Magnetic resonance cholangiopancreatography: The fine art of bilio-pancreatic imaging

With the introduction of endoscopic retrograde cholangiopancreatography in the early 1970s, gastroenterologists have a lot of diagnostic options in the biliopancreatic system to their disposal. Meanwhile, magnetic resonance cholangiopancreatography (MRCP) has become a competitive replacement for diagnostic ERCP with the advantage of avoiding complications related to endoscopic techniques. Mounting evidence suggests that both MRCP and MRI (magnetic resonance imaging) have a profound influence of diagnostic algorithms in a variety of hepatobiliary and pancreatic diseases.     

Magnetic resonance cholangiopancreatography: Objectives and future

Magnetic resonance cholangiopancreatography (MRCP) is a rapidly developing non-invasive imaging method that can depict the biliopancreatic ducts. Compared to direct methods such as endoscopic retrograde cholangiopancreatography (ERCP), MRCP is not painful, does not require contrast media, and its success does not depend, to any great extent, on the operator's skill. It uses three-dimensional data sets for projection images, as well as arbitrary cross-sectional iamges. Faster data acquisition techniques are expanding its indications as a diagnostic tool. MRCP is undoubtedly the method of choice when ERCP is contraindicated or fails. Imaging after the injection of secretin improves pancreatic duct delineation, and may also add functional information to MRCP. Adequate diagnostic evaluation of acute pancreatitis, pancreatic trauma, and mucinous ductal ectasia may also be feasible. Further development and optimization of MRCP will substantially limit the indications for diagnostic endoscopic pancreatography.     

ERCP and MRCP in the differentiation of pancreatic tumors

The introduction of endoscopic retrograde cholangiopancreatography (ERCP) in the early 1970s provided gastroenterologists with a number of diagnostic as well as therapeutic possibilities for examining biliopancreatic systems. In the meantime, magnetic resonance cholangiopancreatography presents a non-invasive alternative to diagnostic ECRP providing the advantage of a lower rate of possible complications. This article addresses the two methods presently available for differentiating pancreatic tumors. The objective of this article is to describe the advantages and disadvantages as well as the possibilities inherent in both methods.     

Diagnostic value of MRCP and indications for ERCP

BACKGROUND/AIMS: To assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) and examine the indications for endoscopic retrograde cholangiopancreatography (ERCP). METHODOLOGY: MRCP was performed in 185 patients with hepatobiliary disease in whom abdominal ultrasonography (US) had not been of diagnostic value. These patients were selected for MRCP in view of their abdominal symptoms, high levels of hepatobiliary enzymes, and pancreatic/bile duct dilatation found by abdominal US. Based on MRCP findings, 75 patients were selected for ERCP. RESULTS: ERCP provided new findings in 14 (18.%) patients. In 110 patients subjected to only MRCP and follow-up as well as in 75 patients with MRCP followed by ERCP, MRCP-based diagnosis corresponded with the final diagnosis. In our study, patients who would have conventionally required ERCP, such as those with natural passed choledocholithiasis and postoperative bile duct dilatation, could be followed up without ERCP. These results the importance of considering indications for ERCP. CONCLUSIONS: MRCP can be an alternative to ERCP at least for diagnosis.     

The substitution of endoscopic ultrasonography for endoscopic retrograde cholangio-pancreatography: implications for service development and training

Diagnostic indications of endoscopic retrograde cholangio-pancreatography (ERCP) have not completely disappeared. But the substitution of this examination by endoscopic ultrasonography (EUS) in the work-up of biliary and pancreatic diseases is supported by EUS's reliability and cost-effectiveness. In the future EUS will be challenged by magnetic resonance cholangiopancreatography (MRCP), when easily available. Therefore, the choice between EUS, MRCP and ERCP will become simplified: MRCP as the first option for diagnosis, EUS in doubtful cases needing sampling for pathology and ERCP as a therapeutic alternative to some surgical procedures.     

Magnetic resonance study of the pancreatic duct.

