Pancreaticobiliary Duct Research Articles

Diagnostic endoscopic retrograde cholangiopancreatography.

The importance of diagnostic endoscopic retrograde cholangiography (ERCP) has dramatically decreased owing to the development of less invasive techniques such as ultrasonography, computed tomography, endoscopic ultrasonography, and finally magnetic resonance cholangiopancreatography (MRCP). MRCP is becoming the gold standard in the diagnostic work-up of the pancreaticobiliary duct. However, MRCP cannot solve all the problems that occur, and still has inadequate resolution for small stones and tiny pancreatic and bile duct lesions. ERCP continues to be useful in difficult cases and when the diagnosis is uncertain, particularly when fluid collection and tissue sampling are necessary. However, several alternatives to sphincter of Oddi manometry have been proposed. Finally, ERCP is always the first step before endoscopic treatment, which in contrast to diagnostic ERCP is still widely used.

Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy.

The objective of this article is to review the available literature on the epidemiology, predisposing factors, and conditions associated with primary gallbladder cancer, and to discuss the role of prophylactic cholecystectomy in high-risk patient populations. Gallbladder cancer is a highly malignant tumor with a poor 5-yr-survival rate. It is a tumor of the elderly and has striking genetic, racial, and geographic characteristics, with an extremely high prevalence in Native Americans and Chileans. Cholelithiasis is a well-established risk factor for gallbladder cancer and the risk seems to correlate with stone size. Polyps that are >1 cm, single, sessile, and echopenic are associated with a higher risk of malignancy. Anomalous junction of pancreaticobiliary ducts (AJPBD), especially without choledochal cyst, and porcelain gallbladder are additional factors that predispose to gallbladder cancer. Lesser associations include chronic bacterial infections of the gallbladder, typhoid carrier state, certain occupational and environmental carcinogens, hormonal changes in women, and certain social, dietary, and familial factors. It is important to identify high-risk groups for gallbladder cancer because of the dismal nature of this tumor. In patients with porcelain gallbladder and anomalous junction of the pancreatic and biliary ducts, cholecystectomy is recommended provided that the patient is a good operative candidate. Patients with large solitary polyps or gallstones require close ultrasonic follow-up. With the advent of endoscopic ultrasound it is expected that early changes of malignancy in polyps will be reliably detected, and more patients will potentially be cured with a simple cholecystectomy. Through a MEDLINE/PAPERCHASE search we identified and reviewed articles regarding gallbladder cancer published in English-language journals between 1966 and 1999, using the key words biliary tract and gallbladder diseases, cancer, neoplasms, surgery, cholelithiasis, gallstones, cholecystitis, gallbladder polyps, risk factors, chemical industry, occupational diseases, typhoid, porcelain gallbladder, bacteremia, and precancerous conditions. We also used the bibliography of relevant articles to increase our search. A total of 122 publications were selected using the mentioned data source.

Choledochal Cyst: Comparison of MR and Conventional Cholangiography

AIMS: To assess the diagnostic value of magnetic resonance (MR) cholangiography versus conventional cholangiography in patients with choledochal cyst and to determine whether MR cholangiography can be considered an alternative to conventional cholangiography.MATERIALS AND METHODS: Thirteen patients with choledochal cyst were examined by MR cholangiography and conventional cholangiograms. Magnetic resonance cholangiography employed T2-weighted axial and coronal fast spin-echo, single and multislab single-shot fast spin-echo sequences, including source images with maximum intensity projections. The diagnostic value of MR cholangiography and conventional cholangiograms was assessed and compared using the criteria of depiction of morphology, anomalous pancreaticobiliary duct union and demonstration of complications such as stones. A four-point diagnostic scale was applied to the delineation of the ductal anatomy with the Wilcoxon signed-ranks test and McNemar's test used for statistical analysis.RESULTS: The depiction of the choledochal cyst was significantly better with MR cholangiography than with conventional cholangiography (P=0.03). The detection rate of an anomalous pancreaticobiliary duct union was not significantly different with either method (P=0.641), nor was the detection rate of bile duct stones (P=0.375).CONCLUSION: Magnetic resonance cholangiography provides data equivalent to or superior to those from conventional cholangiography in evaluating choledochal cyst. Magnetic resonance cholangiography is recommended as a non-invasive examination of choice for the evaluation of choledochal cyst.Kim, S. H. (2000). Clinical Radiology55, 378–383.

