Magnetic Resonance Cholangiopancreatography In Patients Research Articles

Administration of Secretin (RG1068) Increases the Sensitivity of Detection of Duct Abnormalities by Magnetic Resonance Cholangiopancreatography in Patients With Pancreatitis

Administration of secretin improves noninvasive imaging of the pancreatic duct with magnetic resonance cholangiopancreatography (MRCP). We performed a large prospective study to investigate whether synthetic human secretin (RG1068)-stimulated MRCP detects pancreatic duct abnormalities with higher levels of sensitivity than MRCP. We performed a phase 3, multicenter, baseline-controlled study of patients with acute or acute recurrent pancreatitis who were scheduled to undergo endoscopic retrograde cholangiopancreatography (ERCP) between March 26, 2008, and October 28, 2009. Patients underwent a baseline MRCP that was immediately followed by administration of RG1068 and repeat MRCP and then underwent ERCP within 30 days; they were followed up for 30 days. MRCP and ERCP images were read centrally by 3 radiologists and 2 endoscopists, respectively, who were all independent and blinded; pancreatic duct abnormalities were evaluated. The accuracy of MRCP was evaluated using ERCP as the standard. In total, 258 patients were enrolled in the study; 251 MRCP image sets were assessed, and 236 patients had evaluable ERCPs. Pancreatic duct abnormalities were observed in 60.2% of ERCP images. All radiologists identified duct abnormalities in RG1068-ciné MRCP image sets with significantly higher levels of sensitivity (P < .0001) than in images from MRCP, with minimal loss of specificity. Adverse events were reported in 38.0% of patients after MRCP and 68.1% after ERCP. Of the 55 patients who experienced a serious adverse event, 3 (1.2%) and 52 (20.5%) of the events were reported to be temporally associated with MRCP and ERCP, respectively. The adverse events most frequently considered related to RG1068 were nausea, abdominal pain, and flushing; most were mild. Compared with images from MRCP, those from RG1068-stimulated MRCP are improved in many aspects and could aid in diagnosis and clinical decision making for patients with acute, acute recurrent, or chronic pancreatitis. RG1068-enhanced MRCP might also better identify patients in need of therapeutic ERCP (ClinicalTrials.gov, Number: NCT00660335).

Sa1300 Clinical Significance of Biliary Dilatation and Cholelithiasis After Subtotal Gastrectomy: Data From Swan (Sustainable Work and Announcement Network for Pancreas and Biliary Disease) Club in Korea

Background: Choledocholithiasis (CDL) is a common and potentially severe form of gallstone disease. Magnetic resonance cholangio-pancreatography (MRCP) is an increasingly used imaging modality in patients with a suspicion of CDL but limited data exist of the diagnostic accuracy in clinical practice. We aimed to assess its diagnostic performance in patients with a suspicion of CDL. Methods: A retrospective study of patients who were suspected to have CDL that had MRCP in a University Hospital in consecutive patients investigated during one year at this single Institution. Patients with other indications than gallstone disease for MRCP such as malignancy were excluded. Information was obtained on age, gender, liver tests, lipase/amylase and number of patients that underwent ERCP following the MRCP and the outcome of ERCP. Results: A total of 179 patients (females 63%, median age 56 years) had an MRCP due to suspected CDL. MRCP showed stones in the common bile duct (CBD) in 49 patients and none in 130. Overall 55 patients underwent ERCP after an abnormal MRCP (stones and/or dilated ducts) and 39 of them had documented stones (71%). Only 1/49 (2%) patient had a stone demonstrated on ERCP followed by a normal MRCP. None of the other patients with a normal MRCP had symptoms or signs of choledocholithiasis or were hospitalized for gallstone disease during at least 6 months after the normal MRCP. Patients with stones in the CBD on MRCP had higher values of bilirubin (45 μmol/L vs. 19, p=0.001), GGT (458 vs. 286, p=0.04) and AST (214 vs. 130, p=0.03) than those without stones, whereas other blood tests did not differ between the two groups. A total of 37/49 (76%) of patients with CBD stones had elevated bilirubin vs. 52/130 (40%) in those without CBD stones (p,0.05). Overall 46 patients were diagnosed with pancreatitis ( .threefold elevation of lipase) and among those only 9/49 (18%) had stones in the CBD on ERCP and/ or MRCP. The patients diagnosed with gallstones demonstrated in the CBD had a median value of lipase 4068 (981-9332) vs. 4400 (1192-11851) in those without stones (NS). Conclusion: MRCP in patients suspected to have stones in CBD has a very high negative predictive value and can prevent unnecessary ERCPs. Elevation of bilirubin, GGT and AST along with stones and dilated ducts shown on MRCP is a strong indicator of the presence of stones in the CBD. Gallstone pancreatitis is as common in those with and without stones in the CBD, suggesting that in surprisingly many patients the elevation in lipase is associated with spontaneous passage of stones through the CBD.

