results: A total of 86 patients were included in this study. According to the pathological diagnosis, the detection rate of EUS was 87% (36/41) for periampullary tumour lesions with a tumour diameter <1 cm, which was significantly higher than that of MRI-MRCP (59%, 24/41) (P = 0.003) and CT (44%, 18/41) (P < 0.001). For periampullary tumour lesions with a tumour diameter ≥1 cm, the detection rate of MRI-MRCP was 93% (42/45), which was significantly higher than that of EUS (78%, 35/45) (P = 0.036) and CT (76%, 34/45) (P = 0.02). Conclusions: EUS can accurately detect tumour lesions around the ampullary part of the duodenum with minimal gas interference. For periampullary tumour lesions <1 cm, EUS has better diagnostic accuracy than abdominal-enhanced CT and MRI-MRCP. In addition, a biopsy of the lesion can be performed at the same time during the EUS examination. Therefore, EUS has an important clinical significance and value in the diagnosis of duodenal periampullary tumours.

Accelerated Pancreatobiliary MRI for Pancreatic Cancer Surveillance in Patients With Pancreatic Cystic Neoplasms.

BACKGROUND: Pancreatobiliary MRI is often recommended for patients at risk of developing pancreas cancer. But the surveillance MRI protocol has not yet been widely accepted. PURPOSE: To establish an accelerated MRI protocol targeting the table time of 15 minutes for pancreatic cancer surveillance and test its performance in lesion characterization. STUDY TYPE: Prospective. POPULATION: A total of 30 participants were enrolled, who were undergoing follow-up care for intraductal papillary mucinous neoplasms or newly diagnosed pancreatic cysts (≥10 mm) and were scheduled for or had recently undergone contrast-enhanced CT (CECT). FIELD STRENGTH/SEQUENCE: A 3 T; heavily T2WI, 3D MRCP, DWI, dynamic T1WI, two-point Dixon. ASSESSMENT: In-room time and table time were measured. Seven radiologists independently reviewed image quality of MRI and then the presence of high-risk stigmata and worrisome features in addition to diagnostic confidence for accelerated MRI, CECT, and the noncontrast part of accelerated MRI (NC-MRI). STATISTICAL ANALYSIS: Fisher's exact test was used for categorical variables and either the Student's t-test or Mann-Whitney test was performed for continuous variables. The generalized estimated equation was used to compare the diagnostic performance of examinations on a per-patient basis. Interobserver agreement was evaluated via Fleiss kappa. A P value of <0.05 was considered to be statistically significant. RESULTS: The in-room time was 18.5 ± 2.6 minutes (range: 13.7-24.9) and the table time was 13.9 ± 1.9 minutes (range: 10.7-17.5). There was no significant difference between the diagnostic performances of the three examinations (pooled sensitivity: 75% for accelerated MRI and CECT, 68% for NC-MRI, P = 0.95), with the highest significant diagnostic confidence for accelerated MRI (4.2 ± 0.1). With accelerated MRI, the interobserver agreement was fair to excellent for high-risk stigmata (κ = 0.34-0.98). DATA CONCLUSION: Accelerated MRI protocol affords a table time of 15 minutes, making it potentially suitable for cancer surveillance in patients at risk of developing pancreatic cancer. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY STAGE: 2.

Value of 3-T MR imaging in intraductal papillary mucinous neoplasm with a concomitant invasive carcinoma.