7000 Is komi's new classification necessary to reclarify the relationship between the anomalous pancreaticobiliary duct unions (apbu) and their associated cancer in korea?

The frequency and type of APBU in APBU associated diseases varies in different studies, and it remains unclear whether such variations might result from different methods used for detection. This is a multicenter study to reclarity the frequency of APBU and its severeal subtypes in various pancreato biliary diseases using a Komi's new classification in Korea. Cholangiopancreatogram of 77 APBU were carefully examined and analyzed for clear visualization of APBU system to divide into a Komi's new classification. Mean length of common channel was 24.3±7.2 mm (14.0- 37.0 mm). Type I of APBU was seen in 37 (48.1%), type II in 35(45.5%), and type III in 5(6.5%) cases, respectively. Associated diseases were 46 (59.7%) case of choledochal cyst (including each 2 case of bile duct CA and gallbladder CA, respectively), 5 cases (6.5%) of gallbladder CA, 9 cases (11.7%) of bile duct CA, 3 cases (3.8%) of pancreatic CA, and 11 cases (14.3%) of pancreatitis. Choledochal cyst was most frequently observed in 78.4% (29/37) type I APBU, (p

Radiologiclal images, histological findings, and biological factors in the gallbladder mucosa with an anomalous junction of the pancreaticobiliary duct

Radiologiclal images, histological findings, and biological factors in the gallbladder mucosa with an anomalous junction of the pancreaticobiliary duct

Bilan préthérapeutique d'une dilatation congénitale de la voie biliaire principale par cholangio-pancréatographie-IRM

The choledochal cyst is a rare congenital disorder usually diagnosed in childhood. It requires a complete surgical resection to prevent complications, particularly the risk of malignant changes. At present, the preoperative examination requires a direct opacification of the biliary tree, but this is an invasive technique with a high risk of infection, especially in pediatric patients. A choledochal cyst was diagnosed in a five-year-old girl with recurrent abdominal pain. Diagnosis was made by ultrasound and preoperative evaluation by magnetic resonance-cholangiopancreatography using single-shot fast-spin echo sequences. A complete correlation was observed between surgical, preoperative cholangiography and MRCP data. Recent improvement in MRCP techniques provide a complete anatomic analysis of choledochal cysts, enabling one to diagnose an anomalous junction of the pancreaticobiliary duct, even the presence of stones within the biliary tree. This short and noninvasive examination should in the future replace direct opacification of the biliary tree for the preoperative assessment of choledochal cysts.

Endoscopic therapy in anomalous pancreatobiliary duct junction

Anomalous pancreaticobiliary duct junction is associated with bile duct strictures, pancreatitis, choledochal cysts, and biliary carcinoma. Limited data are available for outcomes of endoscopic therapy. Review of 7537 patients undergoing endoscopic retrograde cholangiopancreatography from 1988 to 1997 yielded 18 patients with anomalous pancreaticobiliary duct junction. Therapeutic responses were tallied by chart review and phone calls. There were 13 women and 5 men, with a mean age of 36 years. Twelve patients had no ductographic evidence of pancreatitis and 6 had chronic pancreatitis. Seven had choledochal cysts. Fifteen patients (83%) underwent endoscopic biliary sphincterotomy, two of whom underwent repeat endoscopic biliary sphincterotomy for recurrence of symptoms. The other therapies included stent placement for benign biliary strictures in 5 patients, lithotripsy of pancreatic stones in 1 patient, and choledochal cyst removal in 4 patients. Three cases with malignant biliary strictures are excluded from endoscopic outcome studies. The 12 patients with pancreatitis had a mean of 2.0 episodes per year before any treatment. After endoscopic therapy 7 patients had no further episodes of pancreatitis, whereas 5 patients had further episodes, with a mean of one additional attack per year, over 3 years mean follow-up. Patients with anomalous pancreaticobiliary duct junction have complex pathology associated with strictures, choledochal cysts, pancreatitis, and malignancies. Endoscopic therapy appeared to benefit 13 of 15 patients without malignant disease with elimination of or decreased frequency of pancreatitis. Endoscopic therapy appears to be a logical first step in the management of most symptomatic patients with anomalous pancreaticobiliary duct junction.