Sa1299 Magnetic Resonance Cholangio-Pancreatography (MRCP) Has a High Negative Predictive Value in Patients Suspected to Have Choledocholithiasis

Background: Choledocholithiasis (CDL) is a common and potentially severe form of gallstone disease. Magnetic resonance cholangio-pancreatography (MRCP) is an increasingly used imaging modality in patients with a suspicion of CDL but limited data exist of the diagnostic accuracy in clinical practice. We aimed to assess its diagnostic performance in patients with a suspicion of CDL. Methods: A retrospective study of patients who were suspected to have CDL that had MRCP in a University Hospital in consecutive patients investigated during one year at this single Institution. Patients with other indications than gallstone disease for MRCP such as malignancy were excluded. Information was obtained on age, gender, liver tests, lipase/amylase and number of patients that underwent ERCP following the MRCP and the outcome of ERCP. Results: A total of 179 patients (females 63%, median age 56 years) had an MRCP due to suspected CDL. MRCP showed stones in the common bile duct (CBD) in 49 patients and none in 130. Overall 55 patients underwent ERCP after an abnormal MRCP (stones and/or dilated ducts) and 39 of them had documented stones (71%). Only 1/49 (2%) patient had a stone demonstrated on ERCP followed by a normal MRCP. None of the other patients with a normal MRCP had symptoms or signs of choledocholithiasis or were hospitalized for gallstone disease during at least 6 months after the normal MRCP. Patients with stones in the CBD on MRCP had higher values of bilirubin (45 μmol/L vs. 19, p=0.001), GGT (458 vs. 286, p=0.04) and AST (214 vs. 130, p=0.03) than those without stones, whereas other blood tests did not differ between the two groups. A total of 37/49 (76%) of patients with CBD stones had elevated bilirubin vs. 52/130 (40%) in those without CBD stones (p,0.05). Overall 46 patients were diagnosed with pancreatitis ( .threefold elevation of lipase) and among those only 9/49 (18%) had stones in the CBD on ERCP and/ or MRCP. The patients diagnosed with gallstones demonstrated in the CBD had a median value of lipase 4068 (981-9332) vs. 4400 (1192-11851) in those without stones (NS). Conclusion: MRCP in patients suspected to have stones in CBD has a very high negative predictive value and can prevent unnecessary ERCPs. Elevation of bilirubin, GGT and AST along with stones and dilated ducts shown on MRCP is a strong indicator of the presence of stones in the CBD. Gallstone pancreatitis is as common in those with and without stones in the CBD, suggesting that in surprisingly many patients the elevation in lipase is associated with spontaneous passage of stones through the CBD.

Diagnostic value of magnetic resonance cholangiopancreatography in cholestatic jaundice

The aim of the studyTo evaluate the diagnostic accuracy of magnetic resonance cholangiopancreatography in patients with cholestatic jaundice. Patients and methodsClinical, laboratory and investigational data were evaluated from 50 patients with cholestastic jaundice. MRCP findings were compared with ERCP or operative findings and appropriate clinical endpoints. ResultsThe ERCP or operative findings and appropriate clinical endpoints revealed 23 patients with intra or extra hepatic biliary dilatation and 27 patients without intra or extra hepatic biliary dilatation. As regards the 23 patients with biliary dilatation, biliary dilatation was evident in 19 patients by U/S versus 23 patients by MRCP. ERCP was successful in 20 patients (87%) and was not done in three patients (13%). In cases of obstructive jaundice the sensitivity of MRCP was 100% versus 86% in choledocholithiasis and malignant detection, respectively p value <0.05. ConclusionMRCP is highly sensitive and specific for biliary dilatation and avoids the need for invasive imaging in most patients with cholestasis. MRCP permits reservation of ERCP to patients with a high probability of therapeutic intervention.