OBJECTIVES: To examine the value of 3-T MRI for evaluating the difference between the pancreatic parenchyma of intraductal papillary mucinous neoplasm with a concomitant invasive carcinoma (IPMN-IC) and the pancreatic parenchyma of patients without an IPMN-IC. METHODS: A total of 132 patients underwent abdominal 3-T MRI. Of the normal pancreatic parenchymal measurements, the pancreas-to-muscle signal intensity ratio in in-phase imaging (SIR-I), SIR in opposed-phase imaging (SIR-O), SIR in T2-weighted imaging (SIR-T2), ADC (×10-3 mm2/s) in DWI, and proton density fat fraction (PDFF [%]) in multi-echo 3D DIXON were calculated. The patients were divided into three groups (normal pancreas group: n = 60, intraductal papillary mucinous neoplasm (IPMN) group: n = 60, IPMN-IC group: n = 12). RESULTS: No significant differences were observed among the three groups in age, sex, body mass index, prevalence of diabetes mellitus, and hemoglobin A1c (p = 0.141 to p = 0.657). In comparisons among the three groups, the PDFF showed a significant difference (p < 0.001), and there were no significant differences among the three groups in SIR-I, SIR-O, SIR-T2, and ADC (p = 0.153 to p = 0.684). The PDFF of the pancreas was significantly higher in the IPMN-IC group than in the normal pancreas group or the IPMN group (p < 0.001 and p < 0.001, respectively), with no significant difference between the normal pancreas group and the IPMN group (p = 0.916). CONCLUSIONS: These observations suggest that the PDFF of the pancreas is associated with the presence of IPMN-IC. KEY POINTS: • The cause and risk factors of IPMN with a concomitant invasive carcinoma have not yet been clarified. • The PDFF of the pancreas was significantly higher in the IPMN-IC group than in the normal pancreas group or the IPMN group. • Pancreatic PDFF may be a potential biomarker for the development of IPMN with a concomitant invasive carcinoma.

Patient- and Examination-Related Predictors of 3D MRCP Image Quality in Children.

BACKGROUND. MRCP provides noninvasive imaging of the biliary tree and pancreatic duct. In our experience, MRCP image quality is commonly suboptimal in children. OBJECTIVE. The purpose of this study was to characterize the frequency of nondi-agnostic 3D fast spin-echo (FSE) MRCP acquisitions and determine predictors of nondi-agnostic MRCP image quality in children. METHODS. This retrospective study included 200 randomly selected pediatric patients (101 female and 99 male patients; mean age, 11.7 years) who underwent MRCP between January 1, 2019, and December 31, 2020. Patient- and examination-related variables were recorded. Three fellowship-trained pediatric radiologists independently reviewed 3D FSE MRCP acquisitions for diagnostic quality (diagnostic vs nondiagnostic) and overall image quality score on a scale from 1 to 5 (1 = worst image quality imaginable, 5 = best image quality imaginable). After computing interreader agreement, analyses used readers' most common diagnostic quality assessment and mean image quality score. Multivariable logistic regression and linear regression analyses were used to identify predictor variables of a diagnostic examination and higher image quality score. RESULTS. Interreader agreement for an MRCP acquisition being diagnostic quality, expressed as a kappa coefficient, was 0.53-0.71; interreader agreement for image quality score, expressed as an intraclass correlation coefficient, was 0.68-0.74. A total of 36 of 200 (18%) MRCP acquisitions were nondiagnostic; the mean image quality score was 3.5 ± 1.1 (SD). Multivariable predictors of a diagnostic MRCP acquisition included greater body mass index (OR = 1.11 [95% CI, 1.02-1.21]; p = .02), scanner field strength of 1.5 T (odds ratio [OR] = 2.87 [95% CI, 1.23-6.68]; p = .01), and presence of acute pancreatitis (OR = 4.91 [95% CI, 1.53-15.77]; p = .008). Multivariable predictors of a higher image quality score (ß = 0.05-0.94) included older age (p = .01), imaging performed with patient under sedation or general anesthesia (p < .001), presence of biliary dilatation (p = .004), and inpatient status (p = .02). A lower image quality score was predicted by a scanner field strength of 3 T (ß = -0.61; p < .001). A greater amount of time between the start of the MRI examination and the MRCP acquisition exhibited a nonsignificant association with a decrease in the image quality score (p = .06). CONCLUSION. Pediatric MRCP acquisitions are commonly nondiagnostic. Patient-specific and technical factors systematically impact MRCP image quality in children. CLINICAL IMPACT. Recognition of image quality predictors that are potentially modifiable and amendable to proactive intervention can guide efforts to optimize MRCP image quality in children.

Associations Between Quantitative MRI Metrics and Clinical Risk Scores in Children and Young Adults With Autoimmune Liver Disease.