AIM: to prospectively determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of the normal and diseased pancreatic duct. METHODS: patients seen during a 6-month period with a diagnosis of biliary tract or pancreatic disease underwent endoscopic retrograde cholangiopancreatography (ERCP) after a previous MRCP. The pancreatic duct was evaluated with both techniques in 37 patients. RESULTS: the pancreatic duct appeared normal in ERCP in 27 patients, and also appeared normal in MRCP in 25 of these patients (specificity 93%). ERCP showed moderate-severe pancreatic duct dilation in 8 patients, in whom the same diagnosis was reached with MRCP (sensitivity 100%). The causes of dilation were chronic pancreatitis (2 patients), pancreatic cancer (3 patients) and ampullary tumor (2 patients); in 1 patient the findings with both techniques were suggestive of neoplasm of the head of the pancreas or focal chronic pancreatitis. Pancreas divisum was diagnosed in 2 patients by both methods, and the predominant dorsal duct as well as the ventral duct were visualized by MRCP. CONCLUSIONS: MRCP is an accurate technique for evaluating the normal or diseased pancreatic duct, and for determining the underlying disease.     

Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis

Endoscopic retrograde cholangiopancreatography （ERCP） is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound （EUS） and magnetic retrograde cholangiopancreatography （MRCP）, ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.     

Comparison between magnetic resonance cholangiopancreatography and ERCP for evaluation of the pancreatic duct

OBJECTIVE: To date, ERCP has been the reference technique in the diagnosis of pancreatic duct pathology. The aim of the present study was to evaluate the accuracy of magnetic resonance cholangiopancreatography (MRCP), a relatively new, noninvasive diagnostic method, in studying the pancreatic duct. METHODS: A prospective 15-month study was done of 78 patients with suspected biliopancreatic pathology and indications for ERCP. In all cases, MRCP was performed <72 h before ERCP. Both techniques were used to assess the size of the pancreatic tract (normal or dilated), the presence or absence of obstruction, the level of obstruction where present, and its etiology. RESULTS: Both techniques found the pancreatic tract to be normal and nondilated in 60 patients. The specificity and sensitivity of MRCP in evaluating the normal pancreatic duct were 98% and 94%, respectively. In nine cases, a stenotic duct of Wirsung was detected (seven at the head of the pancreas and two in the body), with the same correlation being shown by ERCP (sensitivity 100%). The sensitivity and specificity of MRCP relating to diffuse irregular and dilated morphologies of the entire pancreatic duct was 86% and 100%, respectively. Nine patients were diagnosed with pancreatic neoplasms by both techniques, with an accuracy of 100%. Four patients presented chronic pancreatitis, which was correctly diagnosed by MRCP in each case. CONCLUSIONS: MRCP is an effective technique for evaluating both the normal and diseased duct of Wirsung, and for establishing the underlying pathology.     

Therapeutic ERCP in paediatric patients

BACKGROUND: Major limitations of endoscopic retrograde cholangiopancreatography in paediatric populations are a low incidence of biliopancreatic disease among children, the equipment dimensions (size of endoscopes and devices) and the increasing role of MR-cholangiopancreatography in the field of diagnostic indications. Aim of this study was to evaluate the diagnostic and therapeutic yields of endoscopic retrograde cholangiopancreatography for biliopancreatic diseases in a paediatric population. METHODS: Between 1996 and 2002, 48 endoscopic retrograde cholangiopancreatographies were performed in 38 children aged 4 weeks to 17 years as part of the diagnostic evaluation for suspected pancreatic or biliary tract disease. Endoscopic retrograde cholangiopancreatography was carried out under general anaesthesia, using prototype paediatric duodenoscopes or standard duodenoscopes in children younger or older than 18 months, respectively. RESULTS: The indications to perform endoscopic retrograde cholangiopancreatography were common bile duct stones (14 children), biliopancreatic abnormalities (8), primary sclerosing cholangitis (2), Wirsung disruption (1), biliary leakage (1), cholestasis (4) and pancreatitis (8). Cannulation was successful in all patients but one. Sphincterotomy together with stone extraction or stent insertion was performed in 30/38 patients. Immediate complications were mild and treated conservatively. CONCLUSIONS: Diagnostic and therapeutic endoscopic retrograde cholangiopancreatography can be used safely and effectively in the management of biliopancreatic diseases in childhood as well. Indications, endoscopic techniques and complications are similar to those reported for adult patients.     