Endoscopic Ultrasound and Magnetic Resonance Cholangiopancreatography in Patients with Idiopathic Acute Pancreatitis

The efficacy of endoscopic ultrasonography (EUS) to diagnose idiopathic acute pancreatitis has been demonstrated but that of magnetic-resonance cholangiopancreatography (MRCP) remains unclear. The aim of our study was to prospectively compare the results of EUS and MRCP to diagnose idiopathic acute pancreatitis when performed later after an acute attack. All patients admitted to our center for acute pancreatitis over a 2-year period received first-line investigations that included medical history, standard biological measurements, abdominal ultrasound, and computerized tomography. If no etiology was found, second-line investigations were scheduled at 2 months (or more if there was severe pancreatitis), which included clinical examinations, biological parameters, EUS, and MRCP. A total of 128 consecutive patients were included (male: 80, mean age: 55.3 years). After first-line investigations, 41 patients with idiopathic acute pancreatitis underwent second-line investigations and were followed-up (38 patients had both EUS and MRCP). EUS and/or MRCP led to recognize a possible etiology of pancreatitis in 19 patients (50 %). The diagnostic yield for EUS was higher than for MRCP (29 vs. 10.5 %). EUS more accurately detected biliary stones whereas MRCP identified pancreatic duct abnormalities, such as intraductal papillary mucinous neoplasm of the pancreas or chronic pancreatitis. The combination of EUS and MRCP, when performed later after idiopathic acute pancreatitis, revealed 50 % of etiologies. The association of these two procedures and the subsequent follow-up reduced the rate of idiopathic pancreatitis by ~66 %.

Respiratory variation of the extrahepatic bile duct: evaluation with deep inspiratory and expiratory MRCP

PurposeThe purpose of the study was to evaluate the respiratory variation of the extrahepatic bile duct in morphology including shape, length and duct diameter on the breath-hold magnetic resonance cholangiopancreatography (MRCP) obtained during deep inspiration and deep expiration in patients with or without biliary diseases. Materials and MethodsThis study included 102 patients with or without biliary diseases. Breath-hold MRCP was obtained twice during the end-inspiration and the end-expiration. MRCP images were evaluated for the length, maximal diameter and “bowing” of the extrahepatic bile duct. ResultsIn the normal group, the mean maximal diameter of the extrahepatic bile duct was significantly larger on the end-inspiratory MRCP (8.0±2.0 mm) than on the end-expiratory MRCP (7.3±1.8 mm) (P<.0001), while it was not significantly different in the dilated group. In the normal group, 25 (39%) of 65 patients had an increase in the mean maximal diameter of more than 1 mm at the end-inspiration, whereas 4 (11%) of 37 patients in the dilated group had it. The bowing of the extrahepatic bile duct on the end-inspiratory MRCP was observed in 60 (92%) of 65 normal patients, while it was seen in 22 (60%) of 37 patients with biliary dilatation (P<.0001). ConclusionDeep inspiratory and expiratory MRCP demonstrated the respiratory variations of the extrahepatic bile duct in the shape (bowing), length and maximal duct diameter in patients with nondilated bile ducts. Awareness of this normal phenomenon will be important for the correct interpretation of MRCP in patients with or without biliary diseases.

Secretin-stimulating MRCP in patients with pancreatobiliary maljunction and occult pancreatobiliary reflux: direct demonstration of pancreatobiliary reflux

We propose the hypothesis that the enlargement of the common bile duct (CBD) or gallbladder (GB) that is occasionally demonstrated on magnetic resonance cholangiopancreatography (MRCP) after secretin stimulation is caused by pancreatobiliary reflux. Recently, occult pancreatobiliary reflux (OPR) has been demonstrated in patients without morphological pancreatobiliary maljunction (MPBM). The aim of this study was to evaluate the efficacy of secretin-stimulating MRCP (SMRCP) in the diagnosis of pancreatobiliary reflux. The study included 14 patients with MPBM and 32 patients with a normal pancreatobiliary junction. OPR was evaluated by bile collection and diagnosed in seven of the 32 patients. All the patients underwent SMRCP; the related findings were considered positive when enlargement of the CBD or GB was observed. Positive findings on SMRCP were observed in all MPBM patients. In the patients with normal pancreatobiliary junction, there was significant difference between the mean amylase levels in the patients with positive and negative SMRCP findings (mean, 4,755.7 and 29.7 IU/l). The sensitivity and specificity of SMRCP for diagnosing OPR was 85.7% and 68.0%, respectively. SMRCP provides a non invasive method for excluding PBR and can identify patients who could benefit from bile duct sampling to diagnose OPR.