Cellular kinetics and gene mutations in gallbladder mucosa with an anomalous junction of pancreaticobiliary duct.

Anomalous junction of the pancreaticobiliary duct (AJPBD) is thought to be an important risk factor for gallbladder carcinoma in Japan. We have reported the characteristic pathology, cellular kinetics, and gene mutations to clarify the mechanism of carcinogenesis in gallbladder mucosa with AJPBD. A comprehensive review of the literature was undertaken, with referencing of major articles on the subject. A sequence of hyperplastic changes, with a corresponding increase in cellular kinetics with progression through dysplasia to carcinoma is important in carcinogenesis of gallbladder mucosa with AJPBD. p53 mutations may contribute to the transition from premalignancy to malignancy in the early stage of carcinogenesis of the gallbladder mucosa, regardless of the presence of AJPBD. The specific mutation of GGT-to-GAT in codon 12 of K-ras may play an important role in carcinogenesis of gallbladder mucosa with AJPBD.

Mucosal cell proliferation activity of the gallbladder in children with anomalous arrangement of the pancreaticobiliary duct.

Anomalous arrangement of the pancreaticobiliary duct (AAPBD) is an anatomical maljunction of the bile duct and the pancreatic duct that is frequently associated with gallbladder carcinoma. In patients with AAPBD, it has been postulated that pancreatic juice regurgitates into the biliary tree, and the mixture of refluxed pancreatic juice and stagnant bile juice acts as an irritant factor to the biliary tract epithelium, leading to chronic inflammation and metaplasia. Eventually these mucosal changes may progress to invasive carcinoma. We reviewed clinicopathologic studies on epithelial changes of the gallbladder in patients with AAPBD to clarify the implications relevant to carcinogenesis. Conventional histological studies have shown that the most characteristic change observed in the gallbladder of children with this anomaly was epithelial hyperplasia. Furthermore, the incidence of mucosal hyperplasia was significantly increased in the gallbladder of children in whom the pancreatic duct joined the common bile duct (P-C type) compared with the incidence in children in whom the common bile duct joined the pancreatic duct (C-P type). In addition, cell kinetic studies have demonstrated increased cellular proliferative activity of the gallbladder in children with AAPBD. Cell proliferative activity was significantly elevated in children with the P-C type of AAPBD compared with that in children with the C-P type of anomaly. In conclusion, AAPBD may yield increased cell proliferation in the gallbladder of patients with this anomaly in early childhood, resulting in epithelial hyperplasia. Although it remains unknown which agents are responsible for promoting the activation of cellular function, it seems that bile acids and refluxed pancreatic proteases are likely play a role in such promotion. Further investigations are needed to elucidate the mechanism of increased cellular function.

Choledochal cyst associated the with anomalous union of pancreaticobiliary duct (AUPBD) has a more grave clinical course than choledochal cyst alone.