磁共振胰胆管造影术与内镜逆行胰胆管造影术的对照研究

目的 通过磁共振胰胆管造影术（ＭＲＣＰ）与内镜逆行胰胆管造影术（ＥＲＣＰ）的对照研究，评价ＭＲＣＰ对胰胆系疾病的诊断价值。方法 ４０例疑有胰胆系疾病的患者进行了ＭＲＣＰ及ＥＲＣＰ检查，两者结果作对照研究。结果 本组资料中ＭＲＣＰ对胰胆系疾病总的诊断价值为敏感度８９．１％、特异度１００％、准确度９０％，ＥＲＣＰ总的诊断价值为敏感度８４．２％、特异度１００％、准确度８５％，两者统计学上无显著性差异。结     

pERCePtions on ERCP utilization in the United States

Endoscopic retrograde cholangiopancreatography (ERCP), once a popular modality for diagnosing biliary tract and pancreatic disease, has passed its peak utilization. In the current issue of AJG, Jamal and colleagues summarize the trends in ERCP utilization in the United States from 1988 to 2002. While ERCP utilization had increased among certain ethnic groups, its overall use has dropped considerably since 1996. In particular, they report that the use of ERCP as a diagnostic tool and in the outpatient setting has declined. The introduction of less invasive pancreaticobiliary imaging tools, namely, endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), is likely responsible for this trend. However, ERCP is still used widely and appropriately in the therapy of pancreaticobiliary disorders. The complementary nature of alternative diagnostic tools such as EUS suggests that ERCP use will continue at its current rate, rather than fall out of favor.     

Magnetic resonance cholangiopancreatography: evaluation in 150 patients.

BACKGROUND AND AIMS: Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique for evaluating the biliary and pancreatic ducts. MRCP has reached a level of resolution and reliability where it may replace diagnostic endoscopic retrograde cholangio-pancreatography (ERCP). We analyzed the results of MRCP in adult patients with biliary or pancreatic disease, and compared the findings with those at surgery or on ERCP. METHODS: Data of 150 patients who underwent MRCP with both single slab and multislice rapid acquisition with relaxation enhancement sequences with half-fourier acquisition single-shot turbo spin echo techniques were analyzed. Patients were divided into four groups according to reason for referral for MRCP: obstructive jaundice (n = 65), chronic/acute pancreatitis (n = 25), screening prior to laparoscopic cholecystectomy (n = 20), and failed ERCP (n = 40). RESULTS: MRCP could accurately identify the level of biliary obstruction in 58 of 61 patients. Characterization of benign or malignant nature of a stricture was possible in 30 of 32 patients when findings of both MRCP and magnetic resonance imaging were analyzed together. MRCP revealed the morphology of the entire pancreatic duct in 13 of 15 patients having ductal changes on endoscopic retrograde pancreatography. CONCLUSION: MRCP has high sensitivity and specificity for detection of biliary dilatation, calculi, strictures and anatomical variants.     

What is the current role of endoscopy in primary sclerosing cholangitis?

Endoscopy has important roles in the management of primary sclerosing cholangitis (PSC), ranging from narrowing down the differential diagnoses, screening for complications, determining prognosis and therapy. While the need for a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be obviated by a positive magnetic resonance cholangiopancreatography (MRCP), a negative MRCP does not exclude PSC and may therefore necessitate an ERCP, which is traditionally regarded as the gold standard. In this editorial we have not covered the endoscopic management of inflammatory bowel disease in the context of PSC nor of endoscopic surveillance and treatment of portal hypertension complicating PSC.     