Dynamic study of pancreaticobiliary reflux using secretin-stimulated magnetic resonance cholangiopancreatography in patients with choledochal cysts

Background/Purpose Refluxes through pancreaticobiliary maljunctions play an important role in the pathophysiology of choledochal cysts. Dynamic studies of the pancreaticobiliary tract were performed using secretin-stimulated magnetic resonance cholangiopancreatography. Methods Six patients with choledochal dilation were recruited for this study. Four patients exhibited cystic and 2 exhibited fusiform dilatation of the common bile duct (CBD). Magnetic resonance cholangiopancreatography images were obtained every minute during the 15-minute period after secretin stimulation. The sequential morphological changes in the biliary trees, pancreas, and duodenum were assessed, and the total pixel values of these organs were measured for each image, then plotted as a ratio against the baseline image. Results In 2 cases involving cystic dilatation, the intensity of bile duct images continued to rise after secretin stimulation. In a case involving fusiform dilatation, a transitory elevation in CBD intensity was observed. In 3 cases involving fusiform or cystic dilatation, the intensity of CBD did not change notably. In all cases, the duodenum was filled well after secretin stimulation. Conclusions The sustained elevation in bile duct intensity after secretin stimulation indicates reflux and bile stasis. Transitory elevation may indicate reflux without stasis. This method allows assessment of the dynamics of pancreatic and bile fluid under more physiologic condition.

A blinded, stratified, randomized clinical trial comparing magnetic resonance cholangiopancreatography (MRCP) to endoscopic ultrasound (EUS) for the evaluation of common bile duct stones (CBDS)

Purpose: MRCP and EUS have emerged as non-invasive / minimally-invasive tests with good accuracy in detecting CBDS. Our aim was to prospectively compare the diagnostic accuracy of EUS to MRCP in patients with suspected CBDS based on clinical criteria.

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Past, Present, and Future of Endoscopic Retrograde Cholangiopancreatography: Perspectives on the National Institutes of Health Consensus Conference

Role of Magnetic Resonance Cholangiopancreatography in Patients With Suspected Choledocholithiasis

To investigate the diagnostic efficacy of magnetic resonance cholangiopancreatography (MRCP) in choledocholithiasis and to determine whether use of MRCP may eliminate the need for purely diagnostic endoscopic retrograde cholangiopancreatography (ERCP). A total of 116 patients with suspected biliopancreatic pathology were studied prospectively between November 1996 and February 1998. Choledocholithiasis was initially suspected in 61 patients and rated before ERCP and MRCP as being of low, intermediate, or high probability based on clinical, laboratory, and/or imaging findings (Cotton criteria). The sensitivity of choledocholithiasis diagnosis was 91%, with a global efficacy of 90%. The level of duct stone obstruction was visualized in all patients. Suprastenotic dilatation also showed a good correlation to ERCP. Choledocholithiasis was found in 32 patients (65%) and 3 patients (33%) in the high- and intermediate-probability groups, respectively. None of the low-probability patients had choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed for only a diagnostic (not therapeutic) purpose in 3 patients (6%) and 2 patients (22%) of the high- and intermediate-probability cases, respectively. Magnetic resonance cholangiopancreatography seems to be effective in diagnosing choledocholithiasis. It plays a fundamental role in patients with a low or intermediate risk of choledocholithiasis, contributing to the avoidance of purely diagnostic ERCP.

Role of Magnetic Resonance Cholangiopancreatography in Patients With Suspected Choledocholithiasis

Role of Magnetic Resonance Cholangiopancreatography in Patients With Suspected Choledocholithiasis

The role of magnetic resonance cholangiopancreatography in patients with suspected biliary obstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) is an accepted and accurate procedure that combines the advantage of diagnosis of biliary obstruction with possible therapeutic endobiliary intervention. However, it is an operator-dependent and invasive procedure that is associated with complications and limitations. Magnetic resonance cholangiopancreatography (MRCP) is a unique noninvasive technique for the diagnosis of biliary obstruction. It is well suited to provide the information required to plan the optimal therapeutic approach for these patients. MRCP has the potential to replace or at least precede ERCP as the first-line imaging effort in the evaluation of suspected biliary obstruction. Significant advantages and some notable limitations inherent to the modality dictate its judicious use in appropriate circumstances. The present article reviews the utility of MRCP in evaluation of biliary obstruction, with brief reference to its principles and techniques.