ObjectiveSince choledochal cyst is frequently associated with the anomalous union of pancreaticobiliary duct (AUPBD), AUPBD has been regarded to be the etiologic factor of choledochal cyst. However, the clinical significance of AUPBD an patients with choledochal cyst has not been clearly defined. Therefore, to clarify the significance of AUPBD in choledochal cyst patients, we compared the clinical features of patients with choledochal cyst according to the presence or absence of AUPBD.MethodsAmong 52 cases which were diagnosed as choledochal cyst out of 5,037 ERCP referrals between August 1990 and December 1996, we selected 44 cases, in which the pancreaticobiliary junction was clearly visualized on cholangio-pancreaticography. These cases were divided into AUPBD-present group (n=28) and AUPBD-absent group (n=16). Clinical features were compared between the two groups. Furthermore, in AUPBD-present group, clinical data were also analyzed according to Kimura’s classification of AUPBD.ResultsIn our study, AUPBD was associated with choledochal cyst in 28 (64%) cases. AUPBD was found only in type I and IV according to Todani’s classification of choledochal cyst. There were no significant differences between the AUPBD-present group and the AUPBD-absent group in the incidence of gallstone disease, while the incidence of acute inflammation was 93% (26/28) in the AUPBD-absent group (p<0.01. Carcinoma developed only in the AUOBD-present group (9/28, 32%) (p<0.05). Pancreatic disorders (i.e. pancreatic stone, pancreatitis or pancreatic cancer) occurred in 12 of 28 cases in the AUPBD-present group (43%), while only in 1 of 16 cases in the AUPBD-absent group (6%) (p<0.05).ConclusionAUPBD associated with choledochal cyst may have implications not only as a possible etiologic factor but also as an important factor that may affect the clinical course, surgical planning and prognosis. In cases with choledochal cyst, we should make an effort to evaluate the presence of AUPBD.

Carcinoma of the gallbladder associated with anomalous junction of the pancreaticobiliary duct in adults

Background: Anomalous junction of the pancreaticobiliary duct (AJPBD) is a congenital anomaly in which the junction is located outside the sphincter of Oddi. A high incidence of gallbladder carcinoma (GBC) has been reported in adult patients with AJPBD. Study Design: Fourteen adult patients with AJPBD and 50 with GBC not associated with AJPBD were reviewed retrospectively to identify the clinical characteristics of AJPBD accompanied by GBC and to clarify the differences in clinicopathologic features between GBC associated with AJPBD and GBC without AJPBD. Results: Among the 14 patients with AJPBD, there were five fusiform, four cystic, and two cylindric dilatations of the biliary tract and three nondilated bile ducts. Nine (64%) of 14 patients had GBC, five with fusiform dilatations, two with cylindric dilatations, and two with nondilated bile ducts. No patient with cystic dilatation had GBC. There were two stage I cancers, four stage II, two stage III, and one stage IVB. One patient with stage IVB GBC died of recurrence 8 months after operation. The remaining 8 patients were well without signs of recurrence from 8 to 72 months after operation. The frequency of grossly polypoid or histologically papillary adenocarcinoma was higher in GBC patients with AJPBD than in those without AJPBD (p < 0.01). The proportion of disease-free survivors was greater among GBC patients with AJPBD than among those without AJPBD (p < 0.05). Conclusions: AJPBD with noncystic dilatation or without dilatation appears to be an important risk factor for GBC. In this limited series, patients with GBC accompanied by AJPBD have had relatively favorable outcomes.

Gene mutations of K-ras in gallbladder mucosae and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct.

In this study, we examined the mutational spectrum of K-ras in cases of gallbladder and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct (AJPBD). We examined 35 gallbladders with AJPBD (20 with hyperplasia, 15 with carcinoma) and 38 gallbladders without AJPBD (four normal gallbladders, four with hyperplasia, six with adenoma, 24 with carcinoma). Polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) and direct sequencing were performed to detect mutations in codon 12 or 13 of K-ras. In the cases with AJPBD, the prevalences of K-ras mutation were 15% (3/20) in hyperplasia, 60% (6/10) in stage I carcinoma, and 100% (5/5) in stage II-IV carcinoma. In the cases without AJPBD, the prevalences of K-ras mutation were 0% (0/4) in normal gallbladder, 0% (0/4) in hyperplasia, 17% (1/6) in adenoma, 7% (1/16) in stage I carcinoma, and 38% (3/8) in stage II-IV carcinoma. Prevalences of K-ras mutation in hyperplasia and carcinoma with AJPBD were greater than those without AJPBD (p < 0.05). The point mutation of GGT to GAT in codon 12 was frequently observed in the cases with AJPBD. These results suggest that the specific K-ras mutation in codon 12 (GGT to GAT) may contribute to the early stage of carcinogenesis in the gallbladder with AJPBD.

