Magnetic Resonance Cholangiopancreatography Research Articles

Post-Cholecystectomy Biliary Leak and its Management in a Tertiary Care Hospital of Lahore City: A Cross Sectional, Descriptive Study

Background and Objective: Leakage of bile after open or laparoscopic cholecystecmy is rare, but if occurred, is associated with higher risk of morbidity and mortality. The objective of this study was to describe the experience of managing post-cholecystectomy biliary leak in a tertiary care hospital of Lahore, Pakistan.Methods: In this descriptive, cross sectional study, twenty-two cases were included using purposive sampling technique. These cases presented with bile leakage after cholecystectomy (open and/or laparoscopic) over the period of 3.5 years in a surgical unit. The patients were managed on case-to-case basis using a standardized revised algorithm. All patients were managed by ultrasonography guided drainage, and laparoscopic wash with control of sepsis. Magnetic Resonance cholangiopancreatography (MRCP) was conducted to classify injury using Strasberg's classification and managed according to the injury type. Data were managed and analyzed using SPSS version 25 and described using frequency and percentages.Results: Cases were aged between 30-60 years and out of 22 patients, twelve presented with bile leaks through drain left in-situ (55%), six presented with peritonitis with drain in-situ (27%), four patients (18%) had abdominal distension and peritonitis. Firty-one percent patients were managed by ultrasound guided drainage and in 9/22 patients laparoscopic wash and drain placement was done. In six patients, ERCP with stent was used. In 5/22 patients, hepaticojejunostomies were performed.Conclusion: Post-cholecystectomy iatrogenic biliary leak can be managed by drain placement, abdominal wash and antibiotics. Presented algorithm will help surgeons to manage post-cholecystectomy biliary leak effectively with low risk of mortality and morbidity.Keywords: Bile duct disease, post-operative complications, Common bile duct injuries, Biliary fistula , fistula biliary, biliary leakage, Cholecystectomy  

Surveillance MRI is associated with improved survival in patients with primary sclerosing cholangitis.

The benefits of regular surveillance imaging for cholangiocarcinoma in patients with primary sclerosing cholangitis (PSC) are unclear. Hence, we aimed to evaluate the impact of regular magnetic resonance cholangiopancreatography (MRCP) on outcomes of patients with PSC in Australia, where the practice of MRCP surveillance is variable. The relationship between MRCP surveillance and survival outcomes was assessed in a multicenter, retrospective cohort of patients with PSC from 9 tertiary liver centers in Australia. An inverse probability of treatment weighting approach was used to balance groups across potentially confounding covariates. A total of 298 patients with PSC with 2117 person-years of follow-up were included. Two hundred and twenty patients (73.8%) had undergone MRCP surveillance. Regular surveillance was associated with a 71% reduced risk of death on multivariate weighted Cox analysis (HR: 0.29, 95% CI: 0.14-0.59, p < 0.001) and increased likelihood of having earlier endoscopic retrograde cholangiopancreatography from the date of PSC diagnosis in patients with a dominant stricture (p < 0.001). However, survival posthepatobiliary cancer diagnosis was not significantly different between both groups (p = 0.74). Patients who had surveillance of less than 1 scan a year (n = 41) had comparable survival (HR: 0.46, 95% CI 0.16-1.35, p = 0.16) compared to patients who had surveillance at least yearly (n = 172). In this multicenter cohort study that employed inverse probability of treatment weighting to minimize selection bias, regular MRCP was associated with improved overall survival in patients with PSC; however, there was no difference in survival after hepatobiliary cancer diagnosis. Further prospective studies are needed to confirm the benefits of regular MRCP and optimal imaging interval in patients with PSC.

A therapeutic ERCP in an only 5.9 kg infant with obstruction jaundice using JF-260V duodenoscope

BackgroundEndoscopic retrograde cholangiopancreatography (ERCP) has found extensive use in pediatric patients; however, challenges persist in the application of therapeutic ERCP in infants.Case presentationThis case report details the presentation of a 5.9-kilogram infant with obstructive jaundice and suspected hemolytic anemia who underwent ERCP to alleviate biliary obstruction. The infant was admitted due to clay-colored stools, jaundice, and liver injury. Ultrasound and magnetic resonance cholangiopancreatography (MRCP) revealed dilation of the common bile duct (CBD) accompanied by the presence of stones. ERCP was conducted using a JF-260V duodenoscope under general anesthesia. Successful stone extraction and biliary drainage were achieved.ConclusionsIn centers with considerable expertise in ERCP and pediatric anesthesia, the use of a conventional adult duodenoscope for therapeutic ERCP in infants can be considered safe and feasible, provided careful and stringent patient selection criteria are applied. In the future, clear guidelines and standardized protocols for the indications and procedures of pediatric ERCP should be established.

