Normal Pancreaticobiliary Junction Research Articles

Occult pancreaticobiliary reflux is a pathogenic factor of some benign biliary diseases and gallbladder cancer

BackgroundPancreaticobiliary maljunction (PBM) is a well-known high-risk factor for biliary malignant tumors because of constant pancreaticobiliary reflux (PBR). However, the impact of occult pancreaticobiliary reflux (OPR), which is characterized by high bile amylase levels in individuals with anatomically normal pancreaticobiliary junction, on biliary diseases remains unclear. The aim of this study was to assess the correlation between OPR and biliary diseases. MethodsWe enrolled 94 consecutive patients with normal pancreaticobiliary junction and primary biliary diseases confirmed by magnetic resonance cholangiopancreatography. We prospectively collected patients’ bile samples and measured bile amylase levels. We investigated the incidence of OPR and the difference in bile amylase levels among these patients and assessed the correlation between high bile amylase levels (HBAL) and benign or malignant biliary diseases, as well as the OPR risk factors. ResultsThe incidence of OPR was 36.6% in patients with benign biliary diseases, 26.7% in those with cholangiocarcinoma and 62.5% in those with gallbladder cancer. The median bile amylase level tended to be higher in patients with gallbladder cancer than in those with benign biliary diseases, but there was no significant difference (165.5 IU/L vs. 23.0 IU/L, P = 0.212). The prevalence of an HBAL with bile amylase levels of 1000-7500 IU/L was similar in patients with gallbladder cancer and benign biliary diseases. However, the incidence of HBAL with bile amylase levels greater than 7500 IU/L was significantly higher in patients with gallbladder cancer than in those with benign biliary diseases (37.5% vs. 4.2%, P = 0.012). Multivariate logistic regression analysis revealed that choledocholithiasis was an independent risk factor for OPR. ConclusionsOPR can occur in benign and malignant biliary diseases, and it may be a pathogenic factor for some benign biliary diseases and a high-risk factor for gallbladder cancer. There is a correlation between choledocholithiasis and OPR.

Elevated bile amylase level without pancreaticobiliary maljunction is a risk factor for gallbladder carcinoma.

Elevated bile amylase level in patients with pancreaticobiliary maljunction (PBM) or high confluence of pancreaticobiliary ducts (HCPBD) is well known as a risk factor for gallbladder carcinoma (GBC) development. However, the effects of occult pancreaticobiliary reflux (OPR), a condition characterized by high bile amylase level in the presence of an anatomically normal pancreaticobiliary junction, on GBC development remain unclear. The aim of this study was to assess the relationship between OPR and GBC. Clinicopathological data of 52 patients who were preoperatively diagnosed with gallbladder (GB) tumor (22 malignant, 30 benign) were retrospectively reviewed. All of the patients underwent preoperative endoscopic retrograde cholangiopancreatography to evaluate pancreaticobiliary junction morphology and bile amylase level. The relationship between the histological diagnosis of GB lesions, and pancreaticobiliary junction morphology and bile amylase level were investigated. Pancreaticobiliary maljunction, HCPBD, and normal pancreaticobiliary junction (NPJ) were identified in 12, nine, and 31 patients, respectively. The rates of GBC in patients with PBM, HCPBD, and NPJ were 58% (7/12), 67% (6/9), and 29% (9/31), respectively. Of the 31 patients with NPJ, 22 had OPR and nine of these had GBC. None of the patients with NPJ and normal bile amylase level had GBC. Additionally, among patients with NPJ, bile amylase level was significantly higher in patients with GBC than in patients with benign tumors. Occult pancreaticobiliary reflux, like PBM and HCPBD, is a risk factor for GBC development.

