Magnetic resonance cholangiopancreatography in conjunction with 3D for assessment of different biliary obstruction causes

Objective

To assess the diagnostic value of magnetic resonance imaging in conjunction with 3D-MRCP, with maximum intensity projections and volume rendered images in different biliary obstruction causes.

Patient and methods

This study retrospectively reviewed the radiology records of 29 patients (18 females and 11 males) suffering from obstructive jaundice. All patients were subjected to magnetic resonance imaging (MRI), 3D-MRCP with maximum intensity projection (MIP) and volume rendered (VR) reformatted images for biliary obstruction diseases in Zagazig University Hospitals between November 2008 and January 2010. MR studies were performed with 1.5-T superconductive magnet (Philips Achieva, class II a). The patient ages were ranging from 23 to 66 years (mean age: 34 years). This study was done to evaluate the diagnostic value and accuracy of the new MRI techniques as a non-invasive tool to diagnose and differentiate between benign and malignant variants of biliary obstruction diseases and to facilitate the management planning. All cases were evaluated by clinical examination, laboratory values, grey and colored scale ultrasonography, conventional MRI, three-dimensional (3D-MRCP), MIP, and VR images. Our results were correlated with the histology of the resected specimen, operative (ERCP) or image-guided biopsy in inoperable patients.

Results

The mean age of benign patients was 30 years compared with 54 years in malignant biliary obstruction. Seventeen patients had benign cases 58.6% (6 cases of benign stricture and 11 cases with choledocholithiasis). The other 12 cases had malignant aetiology. Twenty-three patients were subjected to operative procedures, while the remaining six had ERCP/PTC and stenting. The MRI/MRCP images were of good quality in all patients. The intra- and extra-hepatic biliary radicals were visualized completely including the proximal and distal extent of the stricture. Regarding the benign cases (16/17) were satisfactorily diagnosed, however, one case was false negative, due to missed small stone at the MIP reconstructions. The 12 malignant biliary obstruction cases were as follows: five cases were cholangiocarcinoma (one peripheral type, one perihilar position, one Klatskin’s type, and two cases of the distal type), three pancreatic neoplastic lesions, two ampullary carcinoma, and two malignant lymph nodes. Regarding the benign cases 3D-MRCP had 94.1% diagnostic accuracy, otherwise more accuracy reported in malignant causes 100%.

Conclusion

3D-MRCP with MIP creates global images for pancreatico-biliary system. It is as effective as ERCP in detection of biliary obstruction and can precisely determine its level as well. Furthermore, it can provide a road map for management planning. By avoiding the flow artifacts, the false negative results that previously reported in past studies can be reduced.     

The role of ultrasound and magnetic resonance cholangiopancreatography for the diagnosis of biliary stricture after liver transplantation

Purpose

To identify the diagnostic value of ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) in diagnosing biliary strictures after liver transplantation.

Materials and methods

Sixty patients with clinically suspected biliary strictures after liver transplantation were retrospectively evaluated. All patients underwent US and MRCP before the standard of reference (SOR) procedure: endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography. Radiological images were analyzed for biliary dilatation and strictures.

Results

By SOR, biliary dilatation was present in 55 patients, stricture in 53 (44 anastomotic, 4 intrahepatic, 5 both), and dilatation and/or stricture in 58. Dilatation was diagnosed by US and MRCP in 39 and 45, respectively (sensitivity 71% vs. 82%, p = 0.18). Stricture was diagnosed by US and MRCP in 0 and 42, respectively (sensitivity 0% vs. 79%, p < 0.0001). False positive stricture was diagnosed by MRCP in 2. Dilatation and/or stricture was diagnosed by US in 39 and MRCP in 50 (sensitivity 67% vs. 86%, p = 0.01); however, using both techniques, sensitivity increased to 95%.

Conclusions

MRCP is superior to US for diagnosing biliary strictures after liver transplantation primarily because MRCP can detect stricture. The combination of US and MRCP seems superior to either method alone. Our data suggest that in patients with normal US and MRCP, direct cholangiography could be avoided.     

Assessment of acute cholangitis by MR imaging

Purpose

The purpose of this study is to assess the common MRI findings of acute cholangitis compared with those of non-acute cholangitis.