BACKGROUND. The Mayo risk score and SCOPE (Sclerosing Cholangitis Outcomes in Pediatrics) index are clinical risk scores for monitoring the progression of primary sclerosing cholangitis (PSC) and predicting clinically important endpoints. OBJECTIVE. The purpose of this study was to evaluate relationships between quantitative MRI measures of liver disease and clinical risk scores in children and young adults with autoimmune liver disease (AILD). METHODS. This prospective study included 58 patients (35 male and 23 female patients; mean age, 15.1 ± 1.1 [SD] years [range, 6-24 years]) with AILD (16 with PSC, 30 with autoimmune hepatitis, and 12 with autoimmune sclerosing cholangitis) who underwent research liver MRI examinations including MR elastography, T2*-corrected T1 (cT1), and quantitative MRCP measurements. Associations between quantitative MRI metrics and clinical risk scores were evaluated using Spearman rank-order correlation coefficients and multivariable regression analyses. RESULTS. The mean Mayo risk score was -1.1 ± 0.9 (SD) (range, -2.9 to 1.1); the mean SCOPE index was 2.7 ± 2.2 (range, 0-9). Mean liver stiffness was 2.8 ± 1.1 kPa, whole-liver mean cT1 was 874.7 ± 77.7 ms, and whole-liver cT1 interquartile range (IQR) was 150.8 ± 55.6 ms. The Mayo risk score was significantly correlated with liver stiffness (ρ = 0.56; p < .001), whole-liver mean cT1 (ρ = 0.31; p = .02), whole-liver cT1 IQR (ρ = 0.58; p < .001), and multiple quantitative MRCP measures (ρ = 0.36-0.45, p < .001). SCOPE index was significantly correlated with liver stiffness (ρ = 0.68; p < .001), whole-liver cT1 IQR (ρ = 0.51; p < .001), and multiple quantitative MRCP measures (ρ = 0.47-0.49; p < .001). Multivariable linear regression analyses identified liver stiffness, whole-liver cT1 IQR, and left hepatic duct maximum diameter as significant independent predictors of the Mayo risk score (adjusted R2 = 0.45), and liver stiffness, whole-liver cT1 IQR, maximum common bile duct (CBD) diameter, and median CBD diameter as significant independent predictors of the SCOPE index (adjusted R2 = 0.69). On logistic regression analysis, greater than low risk by SCOPE index was best predicted by liver stiffness [odds ratio [OR] = 49.6; 95% CI, 3.1-793.6) and maximum CBD diameter (OR = 2.5; 95% CI, 1.3-4.7). CONCLUSION. Increased liver stiffness, increased cT1 IQR, and larger bile duct diameters are independently associated with higher (worse) Mayo risk score and SCOPE index among children and young adults with AILD and may be surrogate markers of clinically meaningful endpoints. CLINICAL IMPACT. Multiparametric MRI of the liver incorporating quantitative metrics may serve as a noninvasive diagnostic and prognostic tool in pediatric AILD. TRIAL REGISTRATION. ClinicalTrials.gov: NCT03175471.

Validation of choledocholithiasis predictors from the "2019 ASGE Guideline for the role of endoscopy in the evaluation and management of choledocholithiasis."