Pathological changes of gallbladder mucosa induced by pancreaticobiliary reflux

Objective To investigate pathologic changes of gallbladder mucosa induced by continuous pancreaticobiliary reflux(PBR) in the preliminary stage and occult PBR stage. Methods Female Syrian golden hamsters were assigned into four groups: PBR model group (established by surgery), the blank control group, PBR with BOP group (to induce gallbladder cancer) and the simple BOP group. In addition, 87 patients with normal pancreaticobiliary junction (NPBJ) who underwent cholecystectomy or percutaneous transhepatic cholecystoscopy for gallbladder stones were assigned into two groups based on the value of bile amylase (BA): PBR group and the control group. Pathological changes of gallbladder mucosa between groups were analyzed and compared. Results In PBR model group, the incidences of gallbladder epithelial hyperplasia, pyloric gland metaplasia, intestinal metaplasia and low-grade neoplasia were 6/6, 3/6, 4/6 and 2/6, respectively. The incidence of gallbladder epithelial hyperplasia in PBR model group (6/6) was significantly higher than that of the blank control group (0/5). Incidence of gallbladder cancer (3/6) and high-grade neoplasia(1/6) was higher in PBR with BOP group than in the simple BOP group(0/5). In the clinical study, 70.6%(24/34) patients in PBR group presented high BA value (>1 000 U/L). Significantly higher occurrence of low-grade neoplasia can be observed in this group (73.5%, 25/34) compared with the control group (24.5%, 13/53, P<0.05). Conclusion Gallbladder mucosal hyperplasia and the tendency of high incidence of metaplasia can be detected in the preliminary stage of continuous PBR. High probability of gallbladder carcinoma or high-grade neoplasia can be induced with BOP in PBR model hamsters. Occult PBR can lead to low-grade cell dysplasia and therefore may be the factor of gallbladder malignancy. Key words: Gallbladder neoplasms; Pancreaticobiliary reflux(PBR); Gallbladder mucosa; Pathologic changes

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study.

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Pancreaticobiliary reflux and biliary malignancy in individuals with a normal pancreaticobiliary junction

Pancreaticobiliary reflux and biliary malignancy in individuals with a normal pancreaticobiliary junction

Correlation of intracystic pressure with cyst volume, length of common channel, biochemical changes in bile and histopathological changes in liver in choledochal cyst

Aims:This study was undertaken to establish correlation between intracholedochal cystic pressure (ICCP) with biochemical changes in bile, liver histology, cyst wall histology, length of common channel, and cyst volume.Materials and Methods:In this cross-sectional study, ICCP was measured after surgical access before any mobilization by direct cyst cannulation. Bile was then aspirated for biochemical estimation (bilirubin, amylase, lipase, pH, and electrolytes). Common channel length and cyst volume were determined by preoperative magnetic resonance cholangiopancreatography (MRCP). Liver histology was assessed under parenchymal, bile duct, and portal parameters. Cyst wall was examined for ulceration, inflammation, fibrosis, and metaplasia.Results:ICCP was recorded in 31 patients; mean and median ICCP were 15.64 and 14 mmHg, respectively (range = 6-30 mmHg). Cases with median ICCP < 14 had median cyst volume of 48 cc (range = 36-115) and amylase 2052 IU/L (range = 190-5052) whereas those with ICCP ≥ 15 had volume of 20 cc (range = 10-100) (P = 0.004) and amylase 36 IU/L (range = 0-2806) (P = 0.0004) suggesting inverse correlation. No significant correlation was found with bilirubin and electrolytes. ICCP directly correlated with parenchymal changes like hepatocellular damage (P = 0.002) and cholestasis (P = 0.001). It also correlated with bile duct changes. ICCP inversely correlated with cyst wall changes (P = 0.003, 0.0001, 0.023, 0.0013, respectively). High pressure cysts had normal pancreaticobiliary junction.Conclusion:High-pressure cysts tend to be smaller but have more severe backpressure changes in liver parenchyma. Low-pressure cysts have high volume and higher levels of amylase and lipase and therefore have more severe cyst wall changes.

Pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction: a prospective multicenter study

Pancreatobiliary reflux (PBR) can occur in individuals without pancreaticobiliary maljunction. The aim of this study was to elucidate the incidence of PBR in individuals with a normal pancreaticobiliary junction and its impact on the biliary tree. Data were prospectively collected from 15 centers on 420 patients with a morphologically normal pancreaticobiliary junction who had undergone bile sampling and measurement of the biliary amylase level. We investigated the incidence and predictive factors for high biliary amylase levels (HBAL), as well as the relationship of HBAL with biliary malignancy. Twenty-three patients (5.5%) showed HBAL (≥10,000 IU/L). Univariate analysis showed that risk factors for the elevation of biliary amylase levels were the existence of a relatively long common channel (≥5 mm), acute pancreatitis, and papillitis. Multivariate analysis revealed that only the existence of a relatively long common channel was a significant factor for PBR. Biliary amylase levels in patients with a relatively long common channel were significantly higher than in patients without a long common channel (12,333 vs. 2,070 IU/L, P = 0.001). The incidence of HBAL (P < 0.001), as well as the overall biliary amylase levels (P = 0.007) were significantly higher in patients with gallbladder cancer than in those without gallbladder cancer. The PBR was frequently observed in individuals with a relatively long common channel. Patients showing HBAL with normal pancreaticobiliary junction are at high risk for gallbladder cancer.