Materials and methods

During a 31-month period, we performed MRCP and contrast-enhanced MRI on 173 patients with biliary abnormalities including duct dilatation or stricture. The causes of the biliary abnormalities included biliary stone disease (n = 85), cholangiocarcinoma (n = 47), periampullary cancer (n = 20), GB cancer (n = 4), and others (n = 17). Among 173 patients, 66 consecutive patients were confirmed with acute cholangitis diagnosed according to the Tokyo guideline, and 107 patients were confirmed as having non-acute cholangitis. Two radiologists retrospectively and independently accessed the MR findings, including the cause of biliary abnormality, increased periductal signal intensity on T2-weighted images, the transient periductal signal difference, and the presence of abscess, thrombosis, and ragged duct. They also measured the dilated duct and the thickened wall. The Student t-test and the Pearson chi-square were used. The κ statistics were used to determine interobserver agreement. Logistic regression was used to identify the MR findings that predicted acute cholangitis.

Results

MRI correctly accessed the cause of biliary abnormality in 163 patients (94%). The statistically common findings for acute cholangitis were as follows: increased periductal signal intensity on T2-weighted imaging (n = 26, 39%, p < 0.05); transient periductal signal difference (n = 31, 47%, p < 0.05); abscess (n = 18, 27%, p < 0.05); thrombosis (n = 12, 18%, p < 0.05); and ragged duct (n = 11, 17%, p < 0.05). Interobserver agreement was good to excellent for each finding (κ = 0.74–0.97). The wall thickness showed a statistically significant difference between the acute cholangitis and the non-acute cholangitis group (2.65 mm:2.32 mm, p < 0.05), however, there was no significant difference in duct dilatation in the two groups. The periductal transient attenuation difference was an independent predictor of acute cholangitis (Exp (B) = 6.389, p = 0.018).

Conclusion

MRI accurately assesses the cause of biliary abnormality in patients with cholangitis. Using statistically common MR findings for acute cholangitis, MR imaging is very successful in predicting acute cholangitis.     

Effectiveness of percutaneous metal stent placement in cholangiocarcinoma patients with midterm follow-up: Single center experience

Purpose

Patients with advanced cholangiocarcinoma present with high rate of local complications. The primary aim of this study is to report clinical course of advanced cholangiocarcinoma patients those who were presented with biliary obstruction and treated with percutaneous biliary stenting.

Material and methods

Patients with unresectable locally advanced or metastatic cholangiocarcinoma followed by our center for a period of 4 years were analyzed. For statistical analysis demographic and clinical characteristics of patients, primary biliary drainage method, metal stent occlusion rate, time to stent occlusion, and overall survival rates were recorded.

Results

A total of 34 eligible patients were analyzed. 27 patients had metal stent placement. These 27 patients formed the basis of this study. Median overall survival (OS) was 6.0 months. After metal stent deployment bilurubin levels were normalized within a mean of 10 days. During the follow-up period, 13 patients were experienced metal stent occlusion. Median TtSO was 10 weeks. Cytotoxic chemotherapy was administered to 14 (52%) patients. Patients without stent dysfunction had significantly higher rate of chemotherapy exposure rate (p = 0.021). Statistical analysis, however, failed to exhibit significant effect of stent dysfunction on OS.

Conclusion

In advanced cholangiocarcinoma, relief of bile duct obstruction is an important part of the initial patient management. This study therefore described the clinical value of percutaneous metal stent in cholangiocarcinoma patients and raises the question about patency of metal stent in cholangiocarcinoma whether we can expect success similar to the success achieved in pancreas carcinoma.     

Clinical usefulness of free-breathing navigator-triggered 3D MRCP in non-cooperative patients: comparison with conventional breath-hold 2D MRCP

Purpose

To assess the clinical usefulness of free-breathing 3D MRCP in non-cooperative patients compared conventional breath-hold 2D MRCP.

Materials and methods

We performed FB navigator-triggered 3D MRCP using prospective acquisition correction and BH 2D MRCP in 48 consecutive, non-cooperative patients among 772 patients. Thirteen patients had malignant obstruction. Two radiologists independently graded the likelihood of a malignant obstruction, the overall image quality, and the visibility of ten, individual anatomic segments of both the biliary and pancreatic duct in each sequence. The area under the ROC curve and the repeated measures analyses of variance with multiple comparisons were used for the comparison. The κ statistics were used for interobserver agreement.