Gene mutations of K- ras in gallbladder mucosae and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct

OBJECTIVE: In this study, we examined the mutational spectrum of K- ras in cases of gallbladder and gallbladder carcinoma with an anomalous junction of the pancreaticobiliary duct (AJPBD). METHODS: We examined 35 gallbladders with AJPBD (20 with hyperplasia, 15 with carcinoma) and 38 gallbladders without AJPBD (four normal gallbladders, four with hyperplasia, six with adenoma, 24 with carcinoma). Polymerase chain reaction single-strand conformation polymorphism (PCR-SSCP) and direct sequencing were performed to detect mutations in codon 12 or 13 of K- ras. RESULTS: In the cases with AJPBD, the prevalences of K- ras mutation were 15% (3/20) in hyperplasia, 60% (6/10) in stage I carcinoma, and 100% (5/5) in stage II–IV carcinoma. In the cases without AJPBD, the prevalences of K- ras mutation were 0% (0/4) in normal gallbladder, 0% (0/4) in hyperplasia, 17% (1/6) in adenoma, 7% (1/16) in stage I carcinoma, and 38% (3/8) in stage II–IV carcinoma. Prevalences of K- ras mutation in hyperplasia and carcinoma with AJPBD were greater than those without AJPBD ( p < 0.05). The point mutation of GGT to GAT in codon 12 was frequently observed in the cases with AJPBD. CONCLUSION: These results suggest that the specific K- ras mutation in codon 12 (GGT to GAT) may contribute to the early stage of carcinogenesis in the gallbladder with AJPBD.

Cellular activity in the gallbladder of children with anomalous arrangement of the pancreaticobiliary duct

Background/Purpose: Anomalous arrangement of the pancreaticobiliary duct (AAPBD) is closely related to congenital biliary dilatation and frequently associated with biliary tract malignancy. To examine the mechanism of biliary tract carcinogenesis in patients with AAPBD, we investigated histologically the early changes in cell proliferative kinetics of the gallbladder mucosa of children with AAPBD. Methods: Twenty-three specimens of gallbladder were obtained from 23 children with AAPBD, and six control specimens were obtained from pediatric patients. All specimens were fixed routinely and paraffin embedded and examined histologically with H&E staining and immunohistochemically with monoclonal antibody Ki-67(MIB-1), which reacts with a human nuclear antigen associated with cell proliferation. Ki-67 labeling index (Ki-67 LI) was obtained by counting the numbers of Ki-67-positive cells per 1,000 gallbladder epithelial cells. Results: Significant differences in Ki-67 LI were noted between children with and without AAPBD. Furthermore, Ki-67 LI and the incidence of epithelial hyperplasia of gallbladder were significantly higher in children with AAPBD in whom the major pancreatic duct joined the common bile duct (P-C type) than in those in whom the common bile duct joined the major pancreatic duct (C-P type). Conclusions: Cellular proliferative activity was increased in children with AAPBD, especially those with the P-C-type anomaly. These results suggest that the early mucosal changes of the gallbladder occurred in early childhood of patients with AAPBD and might be associated with gallbladder cancer. Early diagnosis and early surgical division of the biliary tract and pancreatic duct is recommended for children with AAPBD.

Pancreaticobiliary ductal anatomy in Thai people.