Utility of pancreatography for diagnosing autoimmune pancreatitis

AIM: To identify pancreatographic findings that facilitate differentiating between autoimmune pancreatitis (AIP) and pancreatic cancer (PC) on endoscopic retrograde cholangiopancreatography (ERCP) and magnetic resonance cholangiopancreatography (MRCP). METHODS: ERCP findings of 48 AIP and 143 PC patients were compared. Diagnostic accuracies for AIP by ERCP and MRCP were compared in 30 AIP patients. RESULTS: The following ERCP findings suggested a diagnosis of AIP rather than PC. Obstruction of the main panc...     

Diagnostic role of secretin-enhanced MRCP in patients with unsuccessful ERCP

AIM: To evaluate the value of MR cholangiopancreatography (MRCP) in patients in whom endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessfully performed by experts in a tertiary center. METHODS: From January 2000 to June 2003, 22 patients fulfilled the inclusion criteria. The indications for ERCP were obstructive jaundice (n = 9), abnormal liver enzymes (n = 8), suspected chronic pancreatitis (n = 2), recurrent acute pancreatitis (n = 2), or suspected pancreatic cancer (n = 1). The reasons for the ERCP failure were the postsurgical anatomy (n = 7), duodenal stenosis (n = 3), duodenal diverticulum (n = 2), and technical failure (n = 10). MRCP images were evaluated before and 5 and 10 min after i.v. administration of 0.5 IU/kg secretin. RESULTS: The MRCP images were diagnosed in all 21 patients. Five patients gave normal MR findings and required no further intervention. MRCP revealed abnormalities (primary sclerosing cholangitis, chronic pancreatitis, cholangitis, cholecystolithiasis or common bile duct dilation) in 10 patients, who were followed up clinically. Four patients subsequently underwent laparotomy (hepaticojejunostomy in consequence of common bile duct stenosis caused by unresectable pancreatic cancer; hepaticotomy+Kehr drainage because of insufficient biliary-enteric anastomosis; choledochojejunostomy, gastrojejunostomy and cysto-Wirsungo gastrostomy because of chronic pancreatitis, or choledochojejunostomy because of common bile duct stenosis caused by chronic pancreatitis). Three patients participated in therapeutic percutaneous transhepatic drainage. The indications were choledocholithiasis with choledochojejunostomy, insufficient biliary-enteric anastomosis, or cholangiocarcinoma. CONCLUSION: MRCP can assist the diagnosis and management of patients in whom ERCP is not possible.     

Magnetic resonance cholangiopancreatography

The current imaging technique and clinical application of MR cholangiopancreatography (MRCP) is reviewed. MRCP has evolved into a feasible method of non-invasively evaluating the pancreaticobiliary system and has considerable clinical utility. If endoscopic retrograde cholangiopancreatography (ERCP) is incomplete or has failed, or in patients with biliary and gastrointestinal surgical procedures, MRCP is a useful alternative modality. In the near future, MRCP may supplant diagnostic ERCP such that ERCP is reserved primarily for therapeutic interventions. Furthermore, when MRCP is performed in conjunction with abdominal MR and MR angiography, the 'all-in-one' examination can evaluate the solid organs and vessels of the abdomen as well as the ductal systems.     

Prospective study of diagnostic value of magnetic resonance cholangiopancreatography versus endoscopic retrograde cholangiopancreatography in cholangiopancreatic diseases