Revolutionizing the Pancreatic Tumor Diagnosis: Emerging Trends in Imaging Technologies: A Systematic Review

Background and Objectives: The pancreas, ensconced within the abdominal cavity, requires a plethora of sophisticated imaging modalities for its comprehensive evaluation, with ultrasonography serving as a primary investigative technique. A myriad of pancreatic pathologies, encompassing pancreatic neoplasia and a spectrum of inflammatory diseases, are detectable through these imaging strategies. Nevertheless, the intricate anatomical confluence and the pancreas’s deep-seated topography render the visualization and accurate diagnosis of its pathologies a formidable endeavor. The objective of our paper is to review the best diagnostic imagistic tools for the pancreas. Materials and Methods: we have gathered several articles using Prisma guidelines to determine the best imagistic methods. The imperative of pancreatic scanning transcends its diagnostic utility, proving to be a pivotal element in a multitude of clinical specialties, notably surgical oncology. Within this domain, multidetector computed tomography (MDCT) of the pancreas holds the distinction of being the paramount imaging modality, endorsed for its unrivaled capacity to delineate the staging and progression of pancreatic carcinoma. In synergy with MDCT, there has been a notable advent of avant-garde imaging techniques in recent years. These advanced methodologies, including ultrasonography, endoscopic ultrasonography, contrast-enhanced ultrasonography, and magnetic resonance imaging (MRI) conjoined with magnetic resonance cholangiopancreatography (MRCP), have broadened the horizon of tumor characterization, offering unparalleled depth and precision in oncological assessment. Other emerging diagnostic techniques, such as elastography, also hold a lot of potential and promise for the future of pancreatic imaging. Fine needle aspiration (FNA) is a quick, minimally invasive procedure to evaluate lumps using a thin needle to extract tissue for analysis. It is less invasive than surgical biopsies and usually performed as an outpatient with quick recovery. Its accuracy depends on sample quality, and the risks include minimal bleeding or discomfort. Results, guiding further treatment, are typically available within a week. Elastography is a non-invasive medical imaging technique that maps the elastic properties and stiffness of soft tissue. This method, often used in conjunction with ultrasound or MRI, helps differentiate between hard and soft areas in tissue, providing valuable diagnostic information. It is particularly useful for assessing liver fibrosis, thyroid nodules, breast lumps, and musculoskeletal conditions. The technique is painless and involves applying gentle pressure to the area being examined. The resulting images show tissue stiffness, indicating potential abnormalities. Elastography is advantageous for its ability to detect diseases in early stages and monitor treatment effectiveness. The procedure is quick, safe, and requires no special preparation, with results typically available immediately. Results: The assembled and gathered data shows the efficacy of various techniques in discerning the nature and extent of neoplastic lesions within the pancreas. Conclusions: The most common imaging modalities currently used in diagnosing pancreatic neoplasms are multidetector computed tomography (MDCT), endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI), alongside new technologies, such as elastography.

Modified respiratory-triggered SPACE sequences for magnetic resonance cholangiopancreatography

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

Magnetic Resonance Cholangiopancreatography: Diagnostic Role in Evaluating Pancreaticobiliary Abnormalities

Magnetic Resonance Cholangiopancreatography: Diagnostic Role in Evaluating Pancreaticobiliary Abnormalities

Three-dimensional magnetic resonance cholangiography is superior to two-dimensional single-shot magnetic resonance cholangiography for visualization and image quality of the feline and canine biliary tract: A postmortem study.

