Diagnostic role of magnetic resonance cholangiopancreatography in evaluation of obstructive biliopathies and correlating it with final diagnosis and clinical profile of patients

Precision Mapping of Intrahepatic Biliary Anatomy and Its Anatomical Variants Having a Normal Liver Using 2D and 3D MRCP

Despite significant advances in hepatobiliary surgery, biliary injury and leakage remain typical postoperative complications. Thus, a precise depiction of the intrahepatic biliary anatomy and anatomical variant is crucial in preoperative evaluation. This study aimed to evaluate the precision of 2D and 3D magnetic resonance cholangiopancreatography (MRCP) in exact mapping of intrahepatic biliary anatomy and its variants anatomically in subjects with normal liver using intraoperative cholangiography (IOC) as a reference standard. Thirty-five subjects with normal liver activity were imaged via IOC and 3D MRCP. The findings were compared and statistically analyzed. Type I was observed in 23 subjects using IOC and 22 using MRCP. Type II was evident in 4 subjects via IOC and 6 via MRCP. Type III was observed equally by both modalities (4 subjects). Both modalities observed type IV in 3 subjects. The unclassified type was observed in a single subject via IOC and was missed in 3D MRCP. Accurate detection by MRCP of intrahepatic biliary anatomy and its anatomical variants was made in 33 subjects out of 35, with an accuracy of 94.3% and a sensitivity of 100%. In the remaining two subjects, MRCP results provided a false-positive pattern of trifurcation. MRCP competently maps the standard biliary anatomy.

Our experiences in 1000 case single-centre endoscopic retrograde cholangiopancreatography

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has a very important role in both diagnosis and treatment of pancreaticobiliary pathologies. The aim of this study was to review the indications, technical success complications and results of ERCP procedures performed in our centre.

Materials and Methods

In the study, the data of 1000 patients who were diagnosed with extrahepatic cholestasis, obstructive cholangitis/pancreatitis or bile leakage in clinical, medical and radiological data and who underwent ERCP between May 2019 and November 2021 were evaluated retrospectively.

Results

The age distribution was between 14 and 109 years, and the average age was 57.97 years for women (14-109) and 57.48 for men (19-95). Gender distribution was as follows: 552 (55.2%) women and 448 (44.8%) men. ERCP indications in this study were as follows: choledocholithiasis, malignant bile duct obstruction, odysphincter dysfunction (ODS), post-operative bile leakage, hepatic hydatid cyst rupture into the biliary tract and bile duct stenosis. Eight hundred and seventy-one (87.1%) patients had common bile duct stones, 30 (3%) pancreatic head tumour, 22 (2.2%) common bile duct tumour and 20 (2%) cholestasis due to papilla tumour and/or obstructive icterus. Twenty-two (2.2%) patients were treated for sphincter dysfunction (ODS) of Oddi. ERCP was performed in 12 (1.2%) patients with the diagnosis of bile leakage after liver hydatid surgery, 10 (1%) after gall bladder surgery and 8 (0.8%) with the diagnosis of biliary tract stenosis after gall bladder surgery. ERCP was performed in 5 (0.5%) patients due to biliary tract obstruction as a result of rupture of hydatid liver cyst into the biliary tract. Successful cannulation was achieved in 1000 patients listed. Ninety-seven patients who were included in the ERCP procedure but could not be cannulated were not included in the study. Endoscopic sphincterotomy was performed on all patients in the ERCP procedure. In patients with choledochal stones, stone extraction from the common bile duct and/or plastic stent placement in the common bile duct was added. Plastic stent was placed in the common bile duct in patients with pancreatic head tumour, common bile duct tumour, bile duct leakage and common choledochal stenosis. Endoscopic biopsy was taken from all patients with suspected papillary tumour. The processing time varied between 15 and 90 min. The overall complication rate was 17.4%. After ERCP, 93 patients developed amylasaemia that did not require treatment, while 50 patients were diagnosed with clinical and laboratory acute pancreatitis. Intraoperative bleeding, which did not require blood transfusion and could be controlled with adrenaline injection and/or balloon pressure, developed in 10 patients. In one patient, basket and stone were stuck in the papilla during stone extraction. There was no operative mortality.

Conclusion

ERCP is a complex procedure that uses special equipment and must be performed by experienced specialists. To increase the reliability of the ERCP procedure, it is necessary to determine the risk factors for ERCP complications very well. Unnecessary ERCP should be avoided. ERCP should not be performed, especially in patients with low probability of stone or stricture, patients with normal bilirubin and patients who do not show other signs of biliary disease. The use of non-invasive imaging methods as much as possible instead of diagnostic ERCP will reduce the complications associated with ERCP.