Result

The diagnostic performance for detecting malignancy was significantly higher on FB MRCP (A_z = 0.962) than on either BH SS-RARE (A_z = 0.820, P < 0.0185) or MS-HASTE MRCP (A_z = 0.816, P < 0.0067). Interobserver agreement was excellent for FB MRCP (κ = 0.889) and fair for both BH SS-RARE (κ = 0.578) and MS-HASTE MRCP (κ = 0.49). FB MRCP had a significantly higher technical quality than BH MRCP (P < 0.001). FB MRCP was seen to have statistically better visibility of peripheral IHD, right main IHD, CHD, cystic duct, and CBD than BH MRCP (P < 0.001). FB MRCP and BH SS-RARE MRCP had statistically better visibility of both the left main IHD and pancreatic duct than did BH MS-HASTE MRCP (P < 0.001).

Conclusion

FB 3D MRCP is useful for non-cooperative patients in whom conventional BH 2D methods cannot be used successfully.     

Inaccurate preoperative imaging assessment on biliary anatomy not increases biliary complications after living donor liver transplantation

Backgrounds and aims

Accurate assessment of graft bile duct is important to plan surgical procedure. Magnetic resonance cholangiopancreatography (MRCP) has become an important diagnostic procedure in evaluation of pancreaticobiliary ductal abnormalities and has been reported as highly accurate. We aim to estimate the efficacy of preoperative MRCP on depicting biliary anatomy in living donor liver transplantation (LDLT), and to determine whether inaccurate preoperative imaging assessment would increase the biliary complications after LDLT.

Methods

The data of 118 cases LDLT were recorded. Information from preoperative MRCP was assessed using intraoperative cholangiography (IOC) as the gold standard. The possible risk factors of recipient biliary complications were analyzed.

Results

Of 118 donors, 84 had normal anatomy (type A) and 34 had anatomic variants (19 cases of type B, 9 cases of type C, 1 case of type E, 2 cases of type F and 3 cases of type I) confirmed by IOC. MRCP correctly predicted all 84 normal cases and 17 of 34 variant cases, and showed an accuracy of 85.6% (101/118). The incidence of biliary complications was comparable between cases with accurate and inaccurate classification of biliary tree from MRCP, and between cases with normal and variant anatomy of bile duct. While cases with graft duct opening ≤5 mm showed a significant higher incidence of total biliary complications (21.1% vs. 6.6%, P = 0.028) and biliary stricture (10.5% vs. 1.6%, P = 0.041) compared with cases with large duct opening >5 mm.

Conclusion

MRCP could correctly predict normal but not variant biliary anatomy. Inaccurate assessment of biliary anatomy from MRCP not increases the rate of biliary complications, while small-sized graft duct may cause an increase in biliary complications particularly biliary stricture after LDLT.     

Biliary anatomy in potential right hepatic lobe living donor liver transplantation (LDLT): the utility of CT cholangiography in the setting of inconclusive MRCP

Objective

To determine the utility of CT cholangiography (CT-Ch) in preoperative evaluation of the biliary anatomy of living-donor liver transplantation (LDLT) donors when magnetic resonance cholangiopancreatography (MRCP) is inconclusive.

Materials and methods

Over a 2-year period, 22 potential living liver donors underwent contrast-enhanced CT-Ch for preoperative evaluating biliary anatomy due to inconclusive results on MRCP and subsequently donated their right hepatic lobe. Nineteen of them underwent intraoperative cholangiography and were included in this study. Two radiologists retrospectively reviewed both MRCP and CT-Ch with 1-month interval and documented the types of bile duct branching patterns and visualization score of intrahepatic bile ducts (4-point scale).

Results

There were no complications associated with CT-Ch examinations. CT-Ch was concordant with the reference standard in 18/19 (95%) including 7/8 typical branching type and 11/11 anomalous branching types. MRCP was concordant with the reference standard in 14/19 (74%) including 4/8 typical branching types and 10/11 anomalous branching types. The discordant case by CT-Ch was the identification of a tiny accessory right intrahepatic duct joining the common bile duct which was not visualized on intraoperative cholangiography. CT-Ch showed higher visualization score (mean, 3.9) than MRCP (mean, 2.6) (P < .001).