The complex anatomy of the pancreaticobiliary duct was studied to demonstrate basic data in Thai people. Fresh specimens of the pancreas, common bile duct, and duodenum were obtained en bloc from the autopsies of 103 patients who had died of causes not related to trauma or disease of these organs. The length of the pancreas, the location of the pancreatic ducts in relation to the surface of the pancreas, the length and types of the common channels, as well as the anatomy of the ampulla, were studied, using methylene blue infusion via the pancreatic duct cannulation and careful dissection. Ninety-three male and 10 female patients were included. Their ages ranged from 15 to 76 years (mean 31.38 +/- 12.98 years). The length of the pancreas ranged from 10.9-19 cm (mean, 15.60 +/- 1.80 cm). The intrapancreatic portion of the common bile duct showed patterns of three types; most common (90/103; 87.38%) was type A, in which the anterior surface of the common bile duct was totally covered, while its posterior surface was partially covered, by the pancreatic parenchyma. On dissection of the accessory duct of Santorini in the pancreatic substance, the accessory duct was traceable to the duodenal wall in 59 specimens (57.26%). The anatomy of the Wirsung-choledochus confluence was grouped into five different types. The common channel (junction of the common bile duct and pancreatic duct) was found in 76.70% of specimens and its length varied from just a common junction (so-called "V-type" anatomy) to 15 mm (Y-type-b). Separate papillae (so-called "II-type") were found in 12. 62% of specimens. Separate openings in the same papilla (so-called "U-type") were found in 10.68% of specimens. The Wirsung duct at the pancreatic neck was most often located posterior and superior in relation to the surface of pancreas. This study demonstrated several important points regarding the anatomy of the pancreaticobiliary junction and pancreatic ductal system in a Thai population. Some of these data were different from those reported in the literature for other population groups.

Histological and genetic changes in malignant transformation of gallbladder adenoma

Elucidate the histological and genetic changes in malignant transformation of adenoma of the gallbladder. Forty-three adenomas and 20 intramucosal tumors of carcinoma-in-adenomas were studied for histological and genetic changes (particularly K-ras mutation and p53 protein overexpression by immunohistochemistry) in malignant transformation. The genetic changes were compared with those of 164 carcinomas without anomalous union and 17 carcinomas with anomalous union of pancreatico-biliary duct. Atypical cell foci, i.e. spindle cell foci, were observed only in the adenoma area, with a frequency of 23% in 39 adenomas, and of 45% in 20 tumors of carcinoma-in-adenoma. 129 of 130 spindle cell foci examined were negative for Ki-67 staining and all the spindle cell foci were negative for p53 stain. K-ras mutation and p53 overexpression were not found in all adenomas, pure and with carcinoma i.s., and only one carcinoma (1/16, 6%) with adenoma showed p53 overexpression. K-ras mutation was low (10%, 4/40) in carcinomas without adenoma, but high in carcinomas with anomalous union of pancreatico-biliary duct. While, p53 overexpression was high and similar in carcinomas with and without anomalous union. These results suggest that there are three distinct pathways in gallbladder carcinogenesis; that is, de novo carcinoma develops from a predominant p53 alteration with low K-ras mutation, de novo carcinoma with anomalous union from K-ras mutation and p53 mutation, and carcinoma-in-adenoma from K-ras-, p53-, and probably APC-gene-related, as yet unknown, alteration.

TWO CASES OF ANOMALOUS CONNECTION OF PANCREATICOBILIARY DUCTS WITHOUT CHOLEDOCHAL CYSTS IN THE BILE DUCTS

This paper presents two patients with anomalous connection of pancreaticobiliary ducts without choledo-chal cysts in the bile duct (ACPBD). The first patient, a 52-year-old woman, was admitted to the hospital because of upper abdominal pain and a thickening of the gallbladder wall on ultrasonograpaphy (US) Which was pointed out at another hospital. With close examination, she was diagnosed as having an ACPBD without biliary dilatation. Cholecystectomy, resection of the bile duct, and choledo-duodenostomy were performed. The resected material showed hyperplastic mucosa and cholesterolosis of the gallbladder. The second patient, a 39-year-old woman, was admitted to the hospital because of upper abdominal pain and the gallbladder wall thickening which was detected by US. With close examination, she was diagnosed as having an ACPBD without cystic dilatation of the bile duct and adenomyomatosis of the gallbladder. Cholecystectomy, resection of the bile duct, and choledo-duodenostomy were performed. The resected material showed hyperplastic mucosa and adenomyomatosis of the gallbladder. For early detection of ACPBD without cystic dilatation, abdominal US is recommended that indicates the thickening of the gallbladder by characteristic image. And EUS or endoscopic retrograde cholangiopancreatography (ERCP) should be conducted if US revealed the characteristic image.