Magnetic resonance cholangiography (MRC) is an established diagnostic tool for noninvasive assessment of the biliary tract in humans. It has also been found to be feasible in companion animals, but no published studies have compared MRC sequences in veterinary medicine. The present study is part of a prospective, observational, analytical investigation on MR cholangiopancreatography performed on the donated bodies of 12 cats and eight dogs. The main aim of this study was to compare the images of 2D-SSh-TSE-MRC and 3D-TSE-MRC sequences for visualization and image quality of the feline and canine biliary tract. Both sequences are T2-weighted and noncontrast. Three independent readers scored the visibility of four segments of the biliary tract, namely the gallbladder (GB), cystic duct, common bile duct (CBD), and extrahepatic ducts, and the image quality of the two MRC sequences using five-point Likert scales. Wilcoxon signed-rank test was used to compare the scores between the MRC sequences separately for cats and dogs. Inter- and intraobserver agreements were measured using Gwet's AC2 with linear weighting. The 3D-TSE-MRC images were scored significantly higher than the 2D-SSh-TSE-MRC for both visibility and image quality (P<.001-.016 for cats, P=.008-.031 for dogs); the only exception was GB in dogs. In both cats and dogs, interobserver agreement for segment visibility and image quality ranged from slight to substantial in 2D-SSh-TSE-MRC and from poor to almost perfect in 3D-TSE-MRC. Most of the assessments (73% for segment visibility and 66% for image quality) had substantial to almost perfect intraobserver agreement. Findings from the current study support the use of 3D-TSE-MRC over 2D-SSh-TSE-MRC for evaluation of the feline and canine biliary tract, but further studies on live animals are warranted.

A Study to Assess the Role of Date Syrup, Pineapple Juice, and Hematinic Syrup as Magnetic Resonance Oral Contrast Agents in Improving the Image Quality of Magnetic Resonance Cholangiopancreatography

A Study to Assess the Role of Date Syrup, Pineapple Juice, and Hematinic Syrup as Magnetic Resonance Oral Contrast Agents in Improving the Image Quality of Magnetic Resonance Cholangiopancreatography

Quantitative MRCP and metrics of bile duct disease over time in patients with primary sclerosing cholangitis: A prospective study.

Imaging markers of biliary disease in primary sclerosing cholangitis (PSC) have potential for use in clinical and trial disease monitoring. Herein, we evaluate how quantitative magnetic resonance cholangiopancreatography (MRCP) metrics change over time, as per the natural history of disease. Individuals with PSC were prospectively scanned using non-contrast MRCP. Quantitative metrics were calculated using MRCP+ post-processing software to assess duct diameters and dilated and strictured regions. Additionally, a hepatopancreatobiliary radiologist (blinded to clinical details, biochemistry and quantitative biliary metrics) reported each scan, including ductal disease assessment according to the modified Amsterdam Cholangiographic Score (MAS). At baseline, 14 quantitative MRCP+ metrics were found to be significantly different in patients with PSC (N = 55) compared to those with primary biliary cholangitis (N = 55), autoimmune hepatitis (N = 57) and healthy controls (N = 18). In PSC specifically, baseline metrics quantifying the number of strictures and the number and length of bile ducts correlated with the MAS, transient elastography and serum ALP values (p < 0.01 for all correlations). Over a median 371-day follow-up (range: 364-462), 29 patients with PSC underwent repeat MRCP, of whom 15 exhibited quantitative changes in MRCP+ metrics. Compared to baseline, quantitative MRCP+ identified an increasing number of strictures over time (p < 0.05). Comparatively, no significant differences in biochemistry, elastography or the MAS were observed between timepoints. Quantitative MRCP+ metrics remained stable in non-PSC liver disease. Quantitative MRCP+ identifies changes in ductal disease over time in PSC, despite stability in biochemistry, liver stiffness and radiologist-derived cholangiographic assessment (trial registration: ISRCTN39463479).

3D auto-segmentation of biliary structure of living liver donors using magnetic resonance cholangiopancreatography for enhanced preoperative planning.

This study aimed to develop an automated segmentation system for biliary structures using a deep learning model, based on data from magnetic resonance cholangiopancreatography (MRCP). Living liver donors who underwent MRCP using the gradient and spin echo technique followed by three-dimensional modeling were eligible for this study. A three-dimensional residual U-Net model was implemented for the deep learning process. Data were divided into training and test sets at a 9:1 ratio. Performance was assessed using the dice similarity coefficient to compare the model's segmentation with the manually labeled ground truth. The study incorporated 250 cases. There was no difference in the baseline characteristics between the train set (n=225) and test set (n=25). The overall mean Dice Similarity Coefficient was 0.80±0.20 between the ground truth and inference result. The qualitative assessment of the model showed relatively high accuracy especially for the common bile duct (88%), common hepatic duct (92%), hilum (96%), right hepatic duct (100%), and left hepatic duct (96%), while the third-order branch of the right hepatic duct (18.2%) showed low accuracy. The developed automated segmentation model for biliary structures, utilizing MRCP data and deep learning techniques, demonstrated robust performance and holds potential for further advancements in automation.