Conclusion

CT-Ch can be effectively used for the depiction of the branching pattern of the bile duct at the hepatic hilum when MRCP is inconclusive.     

Dual-energy CT-cholangiography in potential donors for living-related liver transplantation: improved biliary visualization by intravenous morphine co-medication

Purpose

To prospectively evaluate whether intravenous morphine co-medication improves bile duct visualization of dual-energy CT-cholangiography.

Materials and methods

Forty potential donors for living-related liver transplantation underwent CT-cholangiography with infusion of a hepatobiliary contrast agent over 40 min. Twenty minutes after the beginning of the contrast agent infusion, either normal saline (n = 20 patients; control group [CG]) or morphine sulfate (n = 20 patients; morphine group [MG]) was injected. Forty-five minutes after initiation of the contrast agent, a dual-energy CT acquisition of the liver was performed. Applying dual-energy post-processing, pure iodine images were generated. Primary study goals were determination of bile duct diameters and visualization scores (on a scale of 0 to 3: 0—not visualized; 3—excellent visualization).

Results

Bile duct visualization scores for second-order and third-order branch ducts were significantly higher in the MG compared to the CG (2.9 ± 0.1 versus 2.6 ± 0.2 [P < 0.001] and 2.7 ± 0.3 versus 2.1 ± 0.6 [P < 0.01], respectively). Bile duct diameters for the common duct and main ducts were significantly higher in the MG compared to the CG (5.9 ± 1.3 mm versus 4.9 ± 1.3 mm [P < 0.05] and 3.7 ± 1.3 mm versus 2.6 ± 0.5 mm [P < 0.01], respectively).

Conclusion

Intravenous morphine co-medication significantly improved biliary visualization on dual-energy CT-cholangiography in potential donors for living-related liver transplantation.     

Intraductal papillary mucinous neoplasm of the pancreas: differentiate from chronic pancreatits by MR imaging

Purpose

To evaluate the differentiating factors for intraductal papillary mucinous neoplasm of the pancreas and chronic pancreatitis as determined by MR imaging.

Materials and methods

During a three-year period, we performed MR imaging on 33, consecutive patients with IPMN and on 41 patients with chronic pancreatitis. All IPMNs were confirmed by surgery. Two radiologists retrospectively analyzed the ductal change, the cyst shape, CBD dilatation, lymphadenopathy, and parenchymal change. The sensitivity and specificity were calculated for each MRI findings using the Chi square test. Statistically significant MR findings were further analyzed using multivariate logistic regression analysis. The diagnostic performance was evaluated according to the area under the receiver operating characteristic curve (A_z) using specific MRI findings. Simple κ statistics were used to evaluate the inter-observer reliability.

Results

Statistically specific findings for IPMN compared with those for chronic pancreatitis, were duct dilatation without stricture (specificity = 95.1%, sensitivity = 75.8%, p < 0.0001), bulging ampulla (specificity = 97.6%, sensitivity = 30.3%, p < 0.0001), nodule in a duct (specificity = 100%, sensitivity = 15.2%, p < 0.0004), grape-like cyst shape (specificity = 97.6%, sensitivity = 78.8%, p < 0.0001), and nodule in a cyst (specificity = 100%, sensitivity = 24.2%, p < 0.0001). Statistically specific findings for chronic pancreatitis compared with those for IPMN, were duct dilatation with strictures (specificity = 93.9%, sensitivity = 95.1%, p < 0.0001), the presence of a stone (specificity = 97.0%, sensitivity = 56.1%, p < 0.0001), and a unilocular cyst shape (specificity = 93.9%, sensitivity = 34.1%, p < 0.0004). Duct dilatation without stricture and a grape-like cyst shape were independently associated with the IPMN. Duct dilatation with strictures was independently associated with the chronic pancreatitis. Interobserver agreement was good to excellent for each finding (κ = 0.762–1.000).

Conclusion

Highly specific findings for IPMN include duct dilatation without stricture, bulging ampulla, nodule in a duct, grape-like cyst shape, and nodule in a cyst. MRI is very useful for differentiating IPMN from chronic pancreatitis using these specific findings.     