BACKGROUND AND AIMS: Identifying patients likely to have CDL is an important clinical dilemma because endoscopic retrograde cholangiopancreatography (ERCP), carries a 5-7% risk of adverse events. The purpose of this study was to compare the diagnostic test performance of the 2010 and 2019 ASGE criteria used to help risk stratify patients with suspected CDL. METHODS: Consecutive patients evaluated for possible CDL from 2013 to 2019 were identified from surgical, endoscopic, and radiologic databases at a single academic center. Inclusion criteria included all patients who underwent ERCP and/or cholecystectomy with intraoperative cholangiogram (IOC) for suspected CDL. We calculated the diagnostic test performance of criteria from both guidelines and compared their discrimination using the receiver operator curve. Univariate and multivariate analysis was used to identify the strongest component predictors. RESULTS: 1098 patients [age 57.9 ± 19.0 years, 62.8% (690) F] were included. 66.3% (728) were found to have CDL on ERCP and/or IOC. When using the 2019 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 65.8, 78.9, 86.3, 54.1, and 70.4%, respectively. Using the 2010 guidelines, the sensitivity, specificity, PPV, NPV, and accuracy are 50.5, 78.9, 82.5, 44.8, and 60.1%, respectively. The AUC for high-risk criteria using the 2019 guidelines [0.726 (0.695, 0.758)] was greater than for the 2010 guidelines [0.647 (0.614, 0.681)]. The key difference providing the increased discrimination was the inclusion of stones on any imaging modality, which increased the sensitivity to 55.0% from 29.1%. Not including CDL on imaging or cholangitis, a dilated CBD was the strongest individual predictor of CDL on multivariate analysis (OR 3.70, CI 2.80, 4.89). CONCLUSION: Compared to 2010, the 2019 high-risk criterion improves diagnostic test performance, but still performs suboptimally. Less invasive tests, such as EUS or MRCP, should be considered in patients with suspected CDL prior to ERCP.

Compliance to endoscopic retrograde cholangiopancreatography according to current guidelines and adverse outcomes of suspected choledocholithiasis in an acute care setting.

INTRODUCTION: Common bile duct (CBD) stones are common among patients who underwent cholecystectomy. However, few studies have investigated the compliance with the guidelines for the prediction of choledochlithiasis (CL). Therefore, we aim to study the compliance with the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL in a major hospital in Saudi Arabia's capital. METHODS: We conducted a retrospective chart review on adult patients admitted to emergency department at King Abdulaziz Medical City, Riyadh with gallstones between January 2016 and January 2019. Our data collection includes demographics and level of suspicion based on Transabdominal Ultrasound, liver function, amylase, and lipase tests. We then determined the likelihood of CL based on ASGE guidelines in order to assess the adherence to ASGE guidelines, the procedure's outcomes and adverse outcomes. RESULTS: We identified 826 patients who met the study's criteria: 384 (46.4%) were compliant, while 442 (53.6%) were non-compliant with ASGE guidelines. There was a significant association between compliance and the presence of stones on ERCP in high likelihood patients. 48 (21.3%) of total ERCP procedures among all the likelihoods had adverse outcomes. 13 (40.6%) of non-compliant ERCP performed in intermediate likelihood have experienced adverse outcomes. There was a significant association between having adverse outcomes and being non-complaint with ASGE guidelines. CONCLUSION: Despite ASGE guidelines' recommendations, a third of high likelihood cases and the majority of intermediate likelihood cases were non-compliant. Additionally, the current guidelines for the intermediate group are somewhat vague, giving ample leeway for patients to be placed in the intermediate group, which might subject them to unnecessary interventions. To conclude, there was a great lack of compliance with ASGE guidelines that is significantly associated with adverse outcomes. Hence, reassessing the current guidelines and monitoring healthcare facilities' compliance with the updated guidelines is highly recommended.

The anatomy of the cystic duct and its association with cholelithiasis: MR cholangiopancreatographic study.

The aims of this article are to detail the anatomy of the cystic duct in patients with and without gallstones as it relates to maneuvering of the duct during endoscopic transpapillary gallbladder cannulation, and to elucidate its role in the dynamics of bile flow during gallbladder contraction. One hundred MRCPs were retrieved from the prospectively maintained radiology data system to assess the configuration of the cystic duct and its confluence vis-a-vis the main biliary duct. The configuration of the cystic duct was broadly classified into four types: Angular (44%), Linear (40%), Spiral (11%), and Complex (5%). The level of emergence of the cystic duct from the bile duct was proximal in 29%, middle in 49% and distal in 20%. Its direction from the bile duct was to the right and angled upward in 69%, right and angled downward in 15%, left and angled upward in 13%, and left and angled downward in 1%. Its orifice was on the lateral surface of the bile duct in 50%, posterior in 19%, anterior in 15% and medial in 14%. In two cases, the cystic duct opened directly into the duodenum. Tortuous cystic ducts and non-lateral unions with the bile duct were significantly more prevalent in gallstone cases than the non-gallstone group (p = 0.02). The present study details the spatial anatomy of the cystic duct vis a vis the main biliary duct. This has not been well investigated to date but has become increasingly relevant with the advent of recent gallbladder interventions.