Pancreatitis crónica

Chronic pancreatitis (CP) is a disease in which, due to different causes, the pancreatic tissue is replaced by fibrous tissue. This results in loss of both endocrine and exocrine function. This may happen due to different causes, often involving various risk factors. Investigating these causes is important due to their different therapeutic and prognostic implications, which are listed in the TIGAR-O classification. The clinical manifestations of CP occur when most of the organ's function has been lost. They include chronic abdominal pain, exocrine pancreatic insufficiency, and endocrine pancreatic insufficiency. There is no gold standard test for diagnosing CP that can provide a definitive diagnosis, but epidemiological, clinical, radiological (mainly endoscopic ultrasound and magnetic resonance cholangiopancreatography), and analytical tests (stool elastase test, complete nutritional study, and, if available, a 13C-labeled mixed triglyceride breath test) must be jointly evaluated. It is not necessary to obtain a histological specimen. Treatment is focused on pain management with medical, endoscopic, or surgical treatment in the most refractory cases; management of exocrine pancreatic insufficiency with lipase enzyme supplementation if available; management of endocrine pancreatic insufficiency (antidiabetics and insulin); and control of risk factors (tobacco use and alcohol use disorder).

Protocolo diagnóstico de la colestasis

The concept of cholestasis refers to difficulty or stoppage of bile flow. It is a common clinical problem that can be the manifestation of multiple diseases. A distinction can be drawn between intrahepatic cholestasis, when there is abnormality in the liver parenchyma, and extrahepatic cholestasis, if the obstruction is located in the common bile duct. A detailed case history and physical examination are essential in order to guide the diagnosis. An abdominal ultrasound is the first imaging test to be performed. In the presence of a normal or inconclusive ultrasound, the study should be expanded with other more specific imaging tests. If malignancy is suspected, an abdominal computed tomography scan should be the first diagnostic procedure. An oral endoscopic ultrasound and magnetic resonance cholangiopancreatography are examinations with a high diagnostic yield that is comparable between them. Endoscopic retrograde cholangiopancreatography allows for direct visualization of the bile duct with the possibility of performing treatment.

The diagnostic value of abbreviated MRI protocol in the surveillance of Branch-Duct intraductal papillary mucinous neoplasm

PurposeTo assess the diagnostic value of abbreviated protocol (AP) MRI to detect the degeneration signs in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) in patients undergoing a routine MRI follow-up. MethodsThis dual-center retrospective study include patients with BD-IPMN diagnosed on initial comprehensive protocol (CP) MRI who underwent routine MRI follow-up. CP included axial and coronal T2-weighted images (T2WI), axial T1-weighted images (T1WI) before and after contrast administration, 3D MR cholangiopancreatography (MRCP) and diffusion-weighted images (DWI). Two APs, eliminating dynamic sequences ± DWI, were extracted from CP. Two radiologists evaluated the APs separately for IPMN degeneration signs according to Fukuoka criteria and compared the results to the follow-up CP. In patients who underwent EUS, imaging findings were correlated with pathological results. Per-patient and per-lesion sensitivity, specificity, PPV, NPV, and accuracy of APs were calculated. Additionally, the acquisition time for different protocols was calculated. ResultsOne hundred-fourteen patients (56.1 % women, median age: 71 years) with 256 lesions were included. Degeneration signs were observed in 24.6 % and 12.1 % per-patient and per-lesion, respectively. Regarding APs, the per patient sensitivity, specificity, PPV, NPV, and accuracy in the detection of the degeneration signs were 100 %, 93.5 %, 83.3 %, 100 %, and 95.1 %, respectively. No additional role for DWI was detected. AP without DWI economized nearly half of CP acquisition time (388 versus 663 s, respectively). ConclusionAP can confidently replace CP for BD-IPMN follow-up with high sensitivity and PPV while offering benefits such as patient comfort, improved MRI accessibility, and reduced dedicated time for image analysis. DWI necessitates special consideration. Clinical Relevance StatementOur data suggest that APs safely detect all degeneration signs of IPMN. While there is an overestimation of mural nodules due to the lack of contrast injection, this occurs in a negligible number of patients.