Pancreaticobiliary reflux in patients with a normal pancreaticobiliary junction: Pathologic implications.

Knowledge on pancreaticobiliary reflux in normal pancreaticobiliary junction and its pathologic implications has experienced tremendous progress during the last few years. This editorial reviews the current knowledge on this condition and its pathological implications on gallbladder diseases. The following aspects were defined appropriate for discussion: (1) Evidence of carcinogenesis associated with pancreaticobiliary reflux; (2) Evidence of pancreaticobiliary reflux in normal pancreaticobiliary junction; and (3) Evidence of sphincter of Oddi (SO) dysfunction as a cause of pancreaticobiliary reflux in normal pancreaticobiliary junction. The articles reviewed were selected and classified according to five levels of evidence: Level I, meta-analysis double-blind randomized clinical trials, Level II, cohort non-blinded studies and non-randomized clinical trials, Level III, good quality case-control studies and non-randomized cohort studies, Level IV, case series and poor quality case-control studies, and Level V, case report articles and experts' opinion. Evidence levels II, III, IV and V were found to support biliary carcinogenesis associated with pancreaticobiliary reflux in normal and abnormal pancreaticobiliary junction. The same levels of evidence were found to support the common occurrence of pancreaticobiliary reflux in normal pancreaticobiliary junction, and SO dysfunction as the most plausible cause of this condition. Although an important body of research has been published regarding pancreaticobiliary reflux in normal pancreaticobiliary junction and its clinical significance, the current evidence does not fully support what has been suggested. Studies with evidence level I have not been undertaken. This is a fascinating subject of study, and if finally supported by evidence level I, the importance of this condition will constitute a major breakthrough in biliary pathology.

Diagnosis and clinical implications of pancreatobiliary reflux

The sphincter of Oddi is located at the distal end of the pancreatic and bile ducts and regulates the outflow of bile and pancreatic juice. A common channel can be so long that the junction of the pancreatic and bile ducts is located outside of the duodenal wall, as occurs in pancreaticobiliary maljunction (PBM); in such cases, sphincter action does not functionally affect the junction. As the hydropressure within the pancreatic duct is usually greater than in the bile duct, pancreatic juice frequently refluxes into the biliary duct (pancreatobiliary reflux) in PBM, resulting in carcinogenetic conditions in the biliary tract. Pancreatobiliary reflux can be diagnosed from elevated amylase level in the bile, secretin-stimulated dynamic magnetic resonance cholangiopancreatography, and pancreatography via the minor duodenal papilla. Recently, it has become obvious that pancreatobiliary reflux can occur in individuals without PBM. Pancreatobiliary reflux might be related to biliary carcinogenesis even in some individuals without PBM. Since few systemic studies exist with respect to clinical relevance and implications of the pancreatobiliary reflux in individuals with normal pancreaticobiliary junction, further prospective clinical studies including appropriate management should be performed.

Gallbladder carcinoma associated with occult pancreatobiliary reflux in the absence of pancreaticobiliary maljunction

We herein report a case of gallbladder carcinoma associated with occult pancreatobiliary reflux (PR) in the absence of pancreatobiliary maljunction. A 67-year-old woman was referred to our hospital for the evaluation and treatment of a gallbladder tumor. Ultrasonography and computed tomography showed a nodular lesion in the fundus of the gallbladder, indicating the possibility of a gallbladder carcinoma. Endoscopic ultrasonography showed the nodular tumor and thickness of the surrounding epithelium. Endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction without the common channel and a slight dilatation of the common bile duct (15 mm in diameter). An open cholecystectomy and partial resection of the liver bed of the gallbladder with regional lymphadenectomy was performed. A C-tube was inserted from the cut end of the cystic duct into the common bile duct to prevent bile stasis. Biliary amylase and lipase levels sampled in the gallbladder were 2604 IU/l and 775 IU/l, respectively. Biliary amylase level in the bile collected from the C-tube in the common bile duct was 119 550 IU/l on postoperative day (POD) 6 and 22 265 IU/l on POD 12. These observations suggested that PR was present in this patient. The histopathological findings of the resected specimen showed a well-differentiated adenocarcinoma of the gallbladder with invasion to the muscle layer and no metastasis of the resected lymph nodes. A high index of nuclear staining for MIB-I in the cancer cells (about 10%) was exhibited, and a few cells in the normal epithelium also stained positive.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases

It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases. One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study. According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001). OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

Early Gallbladder Carcinoma Associated with Pancreatobiliary Reflux

Background: It is well known that pancreatobiliary reflux is considered an important factor for the carcinogenesis of the biliary system in patients with pancreaticobiliary maljunction. Recently, our studies have indicated that pancreatobiliary reflux can occur not only in patients with pancreaticobiliary maljunction but also in those with a normal pancreaticobiliary junction, and could be associated with the occurrence of gallbladder carcinoma. The aim of the present study was to examine the incidence of gallbladder carcinoma associated with pancreatobiliary reflux.

Gallbladder Carcinoma Associated with Occult Pancreatobiliary Reflux

Purpose: Pancreatobiliary reflux can occur even if the patient has a normal pancreaticobiliary junction (occult pancreatobiliary reflux) and it can be associated with the occurrence of gallbladder carcinoma. The aim of the present study was to examine the mucosal changes of the gallbladder in patients with occult pancreatobiliary reflux. Methods: The gallbladder mucosa of 15 cholecystectomized patients, who had a normal pancreaticobiliary junction and whose biliary amylase concentration was more than 10,000 IU/L, was examined histologically. The gallbladder of patients without carcinoma was further examined using immunohistochemical techniques to detect Ki-67, and the results were compared with those of normal controls. Results: Six (40%) of the 15 patients had gallbladder carcinoma, and 9 (60%) did not. Of the 9 patients without carcinoma, 4 (44%) had dysplasia accompanied with hyperplasia, and 3 (33%) had only hyperplasia of the gallbladder. The Ki-67 labeling index was significantly higher in hyperplastic and dysplastic mucosa than in control gallbladder mucosa (p < 0.0004). Conclusions: Occult pancreatobiliary reflux could be associated with the cancerous and pre-cancerous mucosal changes such as hyperplasia and dysplasia of the gallbladder with increased cellular proliferation, and could be a possible risk factor for gallbladder carcinoma.

Severe dysplasia of the gallbladder associated with occult pancreatobiliary reflux

Pancreatobiliary reflux usually occurs in patients with pancreaticobiliary maljunction and can be associated with the occurrence of gallbladder carcinoma. We present the case of a patient with pancreatobiliary reflux despite having a normal pancreatobiliary junction (occult pancreatobiliary reflux; OPBR), in whom the resected gallbladder presented severe dysplasia. The patient, a 61-year-old woman, showed thickness of the gallbladder wall, detected by ultrasonography and computed temography (CT). Her biliary amylase level in the common bile duct was 103,000 IU/l, and in the gallbladder it was 153,500 IU/l, although endoscopic retrograde cholangiopancreatography revealed a normal pancreaticobiliary junction. Immunohistochemical staining showed many p53-positive nuclei in the dysplastic lesion, and about 50% of the dysplastic cells exhibited diffuse nuclear staining for Ki-67. In the present patient, early diagnosis of occult pancreatobiliary reflux led to early detection of a precancerous lesion of the gallbladder mucosa.

Histologic and Genetic Analysis of the Gallbladder in Patients with Occult Pancreatobiliary Reflux

Purpose: Recent studies have suggested that pancreatobiliary reflux occurs not only in patients with pancreaticobiliary maljunction (PBM), but also in patients without PBM and thereby possibly causes biliary tract disease. In this study, we examined prospectively histological findings and genetic analysis in the noncancerous epithelium of the gallbladder in patients with high biliary amylase levels and a normal pancreaticobiliary junction. Subjects and Methods: Twenty-one patients including nine high biliary amylase levels (HBA) patients with gallbladder diseases for which cholecystectomy was performed, prospectively underwent ERCP to assess confluence of pancreaticobiliary ducts in comparison with biliary amylase levels in the gallbladder in our hospital from October 2002 to November 2003.