The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience.

PURPOSE: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.

Dose estimation for cone-beam computed tomography in image-guided radiation therapy using mesh-type reference computational phantoms and assuming head and neck cancer.

This study aimed to estimate the additional dose the cone-beam computed tomography (CBCT) system integrated into the Varian TrueBeam linear accelerator delivers to a patient with head and neck cancer using mesh-type International Commission on Radiological Protection reference computational phantoms. In the first part, for use as a benchmark for the accuracy of the Monte Carlo geometry of CBCT, Particle and Heavy Ion Transport code System (PHITS) calculations were confirmed against measured lateral and depth dose profiles using a computed tomography dose profiler. After obtaining good agreement, organ dose calculations were performed by PHITS using mesh-type reference computational phantom (MRCP) and irradiating the neck region; the effective dose was calculated utilising absorbed organ doses and tissue weighting factors for male and female MRCP. Substantially, it has been found that the effective doses for male and female MRCP are 0.81 and 1.06 mSv, respectively. As this study aimed to assess the imaging dose from the CBCT system used in image-guided radiation therapy, it is required to take into account this dose in terms of both the target organ and surrounding tissues. Although the absorbed organ dose values and effective dose values obtained for both MRCP males and females were small, attention should be paid to the additional dose resulting from CBCT. This study can create awareness on the importance of doses arising from imaging techniques, especially CBCT.

Comparison of MRCP and ERCP findings: A retrospective secondary data analysis.

Objective: To compare the findings of magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients presenting with bile duct disorders. METHODS: The retrospective secondary-data study was conducted at the Gastroenterology Department of Lady Reading Hospital, Peshawar, Pakistan, and comprised data of patients who presented with bile duct disorders from June2019 to May2020. Data was analysed using SPSS 25. RESULTS: Of the 92 patients, 41(44.6%) were males and 51(55.4%) were females. The overall mean age was 50.12 ± 16.7 years (range: 13-80 years). Out of 28 bile duct calculi cases detected by endoscopic retrograde cholangiopancreatography, 25(89.3%) were detected by magnetic resonance cholangiopancreatography, and, of the 64 without calculi, it was 50(78.1%). Out of 8 bile duct strictures detected by endoscopic retrograde cholangiopancreatography, 3(37.5%) were correctly diagnosed by magnetic resonance cholangiopancreatography, and, of the 84 unaffected patients, were excluded 79(94%). Out of 64 bile duct dilatation cases, magnetic resonance cholangiopancreatography correctly diagnosed 59(92.2%), and, of the 28 unaffected patients, it excluded 27(96.4%). CONCLUSIONS: For bile duct stone and dilation, magnetic resonance cholangiopancreatography was found to have high diagnostic accuracy.

Ascaris induced acute pancreatitis in paediatric population - a case series.

The most common helminthic parasitic infection inhabiting human intestine is Ascaris lumbricoides (AL). Being the largest of the helminthic family, it infects almost one billion people worldwide, but any information about local population is unavailable especially in children. When patients present with abdominal pain, having ascaris induced pancreatitis never meets the differential diagnosis list even though AL itself is highly prevalent in our part of the world. Infected patients can present with a variety of symptoms depending on the location of parasite. If the biliary tree is inhabited, patients usually present with symptoms of choledocholithiasis or pancreatitis. We report the case series of 3 patients from paediatric age group, having acute pancreatitis secondary to AL. Patients had upper abdominal pain of varying duration. Ultrasound abdomen showed worm inside the Common Bile Duct (CBD) in all 3 patients. Endoscopic retrograde cholangio-pancreatography (ERCP) showed worms coming out of the ampullary orifice. Two patients received albendazole orally post ERCP and were discharged after complete resolution of symptoms with advice of repeat ERCP after 6 weeks, however one patient was advised Magnetic resonance cholangio-pancreatography (MRCP).