Choledochal Cyst with Pancreas Divisum – Surgical Insight into A Rare Association

&#x0D; &#x0D; &#x0D; &#x0D; Congenital pancreaticobiliary anomalies like pancreatic divisum (PD), choledochal cysts (CDC), anomalous pancreaticobiliary ductal union (APBDU) have been reported in 5.7% of patients undergoing magnetic resonance cholangiopancreatography. CDC’s are characterized by abnormal dilatations of the intrahepatic and/or extrahepatic portion of the biliary tree and can be complicated by cystolithiasis, cholangitis, pancreatitis and malignant transformation necessitating surgical managemnet. While CDCs are commonly associated with APBDU, combination of CDC with PD is rare and a potential surgical challenge. We report a case of recurrent cholangitis in a patient with CDC and coincidental classic PD and illustrate how preoperative identification, fastidious dissection technique to safeguard both the pancreatic ducts and simple intraoperative preemptive strategies may decrease consequences of distal stump blowout. PD, pancreatic divisum; CBD, common bile duct; CDC, choledochal cysts; APBDU, anomalous pancreaticobiliary ductal union; MRCP, magnetic resonance cholangiopancreatography; DOS, Duct of Santorini; DOW, Duct of Wirsung; PTBD, percutaneous transhepatic biliary drainage; RYHJ, roux en Y hepaticojejunostomy.&#x0D; &#x0D; &#x0D; &#x0D;

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature

BackgroundPancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion.Case presentationA 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy.ConclusionThe management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

The first experience in the treatment of small bowel biliary obstruction using tulium laser (Tm:YAG) in a patient with Bouveret syndrome

Cholelithiasis complicated with a bilioenteral fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. To date, modern capabilities of high-tech specialized intra-luminal operative endoscopy with laser lithotripsy can prevent the routine surgical intervention, thus reducing the risk of adverse events and length of hospital stay. This clinical case describes diagnostics of the pathology and the first experience in treating the Bouveret syndrome with lithotripsy and thulium laser (Tm:YAG) light.Purpose: to improve outcomes in patients with small bowel biliary obstruction and a bilioenteral fistula using thulium laser (Tm:YAG) light as the first and final method of surgical (endoscopic) treatment.Material and methods: a patient with pains in the upper abdomen, weakness, vomiting after eating was admitted to the Botkin Hospital. Complete blood analysis, biochemical blood analysis, transabdominal ultrasound and X-ray examination of abdominal organs were made at the reception department. After that, she was transferred to the surgical department where computed tomography, magnetic resonance cholangiopancreatography and esophagogastroduodenoscopy were performed.Results: The performed instrumental diagnostics revealed a large calculus with diameter up to 4.5 cm in the bulb of the duodenum and a fistula passage connecting to the gallbladder with diameter of up 2.0 cm. Because of long disease duration and a formed internal fistula the patient was simultaneously made esophagogastroduodenoscopy and lithotripsy to resolve small bowel obstruction. The calculus was removed using thulum laser (Tm:YAG) technique, a lithotriptor basket and an endoscopic loop for fragments extraction. The performed endoscopic procedure with thulium laser light has showed its high efficiencyConclusion: The effectiveness of laser medical technique with Tm:YA in patients with Bouveret syndrome has been proven by the authors

A comprehensive case study of cholecystectomy in a patient with a gallbladder laden with 442 stones

Cholelithiasis (gallstones), crystalline formations in the gallbladder, presents a common yet intricate medical concern. These stones can vary in size and composition, ranging from cholesterol to pigment-based stones. Treatment often involves surgical intervention, with laparoscopic procedures being a minimally invasive and effective option. However, complications arise when multiple stones are present, leading to heightened inflammation and recurrent symptoms. In this study, we present a case of a 34-year-old, male who came with complaints of abdominal pain and bloating, intermittent nausea, vomiting, and jaundice for more than 5 days. He was diagnosed with multiple calculi in the gallbladder (acute cholecystitis with cholelithiasis) based on ultrasonography. Since the patient had jaundice, he was suggested to get a magnetic resonance cholangiopancreatography (MRCP) to rule out any pathoanatomy. He received treatment by laparoscopic cholecystectomy and showed improvement within 5 days of surgery.

A case of young male with recurrent acute pancreatitis caused by an intrapancreatic gastric duplication cyst.