A CASE OF PERFORATED CHOLEDOCHAL CYST

A case of perforated choledochal cyst is reported with a review of the literature. A healthy 2-year-old 11 month boy was admitted to the hospital because of acute onset of epigastralgia, vomiting and elevated plasma level of amylase with high-grade fever. Imaging studies revealed a cystic dilatation of the common bile duct, Auggesting a choledochal cyst with pancreatitis. The disease was well controlled conservatively 4 days following admission, when he abruptly developed a severe right upper quadrant abdominal pain. There were abdominal distension, rebound tenderness and muscular defense at the same region. Emargency laparotomy revealed darkly stained ascites and thickened wall of the choledochal cyst with two perforated holes on the anterior wall. Biliary peritonitis due to perforated choledochal cyst was suggested. Peritoneal drainage was performed and a T-tube was placed through the holes into the cyst. A postoperative T-tube cholangiogram confirmed the presence of an anomalous insertion of the pancreatic duct into the common duct. Three months after the initial surgery, the choledochal cyst was resected and the biliary tract was reconstructed by hepaticojejunostomy. An anomalous arrangement of the pancreaticobiliary duct seemed to facilitate reflux of pancreatic secretions into the biliary tree and contribute to cholangitis followed by spontaneous perforation of the choledochal cyst.

Value of MR cholangiopancreatography in evaluating choledochal cysts.

The aim of this retrospective study was to clarify whether MR cholangiopancreatography (MRCP) is a suitable replacement for ERCP in evaluation of the choledochal cyst. Sixteen patients (six adult and 10 pediatric) with choledochal cysts underwent MRCP using a half-Fourier acquisition single-shot turbo spin-echo sequence. Extent of the cyst, defects within the biliary tree, and presence or absence of the anomalous junction of the pancreaticobiliary duct were evaluated. Findings were compared with those of ERCP. MRCP better defined the proximal biliary tree than did ERCP in two patients. Defects within the biliary tree were diagnosed correctly on MRCP in eight patients; however, two defects within the distal common bile duct were missed in pediatric patients. The presence of the anomalous junction of the pancreaticobiliary duct was revealed accurately by MRCP in all adult patients but was revealed accurately in only four of the 10 pediatric patients. MRCP appears to offer diagnostic information that is equivalent to that of ERCP for assessment of choledochal cysts in adults. In pediatric patients, MRCP should not replace ERCP; however, MRCP can play an important role as a noninvasive examination and should be considered a first-choice imaging technique for evaluation of choledochal cysts.

Neoplastic pancreaticobiliary duct obstruction: evaluation with breath-hold MR cholangiopancreatography.

The purpose of this study was to investigate the use of breath-hold single-shot fast spin-echo MR cholangiopancreatography in neoplastic pancreaticobiliary duct obstruction. Breath-hold MR cholangiopancreatography was performed for preoperative examination of 32 consecutive patients with pathologically confirmed neoplastic obstruction of the biliary tract or pancreatic duct using a single-shot fast spin-echo sequence. Two observers, unaware of clinical or pathologic findings, independently reviewed the MR cholangiopancreatograms to assess level of obstruction and site of underlying tumor. Pathologic diagnoses, based on surgical or CT-guided biopsy specimens, were pancreatic tumor (n = 12), gallbladder cancer (n = 9), intrahepatic cancer (n = 9), and ampullary cancer (n = 2). On the basis of conventional cholangiography, CT, and surgical findings, 20 patients had isolated bile duct obstruction, 11 patients had combined pancreatic and bile duct obstruction, and one patient had isolated pancreatic duct obstruction. Isolated bile duct obstruction was classified as lobar (n = 5), hilar (n = 12), or distal (n = 3). These levels of obstruction were correctly identified in 27 (84%) and 28 (88%) of the 32 cases by the two observers. The site of the underlying tumor was identified in 27 (84%) and 29 (91%) cases by the two observers. Good interobserver agreement was reached for both level of obstruction (kappa = .70) and identification of tumor site (kappa = .75). Breath-hold single-shot fast spin-echo MR cholangiopancreatography is accurate in identifying the level of obstruction and the site of underlying tumor in neoplastic pancreaticobiliary duct obstruction, with good interobserver agreement.