The efficacy of pineapple juice as a negative oral contrast agent in magnetic resonance cholangiopancreatography

Background

During magnetic resonance cholangiopancreatography (MRCP), the pancreatobiliary ducts can be obscured by the high-intensity signal from the stomach and duodenum. Pineapple juice may be an alternative to commercially available negative contrast agents, but has not been evaluated locally.

Objectives

To evaluate the efficacy of a local, off-the-shelf pineapple juice preparation as a negative oral contrast agent for MRCP.

Method

An observational, analytical study was conducted during January–December 2017. A 1.5 Tesla MRCP sequence was performed immediately before and after ingestion of 250 mL of a local, commercially-available pineapple juice preparation. Image evaluation was performed by two radiologists with independent, blind assessment of gastric/duodenal signal intensity and biliary /pancreatic duct visibility, before and after pineapple juice.

Results

Fifty adult patients (F = 44, 88%) with median age 44 years (IQR: 34.75, 57) were included. After pineapple juice administration, there was significant measured (1661.51 vs. 1409.94, p < 0.01) and perceived (2.16 vs. 2.72, p < 0.01) duodenal signal reduction but no significant change in measured (1081.17 vs. 1044.38, p = 0.34) or perceived (2.73 vs. 2.84, p = 0.14) gastric signal intensity. Visibility of the common bile duct was significantly improved (3.67 vs. 3.86, p < 0.01), whilst that of the main pancreatic duct showed no significant change (2.92 vs. 2.86, p = 0.44).

Conclusion

The local pineapple juice preparation used in this study is an effective, affordable and natural negative oral contrast agent for enhancement of MRCP images, and specifically improves visualisation of the common bile duct.

Performance survey on a new standardized formula for oral signal suppression in MRCP

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Recently, a new biological standardized product for MRCP became available.

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The product is considered effective as oral signal suppressor in T2-w images.

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Obtained MRCP imagery show a good image quality.

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Patients’ feedback on taste and palatability is very high.

Background

Orally administered substances, which reduce image contamination by overlying gastrointestinal fluid signals, can be used to enhance the quality of MRCP images. Recently, a new standardized formula consisting of biological substances has become available. The objective of this study is to provide a first assessment of achievable MRCP image quality, taste and palatability of this new dedicated agent.

Methods

In January 2015 to May 2015 practicing radiologists in Germany, Austria and Switzerland were asked to evaluate image quality as well as taste and palatability when using the new agent (LumiVision^®; b.e. imaging; Baden-Baden; Germany) in MRCP questionnaire. Both criteria were rated with a 6-point Likert scale ranging from “1” (best) to “6” (worst).

Results

A total 185 of 475 radiologic institutions (39%) submitted feedback on image quality, 187 (39%) on the taste/palatability. Assessments of image quality regarding presence of disturbing gastrointestinal fluid signal resulted in a median of 2. The majority of patients rated the subjective taste as very good (median of 1). No side effects of relevance were recorded.

Conclusion

This large survey shows that the tested product is considered effective by radiologists regarding MRCP image quality. Patients’ feedback on taste and palatability was very positive.

Efficacy of oral contrast agents for upper gastrointestinal signal suppression in MRCP: A systematic review of the literature

Background

Orally administered substances which suppress signals from gastrointestinal fluid can be used to enhance image quality in magnetic resonance cholangiopancreatography (MRCP). In daily practice, the available substances range from commercial products to regular viands such as fruit juices.

Purpose

To provide an overview on the significance of and the substances used as gastrointestinal fluid signal suppressors in MRCP.

Material and Methods

A systematic review of the existing literature was performed to evaluate the efficacy and efficiency of oral T2-signal suppressors in MRCP.

Results

Twenty-five publications on 16 different oral contrast media were identified. The most commonly used substances were ferumoxsil, ferric ammonium citrate, and pineapple juice. Twenty-three out of 25 publications supported the use of oral signal suppressors in MRCP. Advantages of oral signal suppressors include improved visualization of the pancreatobiliary ductal system, increased help with differential diagnoses, and higher detection rates of relevant diagnoses due to a reduction of overlaying signals.

Conclusion

The application of oral substances for gastrointestinal signal suppression in MRCP is recommendable. A variety of substances are used in daily routine with good but varying effectivity and patient tolerance.