Gastric duplication cyst (GDC) is a rare gastrointestinal malformation that frequently occurs in the greater curvature of the gastric antrum or corpus. Herein, we reported a case of intrapancreatic GDC found as a result of recurring pancreatitis. A 15-year-old man experienced repeated episodes of acute pancreatitis and was found to have a cystic lesion in the pancreatic tail. Contrast-enhanced computed tomography revealed a 20-mm cystic lesion with an enhanced thick wall. Endoscopic ultrasonography revealed an anechoic cyst with a three-layered wall. Magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography (ERP) revealed a connection between the cyst and the main pancreatic duct (MPD), and the duplication of the MPD. ERP showed the pancreatic duct stenosis downstream of the cyst. Although preoperative diagnosis was difficult, distal pancreatectomy was performed to prevent recurrence of pancreatitis. Pathological examination revealed that the cystic lesion was circumferentially surrounded by the pancreatic parenchyma. The epithelial lining of the cyst was crypt epithelium containing the fundic or pyloric glands and surrounded by a smooth muscle layer. The final diagnosis was intrapancreatic GDC.

Using artificial intelligence to predict choledocholithiasis: can machine learning models abate the use of MRCP in patients with biliary dysfunction?

Prompt diagnosis of choledocholithiasis is crucial for reducing disease severity, preventing complications and minimizing length of stay. Magnetic resonance cholangiopancreatography (MRCP) is commonly used to evaluate patients with suspected choledocholithiasis but is expensive and may delay definitive intervention. To optimize patient care and resource utilization, we have developed five machine learning models that predict a patients' risk of choledocholithiasis based on clinical presentation and pre-MRCP investigation results. Inpatients admitted to the Royal Hobart Hospital from 2018 to 2023 with a suspicion of choledocholithiasis were included. Exclusion criteria included prior hepatobiliary surgery, known hepatobiliary disease, or incomplete records. Variables related to clinical presentation, laboratory testing, and sonographic or CT imaging were collected. Four machine learning techniques were employed: logistic regression, XGBoost, random forest, and K-nearest neighbours. The three best performing models were combined to create an ensemble model. Model performance was compared against the American Society for Gastrointestinal Endoscopy (ASGE) choledocholithiasis risk stratification guidelines. Of the 222 patients included, 113 (50.9%) had choledocholithiasis. The most successful models were the random forest (accuracy: 0.79, AUROC: 0.83) and ensemble (accuracy and AUROC: 0.81). Every model outperformed the ASGE guidelines. Key variables influencing the models' predictions included common bile duct diameter, lipase, imaging evidence of cholelithiasis, and liver function tests. Machine learning models can accurately assess a patient's risk of choledocholithiasis and could assist in identifying patients who could forgo an MRCP and proceed directly to intervention. Ongoing validation on prospective data is necessary to refine their accuracy and clinical utility.

Early detection of occupational cholangiocarcinoma in a high-risk patient under intensive surveillance: a case study

BackgroundOccupational cholangiocarcinoma is associated with exposure to organic solvents, such as dichloromethane (DCM) and 1,2-dichloropropane (DCP). This report describes a case of occupational cholangiocarcinoma detected through regularly imaging following the discovery of elevated serum γ-glutamyl trans peptidase (γ-GTP) levels revealed during regular checkup.Case presentationA 43-year-old man who had been working in a printing company with 15 years of exposure to organic solvents presented to our hospital owing to abnormalities found during a routine checkup. Ultrasound (US) imaging revealed thickening of the gallbladder wall accompanied by gallstones, although in the blood tests, γ-GTP levels were within normal range. Given the high risk of cholangiocarcinoma development, the patient underwent regular monitoring with abdominal US and blood tests at a local doctor's office. At the age of 48, his serum γ-GTP level mildly elevated for the first time, prompting the initiation of semi-annual magnetic resonance cholangiopancreatography (MRCP). By the age of 50 years, dilation in B8 was detected, and one and a half years later, a tumor on the central side of the B8 dilation appeared. The patient was diagnosed with intrahepatic cholangiocarcinoma, which was treated with anterior sectionectomy. Pathological examination revealed an adenocarcinoma with a papillary glandular ductal structure at the root of the B8. In addition, biliary intraepithelial neoplasia (BilIN) and dysplasia have been identified around the tumor and periphery bile ducts and in noncancerous bile ducts. Postoperatively, the patient received 6 months of adjuvant chemotherapy with S-1monotherapy. Eight months after surgery, the patient remained under observation with no signs of recurrence.ConclusionsWe report a case of occupational cholangiocarcinoma detected during a prolonged period of regular follow-up after exposure to DCM and DCP. Given the delayed carcinogenesis process, occupational cholangiocarcinomas manifest long after exposure to organic solvents, therefore, ongoing screening is extremely important. Vigilance is essential to avoid underdiagnosis, particularly for individuals who are at an increased risk of developing this form of cancer. Continuous monitoring is key to the early detection and effective management of occupational cholangiocarcinoma.