Unenhanced versus multiphase MDCT in patients with hematuria, flank pain, and a negative ultrasound

Objectives

To compare the impact of unenhanced and contrast-enhanced multi-detector computed tomography (MDCT) for the detection of urinary stones and urinary obstruction in patients with suspected renal colic.

Methods

95 patients with suspected renal colic underwent a three-phase MDCT for evaluation of the urinary tract. The unenhanced scan and the multiphase examination were reviewed retrospectively by two radiologists for the characterization of urinary stones and signs of obstruction. Results of unenhanced MDCT were compared with those obtained during the second review of the entire multiphase examination.

Results

Overall diagnosis of urinary stones revealed an accuracy of 97.0% for unenhanced, and 98.9% for multiphase MDCT with a significant difference between both protocols (mixed-effects logistic regression: odds ratio 3.3; p = 0.019). With 3 versus 15 false positive ratings, multiphase MDCT was superior to unenhanced MDCT for the diagnosis of urinary stones.There was no significant difference in detecting signs of obstruction. Inter-reader agreement for overall stone detection was excellent on both unenhanced (kappa 0.84) and multiphase (kappa 0.88) MDCT.

Conclusion

Contrast-enhanced multiphase MDCT offers distinct advantages compared to an unenhanced approach for the assessment of urinary stone disease, and therefore should be considered as a complementary examination for patients with inconclusive findings.     

Primary biliary cirrhosis: evaluation with T2-weighted MR imaging and MR cholangiopancreatography

Purpose

The aim of this retrospective study is to evaluate the role of T2-weighted MR imaging (MRI) and MR cholangiopancreatography (MRCP) findings in the diagnosis of primary biliary cirrhosis (PBC).

Materials and methods

The following T2-weighted MRI and MRCP findings: segmental hepatic atrophy/hypertrophy, irregular liver surface, parenchymal lace-like fibrosis, rounded low signal intensity lesions centering portal vein branches (periportal halo sign), periportal hyperintensity (cuffing), splenomegaly, ascites, lymphadenopathy, venous collaterals, and the configuration of intrahepatic biliary ducts were reviewed for their diagnostic significance by two observers in 13 female patients (mean age: 49 years) with PBC. Discordant readings of the observers were resolved at consensus.

Results

When parenchymal lace-like fibrosis and periportal halo sign were seen together the sensitivity of T2-weighted MR images was 69%. In six cases periportal hyperintensity (cuffing) and periportal halo sign were seen together. Segmental hypertrophy was present in nine patients and hepatic surface irregularity due to regenerative nodules were present in 10 patients. Lymphadenopathy was seen in 10, splenomegaly was seen in 5, collateral vascular structures were seen in 2 and minimal perihepatic free fluid was seen in 2 patients. MRCP images revealed various mild irregularity in the intrahepatic bile ducts in 8 patients and focal narrowing at the common bile duct level in 1 patient.

Conclusion

MRI and MRCP may support the clinical and laboratory findings of PBC even in the early stages of the disease. MRI can also be a choice of method for the recommended prolonged follow up.     

Unenhanced urinary CT: value of parenchymal attenuation measurements in differentiating acute vs. chronic renal obstruction

Objective

We aimed to search if the renal parenchymal attenuation measurements on unenhanced CT scans could be useful in differentiating acutely obstructed kidneys from chronic cases or unobstructed kidneys.

Material and methods

Unenhanced CT scans of 101 patients were retrospectively reviewed. Thirty-two patients with unilateral acute renal obstruction, 34 patients with unilateral chronic renal obstruction due to various reasons and 35 control subjects were included in the study. The parenchymal densities of both kidneys were measured, from the upper poles, middle portions, and lower poles of each kidney. The mean parenchymal densities of both kidneys were calculated in all three groups of subjects. Secondary signs of renal obstruction such as perinephric stranding, size of ureteral stone, degree of hydronephrosis were also noted for each kidney.

Results

The mean parenchymal attenuation value on the acutely obstructed side was lower than the unobstructed side, 24.21 ± 3.68 and 30.68 ± 4.75 respectively (p < 0.001). The mean parenchymal attenuation value on the acutely obstructed side (24.21 ± 3.68) was lower than both the chronically obstructed side (30.85 ± 4.53), and the control subjects (29.62 ± 3.03 on corresponding side). There was no statistically significant attenuation difference between right and left kidneys in the control group and chronic obstruction group.