The decision-making value of magnetic resonance cholangiopancreatography in patients seen in a referral center for suspected biliary and pancreatic disease

European Journal of Gastroenterology & Hepatology: September 2001 - Volume 13 - Issue 9 - p 1129-1130

Potential Impact of Magnetic Resonance Cholangiopancreatography on Endoscopic Retrograde Cholangiopancreatography Workload and Complication Rate in Patients Referred Because of Abdominal Pain

Endoscopic retrograde cholangiopancreatography (ERCP) has a significant mortality, morbidity, and failed cannulation rate. Magnetic resonance cholangiopancreatography (MRCP) is a safer, noninvasive method of imaging the pancreaticobiliary tree. A substantial number of patients are referred for ERCP because of abdominal pain, a high proportion of whom have normal ducts or pathology not requiring interventional ERCP. The aim was to assess the potential impact of MRCP on overall ERCP workload and patient outcome if MRCP were the primary investigation in patients referred for ERCP because of abdominal pain. 1758 consecutive ERCPs performed in 1148 patients over a 3-year period in a single tertiary referral center in the pre-MRCP era were reviewed. Cannulation failure, ERCP findings, need for follow-up ERCP and all 30-day major complication rates were analyzed with regard to clinical indications. The overall workload comprised 1108 (63 %) successful initial ERCPs, 188 (11 %) failed cannulation attempts and 462 (26 %) follow-up ERCPs. Of the patients, 299 (27 %) had normal ERCP findings, 331 (30 %) had choledocholithiasis and 246 (22 %) had strictures. lf MRCP had been used as the primary imaging investigation in the 451 patients (39 %) referred for ERCP because of abdominal pain, we estimate that 197 patients (44 %) would have avoided ERCP, and the overall ERCP workload would have been reduced by 13 %. Initial MRCP in suspected gallstone pancreatitis and certain miscellaneous groups, it was estimated, would have further decreased ERCP workload by 9 %. Four of 40 major ERCP-related complications (3.5 %) and one of four ERCP-related deaths (0.35 %) would potentially have been avoided. Initial MRCP in patients referred with abdominal pain would potentially have avoided ERCP in 44 % of cases, reduced ERCP workload by 13 % and significantly reduced patient morbidity and mortality. The relatively small reduction in ERCP workload among these patients reflects the fact that over half of them had probable sphincter dysfunction, a significant proportion of whom might have benefited from biliary manometry and/or endoscopic intervention despite a normal MRCP. Furthermore, a small number of patients with calculi and subtle biliary and pancreatic strictures would be missed by this approach.

The decision-making value of magnetic resonance cholangiopancreatography in patients seen in a referral center for suspected biliary and pancreatic disease

OBJECTIVE: To assess the ability of MRCP to alter the differential diagnosis and to prevent diagnostic and/or therapeutic ERCP. The diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) for biliary and pancreatic disease is well documented. Some believe MRCP may prevent diagnostic ERCP or add useful information, however there are no reports of its impact on clinical management. METHODS: Consecutive patients referred for ERCP underwent clinic evaluation, then MRCP, and then ERCP. In Phase 1, the number of differential diagnoses and the perceived need for diagnostic ERCP were evaluated after each step by the endoscopist who performed the ERCP. In Phase 2, the process was repeated after presenting clinical information and MRCP results to different individual physicians: another endoscopist, a hepatologist, a radiologist, and a surgeon (all were blinded to ERCP results). RESULTS: Forty patients were enrolled. Clinical contexts were jaundice (19.7%), abnormal liver enzymes (42.6%), abdominal pain (11.5%), recurrent acute pancreatitis (11.5%), and suspected complications of chronic pancreatitis (14.7%). In Phase 1, adding MRCP information to diagnostic ERCP information did not change the mean number of differential diagnoses significantly and prevented no therapeutic ERCP. In Phase 2, adding MRCP to clinical information only (without ERCP) reduced the differential diagnosis significantly for the radiologist and the surgeon only and would have prevented ≤3% of diagnostic and therapeutic ERCP for all physicians. CONCLUSION: The value of MRCP information may be limited if patient selection is inappropriate and may differ in physicians depending on their speciality.

A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction

Background—The value of magnetic resonance cholangiopancreatography (MRCP) is under debate.Aims—To assess the diagnostic accuracy of MRCP and endoscopic retrograde cholangiopancreatography (ERCP) and to determine whether MRCP may help to prevent...