OBJECTIVE: To compare the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) versus endoscopic retrograde cholangiopancreato­graphy (ERCP) in the detection of cholangiopan­creatic diseases via a prospective study. METHODS: Magnetic resonance cholangiopancreatography was performed in 63 patients with suspected cholangiopancreatic diseases and followed by ERCP within 24 h. The MRCP and ERCP images were analyzed and compared. RESULTS: Of the 63 patients studied, 56 (88.9%) were correctly diagnosed by using ERCP and seven (11.1%) by using percutaneous transhepatic cholangio­graphy (PTC); however, all these patients were successfully diagnosed by using MRCP. Cholangio­pancreatic diseases were diagnosed by MRCP with a sensitivity of 98.2%, a specificity of 83.3%, a misdiagnostic rate of 16.7% and a missed diagnostic rate of 1.8%. The total concordance rate of MRCP, ERCP and PTC was 85.7%. For specific conditions, the concordance rates were as follows: biliary calculi 100%; tumors of the bile duct 92.9%; papillary lesions 70.6%; hepatic distomiasis 66.7%; chronic pancreatitis 100%. The complications associated with ERCP were five cases of acute pancreatitis and one case of perinephric abscess. The patient with perinephric abscess had previously had a B‐II operation. The complication rate associated with ERCP was 9.5% (6/63), but no complications were associated with MRCP. CONCLUSION: We conclude that MRCP is as effective as ERCP for the diagnosis of bile duct lesions, such as biliary calculi and tumors, but not for papillary lesions and liver fluke infections. Although MRCP can be used in patients who can’t tolerate ERCP or when there are contraindications to using ERCP, it should not be used for therapeutic purposes.     

两种胆胰管造影方法临床应用价值的荟萃分析

目的评价内镜下逆行胰胆管造影术（ERCP）和磁共振胰胆管造影术（MRCP）在具有可疑胆胰疾病患者中的应用价值。方法通过MEDLINE、EMBASE等数据库检索国内外已发表和未发表的相关文献。选择针对具有可疑胆胰疾病患者,使用ERCP和MRCP两种方法进行比较的前瞻性研究。由2位评价者分别按以上检索策略收集资料,按选择标准人选,主要对两种检查方法的敏感性和特异性进行荟萃分析。结果ERCP和MRCP诊断胆总管结石、胆胰管狭窄、胆胰系统恶性疾病的敏感性差异无统计学意义。两者对上述疾病诊断的特异性方面,仅在诊断胰胆管狭窄时,ERCP高于MRCP,OR为6．17,95％CI为1,35～20．24,P=0．02。对于总体胆胰系统疾病的诊断,ERCP的敏感性和特异性均优于MRCP,OR分别为1．72和4．05.95％CI分别为1．04～2．85和1．32．12．42,P值分别为0．04及0．01。结论在诊断胆胰系统疾病时,总体敏感性和特异性都是ERCP优于MRCP。临床医生可以根据患者耐受程度和价效分析进行对ERCP和MRCP的取舍决策。     

Advanced Imaging of Chronic Pancreatitis

Chronic pancreatitis is characterized by continuing inflammation, destruction, and irreversible morphological changes in the pancreatic parenchyma and ductal anatomy. These changes lead to chronic pain and/or loss of function. Although these definitions are simple, the clinical diagnosis of chronic pancreatitis remains difficult to make, especially for early disease. Routine imaging modalities such as transabdominal ultrasound and standard CT scans are insensitive for depicting early disease, and detect only advanced chronic pancreatitis. Advances in imaging modalities including CT, MRI with gadolinium contrast enhancement, MRI with magnetic resonance cholangiopancreatography (MRI/MRCP), MRI/MRCP with secretin-stimulation (S-MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS) allow earlier diagnosis of chronic pancreatitis. This article reviews the recognized findings, advantages, and disadvantages of the various imaging modalities in the management of chronic pancreatitis, specifically CT, MRI with or without MRCP and/or S-MRCP, ERCP, and EUS.     

Endoscopic ultrasonography can diagnose distal biliary strictures without a mass on computed tomography

AIM:To assess the diagnostic ability of endoscopic ultrasonography(EUS)for evaluating causes of dista biliary strictures shown on endoscopic retrograde chol angiopancreatography(ERCP)or magnetic resonance cholangiopancreatography(MRCP),even without iden tifiable mass on computed tomography(CT). METHODS:The diagnostic ability of EUS was retro spectively analyzed and compared with that of routine cytology(RC)and tumor markers in 34 patients with distal biliary strictures detected by ERCP or MRCP a Dokkyo Medi...