Conclusion

Renal parenchymal attenuation measurements and attenuation differences of both kidney of same patient could be useful in differentiating acute unilateral obstruction from chronic cases.     

Correlation of CT angiographic pulmonary artery obstruction scores with right ventricular dysfunction and clinical outcome in patients with acute pulmonary embolism

Objective

To correlate CTA pulmonary artery obstruction scores (OS) with right ventricular dysfunction (RVD) and clinical outcome in patients with acute pulmonary embolism (PE).

Materials and methods

In a prospective study of 50 patients (66 ± 12.9 years) with PE pulmonary artery OS (Qanadli, Mastora, and Mastora central) were assessed by two radiologists. To assess RVD all patients underwent echocardiography within 24 h. Furthermore, RVD on CT was assessed by calculating the right ventricular/left ventricular (RV/LV) diameter ratios on transverse (RV/LVtrans) and four-chamber views (RV/LV4ch) as well as the RV/LV volume ratio (RV/LVvol). OS were correlated with RVD and the occurrence of adverse clinical outcomes (defined as death, need for intensive care treatment, or cardiac insufficiency ≥NYHA III).

Results

Mean Mastora, Qanadli, and Mastora central OS were 26.4 ± 17.7, 12.6 ± 9.9 and 7.5 ± 9, respectively. Echocardiography demonstrated moderate and severe RVD in 10 and 5 patients, respectively. Patients with moderate and severe RVD showed significantly higher Mastora central scores than patients without RVD (14 ± 10.8 vs. 5.9 ± 7.8 [p = 0.05]; 17.6 ± 13.2 vs. 5.9 ± 7.8 [p = 0.038]). A relevant correlation (i.e. r ≥ 0.6) between OS and CT parameters for RVD were only found for the Mastora score and the Mastora central score (RV/LV4ch: r = 0.61 and 0.68, RV/LVvol: r = 0.61 and 0.6). 18 patients experienced an adverse clinical outcome. None of the OS differed significantly between patients with and without adverse clinical outcome.

Conclusion

Pulmonary artery obstruction scores can differentiate between patients with and without RVD. However, in this study, obstruction scores were not correlated to adverse clinical outcome.     

Intra-biliary contrast-enhanced ultrasound for evaluating biliary obstruction during percutaneous transhepatic biliary drainage: A preliminary study

Objectives

The aimed of this study was to investigate the value of intra-biliary contrast-enhanced ultrasound (IB-CEUS) for evaluating biliary obstruction during percutaneous transhepatic biliary drainage (PTBD).

Materials and methods

80 patients with obstructive jaundice who underwent IB-CEUS during PTBD were enrolled. The diluted ultrasound contrast agent was injected via the drainage catheter to perform IB-CEUS. Both conventional ultrasound and IB-CEUS were used to detect the tips of the drainage catheters and to compare the detection rates of the tips. The obstructive level and degree of biliary tract were evaluated by IB-CEUS. Fluoroscopic cholangiography (FC) and computer tomography cholangiography (CTC) were taken as standard reference for comparison.

Results

Conventional ultrasound displayed only 43 tips (43/80, 53.8%) of the drainage catheters within the bile ducts while IB-CEUS identified all 80 tips (80/80, 100%) of the drainage catheters including 4 of them out of the bile duct (P < 0.001). IB-CEUS made correct diagnosis in 44 patients with intrahepatic and 36 patients with extrahepatic biliary obstructions. IB-CEUS accurately demonstrated complete obstruction in 56 patients and incomplete obstruction in 21 patients. There were 3 patients with incomplete obstruction misdiagnosed to be complete obstruction by IB-CEUS. The diagnostic accuracy of biliary obstruction degree was 96.3% (77/80).

Conclusion

IB-CEUS could improve the visualization of the drainage catheters and evaluate the biliary obstructive level and degree during PTBD. IB-CEUS may be the potential substitute to FC in the PTBD procedure.     