Histologic and genetic analysis of the gallbladder in patients with occult pancreatobiliary reflux

Recent studies have suggested that pancreatobiliary reflux occurs not only in patients with pancreaticobiliary maljunction (PBM), but also in patients without PBM and thereby possibly causes biliary tract disease. In this study, we examined prospectively histological findings and genetic analysis in the non-cancerous epithelium of the gallbladder in patients with high biliary amylase levels and a normal pancreaticobiliary junction. Ki-67 L.I of non-cancerous epithelium was 14.4 and 3.5% in the high biliary amylase levels (HBA) group and the low biliary amylase levels (LBA) group, respectively (p<0.01). There was no case showing p53 overexpression regardless of amylase levels of bile. COX-2 expression was detected in the cytoplasm of non-cancerous epithelium in 9 cases in the HBA group and 5 cases in the LBA group. The positive rate of COX-2 overexpression was significantly higher in the HBA group than in the LBA group (p<0.05). COX-2 overexpression cases showed higher Ki-67 L.I than COX-2 non-overexpression cases (21.2 vs. 7.9%, p<0.05). Mutations of the K-ras gene were detected in non-cancerous gallbladder epithelium in 3 cases, only in the HBA group. Patterns of K-ras mutation at codon 12 were GAT in two cases and GTT in one case. Three cases showing COX-2 overexpression also showed K-ras mutation. These three cases showing K-ras mutation had comparatively high cellular proliferative activity (28, 26 and 14%). In conclusion, our data suggest that occult pancreaticobiliary reflux, especially with high biliary amylase levels, represents an important risk factor for the development of gallbladder carcinoma as well as PBM, and it may be possible to detect patients with such high biliary amylase levels by ERCP.

Assessment of Occult Pancreatobiliary Reflux by Biliary Amylase Levels in Patients with Pancreaticobiliary Disease

Assessment of Occult Pancreatobiliary Reflux by Biliary Amylase Levels in Patients with Pancreaticobiliary Disease Takao Itoi, Kazuto Nakamura, Atsushi Sofuni, Fumihide Itokawa, Kazuhiro Kakimi, Jun Sanada, Fuminori Moriyasu Objectives: Pancreatobiliary maljunction (PBM) is a high risk factor for biliary tract cancer. Carcinogenesis by PBMhas yet to be completely clarified; however, it has been suggested that the mixing of pancreatic juice and bile could activate pancreatic enzymes. Recently, however, several investigators reported existence of pancreatobiliary reflux in patients with a normal pancreaticobiliary junction. The aim of this study was to prospectively examine pancreatobiliary reflux in patients with a normal pancreaticobiliary junction by measuring the amylase level in bile obtained during ERCP. Methods: Eligible patients included 86 consecutive cases of pancreaticobiliary disease with prospective implementation of bile collection during an ERCP procedure. Patients with PBM were excluded. Nineteen cases of eligible patients had simultaneous collection of gallbladder bile. Bile was further collected by cholecystectomy in eight cases. Results: Twenty-two cases (26%) revealed a common bile duct higher than serum amylase (high bile amylase level HBA group) and sixty-six cases exhibited a common bile duct amylase level lower than serum (LBA group). The mean values of common bile duct amylase level in the HBA and LBA groups were 5,502 IU/L and 29 IU/L, respectively. The rate of HBA was significantly higher in patients who were elderly, had a dilated common bile duct, and with choledocholithiasis (p<0.05). Three cases (16%) showed a common bile duct amylase level greater than twice the gallbladder amylase level. Eleven cases (58%) exhibited a gallbladder amylase level higher than the common bile duct amylase level. The values of gallbladder amylase level obtained during ERCP and cholecystectomy were consistent. Conclusions: In conclusion, the data in our study suggested that non-PBMpatients with pancreaticobiliary disease that shows a normal pancreaticobiliary junction might have occult pancreatobiliary reflux under physiological conditions, thereby possibly leading to biliary diseases. *T1442 Importance of Real Time Interpretation (INTERP) of ERCP Films Over Conventional Static Images: Medicolegal Implications Miriam Thomas, Joseph E. Geenen, Marc F. Catalano ERCP is a complex procedure requiring technical skill, careful attention to endoscopic and radiographic (INTERP) that frequently requires evaluation of both real time & hard film copies. Although ERCP X-Rays are reviewed & formally reported by radiologist (RAD), gastroenterologist (GE) perform the studies & interpret fluoroscopic images. Differences in INTERP could lead to medicolegal liability. METHOD: ERCP records of 154 consecutive pts were prospectively evaluated.GE INTERP of ERCP films using real time&hard copies were documented & compared with available text documentation by RAD. Components of each exam were assessed for differences in final INTERP between GE andRAD. Biliary &pancreatic cases were reviewed for documentation of duct diameter, duct INTERP, strictures, stones, cytology, dilatation & stone removal. RESULT: Bile duct (BD) INTERP byGE&RADwere ABN&NL in 64%, 36% compared to 56%, 44% respectively. PD INTERP by GE was documented to be ABN in 63%, NL in 38% compared to 53% & 46% respectively by RAD. There was significant disagreement between GE & RAD regarding ductal INTERP (P<0.05). For the presence of BD stones, PD stones, BD stricture, PD stricture there was an agreement of 52%, 73%, 79% & 84% respectively. In therapeutic cases agreement between RAD & GE of BD cytology, duct dilation, stone removal, PD cytology, PDdilatation, PD stone removal was present in 73%, 50%, 32%, 53%, 44%, & 42% respectively. When compared to GE documentation RAD failed to document the CBD & PD diameter, 27% of BD cytology cases, 50% of biliary dilatation, 68% of BD stone removal, 47% of PD cytology, 55% of PD dilatation & 58%of PD stone removal. Under INTERP of findings frequently occurred in RAD dictated report when compared to GE. CONCLUSION: Many important aspects of the ERCP findings are under documented when interpreting findings using hard copies only. This could be due to lack of adequate film documentation of the procedure. The extent of documentation carries clinical & medicolegal importance. Careful reviews of both real time images & hard film copies are essential to ensure accurate final INTERP.