MRCP as a biomarker of motor action with varying degree of central and peripheral contribution as defined by ultrasound imaging.

Motor imagination is an alternative rehabilitation strategy for people who cannot execute real movements. However, it is still a matter of debate to which degree it involves activation of deeper muscle structures, which cannot be detected by surface electromyography (SEMG). Sixteen able-bodied participants performed cue based isometric ankle plantar flexion (active movement) followed by active relaxation under four conditions: executed movements with two levels of muscle contraction (fully executed and attempted movements, EM and AM) and motor imagination with and without detectable muscle twitches (IT and I). The most prominent peaks and distinctive phases of movement-related cortical potential (MRCP) were compared between conditions. Ultrasound imaging (USI) and SEMG were used to detect movements. IT showed spatially distinctive significant differences compared to both I and AM during active movement preparation and reafferentation phase; further widespread differences were found between IT and AM during active movement execution and posteriorly during preparation for active relaxation. EM and AM showed the largest differences frontally during active movement planning and posteriorly during execution of active relaxation. Movement preparation positivity P1 showed a significant difference in amplitude between IT and AM but not between IT and I. USI can detect subliminal movements (twitches) better than SEMG. MRCP is a biomarker sensitive to different levels of muscle contraction and relaxation. IT is a motor condition distinguishable from both I and AM. EEG biomarkers of movements could be used to identify pathological conditions, that manifest themselves during either active contraction or active relaxation.NEW & NOTEWORTHY Ultrasound imaging can detect subtle muscle movements (twitches) that are not detectable with electromyography. Almost a quarter of trials of imagined movements in able-bodied people are accompanied by twitches. Analysis of movement-related cortical potential showed that motor imagination with twitches is a condition distinguishable from motor imagination without twitches and from motor attempts.

Pancreatobiliary Flow Dynamics: Association Between Bile and Pancreatic Juice Evaluated With Cine-Dynamic Magnetic Resonance Cholangiopancreatography Using Spatially Selective Inversion Recovery Pulse.

BACKGROUND: The physiological flow patterns and the reciprocal relationship between pancreatic juice and bile excretion dynamics have not been clearly elucidated by imaging. PURPOSE: To assess the physiological flow patterns of bile and pancreatic juice simultaneously in order to clarify the pancreatobiliary flow dynamics using cine-dynamic magnetic resonance cholangiopancreatography (MRCP) with a spatial selective inversion recovery (IR) pulse. STUDY TYPE: Retrospective. POPULATION: A total of 85 patients with physiologically normal pancreatobiliary flow without ductal dilatation (normal group) and 19 patients with dilated pancreatic duct. FIELD STRENGTH/SEQUENCE: A 3 T, fast spin echo sequence with IR pulse to nullify the signal of static pancreatic juice and bile. ASSESSMENT: The frequency and secretion grade of the antegrade and reverse flow of the pancreatic juice and bile on cine-dynamic MRCP were visually evaluated. Additionally, the reciprocal relationship between pancreatic juice and bile flow was evaluated based on its flow patterns. STATISTICAL TESTS: Spearman's rank correlation coefficient analysis and the Kruskal-Wallis and Mann-Whitney U tests were used. P values of <0.05 were considered to indicate statistical significance. RESULTS: In the normal group, the antegrade pancreatic juice flow and no bile flow pattern was most frequently observed (29%), followed by the no pancreatic juice flow and no bile flow pattern (23%), the antegrade pancreatic juice flow and antegrade bile flow pattern (22%), and the no pancreatic juice flow and reverse bile flow pattern (9%). The flow of the pancreatic juice and bile were synchronized with each other in 47%, while they were not in 53%. In the dilated pancreatic duct group, the mean secretion grade of the antegrade bile and pancreatic juice flow was significantly lower than in the normal group. DATA CONCLUSION: Cine-dynamic MRCP with a spatially selective IR pulse can visualize the variations of the physiological flow patterns of bile and pancreatic juice including 53% of unsynchronized patterns. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY: Stage 5.