Navigator-triggered isotropic three-dimensional magnetic resonance cholangiopancreatography in the diagnosis of malignant biliary obstructions: comparison with direct cholangiography

PURPOSE: To compare the diagnostic accuracy of navigator-triggered isotropic three-dimensional (3D) MR cholangiopancreatography (MRCP) using parallel imaging for malignant biliary obstruction with direct cholangiography. MATERIALS AND METHODS: A total of 23 patients with malignant biliary obstruction underwent MRCP and endoscopic retrograde cholangiopancreatography (ERCP)/percutaneous transhepatic cholangiography (PTC). Two observers retrospectively evaluated 3D-MRCP and ERCP/PTC and recorded the level of obstruction and extent of tumor along with their confidence. The quality of images and morphologic appearance of stricture were also evaluated by two reviewers. The results of MRCP and ERCP/PTC were compared with surgical and histopathological data. RESULTS: 3D-MRCP was of diagnostic quality and free of artifacts in all patients, whereas ERCP/PTC examinations failed in three patients. For the evaluation of level of obstruction, there was no statistical significance between 3D-MRCP and ERCP/PTC. 3D-MRCP was superior to ERCP/PTC in the assessment of anatomical extent of hilar bile duct involvement, but did not show statistical significance. The accuracy of 3D-MRCP in determining tumoral extent of hilar cancer was higher than that of ERCP/PTC, but it was not statistically significant. The image quality of 3D-MRCP was superior to ERCP/PTC. There was good agreement between morphologic appearance at MRCP and those at ERCP/PTC. CONCLUSION: 3D-MRCP can accurately assess the level of obstruction and extent of tumor in patients with malignant biliary obstruction.     

Diagnostic performance of MRI and EUS in the differentiation of benign from malignant pancreatic cyst and cyst communication with the main duct

Purpose

To assess the diagnostic ability of MRI and EUS for differentiating benign from malignant pancreatic cyst focusing on cyst communication with pancreatic duct.

Materials and methods

During 44 months, we performed MRI on 65 pancreatic cysts. Among them, 36 patients had confirmed cyst communication with duct by ERCP or surgery and 39 patients underwent EUS. Fifty-one had proven by surgery or aspiration. Among them, 36 had confirmed malignant cysts. Two radiologists independently graded cyst communication with duct and the likelihood of malignancy. When the readers’ interpretations differed, third opinion was obtained. They also measured the size of cyst and main duct. The diagnostic performance was analyzed using the ROC curve. The Mann–Whitney U test and κ statistics were used to determine interobserver agreement.

Results

The Az of MRI and EUS for determining diagnostic performance regarding the cyst communication with duct, were 0.931 and 0.930, without statistically difference (p = 0.6). Interobserver agreement was excellent (κ = 0.81) on MRI and substantial (κ = 0.69) on EUS. The Az of MRI and EUS for assessing diagnostic performance to differentiate malignant from benign cyst, was 0.902 and 0.923, without statistically difference (p = 0.587). Interobserver agreement was excellent (κ = 0.81) on MRI and moderate (κ = 0.47) on EUS. The mean cyst size (3.98 cm + 2.74: 3.17 cm + 1.26, p = 0.327) and the duct size (5.20 mm + 3.22: 4.39 mm + 4.12, p = 0.227) showed no statistically difference between malignant and benign cysts.

Conclusion

MRI and EUS can accurately assess pancreatic cyst communication with duct and are very useful for obtaining a differential diagnosis of malignant cyst versus benign pancreatic cyst.     

MR-imaging of the thoracic aorta: 3D-ECG- and respiratory-gated bSSFP imaging using the CLAWS algorithm versus contrast-enhanced 3D-MRA

Objective

To compare a contrast-enhanced 3D angiography (CE-3D-MRA) with the ECG- and respiratory gated 3D balanced steady state free precession (bSSFP) sequence using the CLAWS algorithm (3D-bSSFP-CLAWS) with respect to acquisition time, image quality, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR).

Methods

14 patients (4 women, mean age ± SD: 52 ± 18) with known or suspected thoracic aortic disease were imaged on a 1.5 T scanner with both sequences. Two readers scored image quality of predefined levels of the thoracic aorta. Acquisition time, SNR and CNR were calculated for each examination.