Occult pancreatobiliary reflux in patients with a normal pancreaticobiliary junction

Background: The aim of this study was to investigate pancreatobiliary reflux in individuals with a normal pancreaticobiliary junction. Methods: Seventy-four patients with a normal pancreaticobiliary junction, as determined by ERCP, underwent secretin injection MRCP before cholecystectomy. Based on changes in the diameter of the biliary system after secretin injection, patients were categorized into enhanced or nonenhanced groups. Results: Biliary amylase was measured in the 4 patients allocated to the enhanced group and 60 in the nonenhanced group. The mean (SD) biliary amylase level in the gallbladder was 123,723 (115,125) IU/L in the enhanced group and 238 (507) IU/L in the nonenhanced group (p < 0.0001). The mean (SD) biliary amylase level in gallbladders with carcinoma (n = 7) was 68,281 (106,500) IU/L, which was significantly higher than that in gallbladders without carcinoma (p < 0.01). Conclusion: Pancreatobiliary reflux similar to that seen in patients with pancreaticobiliary maljunction can occur in individuals with a normal pancreaticobiliary junction and may be associated with carcinoma of the gallbladder. Secretin injection MRCP is useful for identifying these individuals. (Gastrointest Endosc 2003;57:364-8.)

A case of gallbladder carcinoma accompanied with occult pancreatobiliay reflux in normal pancreaticobiliary junction

A case of gallbladder carcinoma accompanied with occult pancreatobiliay reflux in normal pancreaticobiliary junction

Diagnosis of anomalous pancreaticobiliary junction: Value of magnetic resonance cholangiopancreatography

Background: Anomalous pancreaticobiliary junction (a long common channel), with or without congenital choledochal cyst, is frequently associated with biliary tract carcinoma. We assessed the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) for patients with anomalous pancreaticobiliary junction (PBJ). Methods: In 159 adult patients with pancreatobiliary disease, breath-hold (1 to 18 seconds) MRCP was performed according to a half-Fourier acquisition single-shot turbo spin-echo sequence. In all patients the length of the common channel demonstrated by MRCP was compared with that demonstrated by endoscopic retrograde cholangiopancreatography. In 11 patients with anomalous PBJ (the common channel ≥ 15 mm on endoscopic retrograde cholangiopancreatography), the diagnostic accuracy of MRCP for associated biliary diseases was evaluated. Results: No complications were encountered in performing MRCP. On MRCP, the length of the common channel was calculated to be 15 mm or longer in nine (82%) of 11 patients with anomalous PBJ. In patients with normal PBJ, MRCP identified PBJ with the channel measuring 0 mm in length. MRCP allowed detailed visualization of congenital choledochal cyst (all seven patients) but failed to depict carcinoma (one patient) and mucosal hyperplasia (five patients) of the gallbladder. Conclusions: MRCP is a noninvasive and accurate imaging method for diagnosing anomalous PBJ and congenital choledochal cyst. (Surgery 1998;123:391-7.)