Results

Image quality achieved with the 3D-bSSFP-CLAWS was scored significantly better than with the CE-3D-MRA for the aortic annulus (P = 0.003), the sinuses of Valsalva (P = 0.001), the proximal coronary arteries (P = 0.001) and the sinotubular junction (P = 0.001). Effective acquisition time for the 3D-bSSFP-CLAWS and corrected acquisition time (corrected for imaging parameters) was significantly longer compared to the CE-3D-MRA (P = 0.004 and P = 0.028). SNR and CNR were significantly higher for the CE-3D-MRA (P = 0.007 and P = 0.001).

Conclusions

Providing the highest scan efficiency for a given breathing pattern, image quality for the proximal ascending aorta achieved with the 3D-bSSFP-CLAWS is significantly superior in contrast to the CE-3D-MRA.     

Influence of left ventricular hypertrophy on infarct size and left ventricular ejection fraction in ST-elevation myocardial infarction

Background

Left ventricular hypertrophy (LVH) predisposes to larger infarct size, which may be underestimated by the left ventricular ejection fraction (LVEF) due to supranormal systolic performance often present in patients with LVH. The aim of the study was to compare infarct size and LVEF in patients with ST-segment elevation myocardial infarction (STEMI) and increased left ventricular mass on cardiac magnetic resonance (CMR).

Methods

The study included unselected group of 52 patients (61 ± 11 years, 69% male) with first STEMI who had CMR after median 5 days from the onset of the event. Left ventricular hypertrophy (LVH) was defined as left ventricular mass index exceeding 95th percentile of references values for age and gender. Infarct size was assessed with means of late gadolinium enhancement (LGE).

Results

LVH was found in 16 patients (31%). In comparison to the rest of the group, patients with LVH had higher absolute and relative infarct mass (p = 0.002 and p = 0.02, respectively). LVH was related to higher prevalence of microvascular obstruction and myocardial haemorrhage and higher number of LV segments with transmural necrosis (p = 0.02, p = 0.01 and p = 0.01, respectively). Despite marked difference in the infarct size between both studied subgroups there was no difference in LVEF and mean number of dysfunctional LV segments.

Conclusions

Patients with LVH undergoing STEMI have larger infarct size underestimated by the LV systolic performance in comparison to patients without LVH.     

Shape and volume of internal anal sphincter showed by three-dimensional anorectal ultrasonography

Purpose

The aim of this work is to characterize the shape and the volume of the internal anal sphincter (IAS) in normal subjects by three-dimensional anorectal ultrasonography.

Methods

Thirty-nine normal volunteer males (mean age 58.5 ± 18.7) and 25 females (mean age 59.4 ± 14.1) were submitted to anorectal ultrasonography.The tissue is defined by a semiautomatic procedure. Measurements of thickness, length and volume were assessed automatically.The software provides an average number of 57,600 thickness measurements, 360 length measurements for each zone (90 for each quadrant) and seven volume measurements (one for each anatomical area).The mean values of magnitudes were calculated for the entire volume in each quadrant and zone. Age and gender-related variations were analyzed.

Results

In assessments of the whole tissue, only thickness was gender-related, with greater thickness for females (male thickness: 1.81 ± 0.47 mm, female thickness 2.16 ± 0.57 mm, P-value < 0.01).In the distal zone: thickness, length and volume were all larger in females (for male and female respectively: 1.83 ± 0.49 mm vs 2.34 ± 0.58 mm, P-value < 0.01, for the thickness; 10.87 ± 2.10 mm vs 12.18 ± 2.21 mm, P-value < 0.02 for the length and 1501 ± 605 mm³ vs 2169 ± 871 mm³, P-value < 0.01 for the volume). In the medial zone, only thickness was gender-related, with greater thickness in females (male thickness: 2.04 ± 0.60 mm, female thickness:2.44 ± 0.74 mm, P-value < 0.02).The only variation observed in the proximal zone concerned length, larger in males (respectively: 11.27 ± 2.84 mm vs 9.55 ± 2.43 mm, P-value < 0.02).The male population was significantly positively correlated with ageing for volume in the whole tissue (ρ = 0.32, P-value < 0.05), and for both thickness and volume in the medial zone (ρ = 0.33, P-value < 0.05 for thickness; ρ = 0.39, P-value < 0.02 for the volume).

Conclusion

This new method is useful to understand both functional anal disorders and local damage which may affect only part of the muscle tissue.     

Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols

Objective

To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis.

Materials and methods

We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl).

Results

All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort.

Conclusion

A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.