Breathhold unenhanced and gadolinium-enhanced magnetic resonance tomography and magnetic resonance cholangiography in hilar cholangiocarcinoma

We assessed the imaging characteristics of hilar cholangiocarcinoma in magnetic resonance imaging (MRI) and magnetic resonance cholangiography (MRC). Breathhold MRI (T2-weighted turbo spin echo sequences, unenhanced T1-weighted gradient echo sequences, and gadolinium-enhanced fat-suppressed gradient echo sequences) and breathhold MRC (fat-suppressed two-dimensional projection images) performed in 12 patients with histologically confirmed hilar cholangiocarcinoma were retrospectively reviewed for morphological tumor characteristics and contrast enhancement patterns. MRC demonstrated a significant bile duct stenosis with intrahepatic bile duct dilatation in all cases except in one patient who received an endoprothesis prior to imaging. Hilar cholangiocarcinoma was diagnosed by MRC only in one patient and MRI and MRC in 11. Mass lesions were seen in nine patients and circumferential tumor growth in three, including the patient diagnosed by MRC only. The tumor appeared hypointense relative to liver parenchyma in 10 of 11 patients in unenhanced T1-weighted images. T2-weighted sequences showed isointense or only slightly hyperintense signal in 5 of 11 patients, 3 of whom demonstrated desmoplastic reactions by histology. The other 6 patients revealed strongly hyperintense signal intensities. Contrast enhancement was increased compared to liver in 5 of 11 patients and decreased in 6 of 11 patients. MRI with MRC seem to be a sensitive tools in the detection of hilar cholangiocarcinomas. The variable imaging characteristics are most probably related to the inhomogeneous histological appearance of this tumor entity.     

Potential utility of magnetic resonance cholangiography in the management of endoscopic biliary drainage tubes

An 80-yr-old woman with advanced hilar cholangiocarcinoma underwent a placement of endoscopic biliary drainage (EBD) tube from the common hepatic to common bile duct through the stricture. Magnetic resonance cholangiography clearly demonstrated the later dislocation and obstruction of the EBD tube. The present case suggests that magnetic resonance cholangiography may be a potentially useful tool in the management of EBD tubes.     

Prospective comparison of transcutaneous 3-dimensional US cholangiography, magnetic resonance cholangiography, and direct cholangiography in the evaluation of malignant biliary obstruction

BACKGROUND: The purpose of this study was to investigate the ability of transcutaneous three-dimensional US cholangiography to depict the biliary tree in malignant obstruction, compared with that of MRCP and direct cholangiography. METHODS: Three-dimensional US and MRCP and direct cholangiography were performed in 40 patients with suspected malignant biliary obstruction. Diagnostic quality of the images, presence, level, and cause of ductal obstruction were assessed in a prospective, blinded fashion. The results were correlated with consensus interpretation (3 investigators), intra-operative findings, and histopathology or clinical follow-up. RESULTS: Three-dimensional US produced cholangiographic images of diagnostic quality. The appearance of these images was similar to that of MRCP or ERCP/percutaneous transhepatic cholangiography images. All modalities were highly sensitive in the detection of biliary dilatation. The accuracy of 3-dimensional US, MRCP, and ERCP/percutaneous transhepatic cholangiography in determining the level of obstruction was, respectively, 92%, 95%, and 98%. Transcutaneous 3-dimensional US and MRCP accurately identified the cause of obstruction in, respectively, 90% and 95% of cases. Direct cholangiography revealed the correct diagnosis in 95% of the patients. CONCLUSIONS: Three-dimensional US cholangiography is a new, noninvasive method with the capability to produce diagnostic cholangiograms. Three-dimensional US cholangiography may be used increasingly as an initial test to select patients who require further diagnostic evaluation by MRCP or therapeutic ERCP.     

Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures

BACKGROUND: Magnetic resonance cholangiography (MRC) is currently under investigation for non-invasive biliary tract imaging. AIM: To compare MRC with endoscopic retrograde cholangiography (ERC) for pretreatment evaluation of malignant hilar obstruction. METHODS: Twenty patients (11 men, nine women; median age 74 years) referred for endoscopic palliation of a hilar obstruction were included. The cause of the hilar obstruction was a cholangiocarcinoma in 15 patients and a hilar compression in five (one hepatocarcinoma, one metastatic breast cancer, one metastatic leiomyoblastoma, two metastatic colon cancers). MRC (T2 turbo spin echo sequences; Siemens Magnetomvision 1.5 T) was performed within 12 hours before ERC, which is considered to be the ideal imaging technique. Tumour location, extension, and type according to Bismuth's classification were determined by the radiologist and endoscopist. RESULTS: MRC was of diagnostic quality in all but two patients (90%). At ERC, four patients (20%) had type I, seven (35%) had type II, seven (35%) had type III, and two (10%) had type IV strictures. MRC correctly classified 14/18 (78%) patients and underestimated tumour extension in four (22%). Successful endoscopic biliary drainage was achieved in 11/17 attempted stentings (65%), one of which was a combined procedure (endoscopic + percutaneous). One patient had a percutaneous external drain, one had a surgical bypass, and in a third a curative resection was attempted. Effective drainage was not achieved in six patients (30%). If management options had been based only on MRC, treatment choices would have been modified in a more appropriate way in 5/18 (28%) patients with satisfactory MRC. CONCLUSION: MRC should be considered for planning treatment of malignant hilar strictures. Accurate depiction of high grade strictures for which endoscopic drainage is not the option of choice can preclude unnecessary invasive imaging.     

Malignant perihilar biliary obstruction: magnetic resonance cholangiopancreatographic findings

OBJECTIVE: We studied the efficacy of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of malignant perihilar biliary obstructions, with reference to endoscopic retrograde cholangiopancreatography (ERCP). METHODS: A total of 40 patients with malignant perihilar biliary obstructions, who underwent both MRCP (Magnetom Vision; Siemens, Erlangen, Germany; projection technique and multislice plus maximum intensity projection) and ERCP examinations, were studied. The study group included hilar cholangiocarcinoma (Klatskin tumor) in 26 patients, icteric hepatocellular carcinoma in four patients, gallbladder carcinoma in five patients, and metastasis from other than hepatobiliary origin in five patients. Axial and coronal magnetic resonance (MR) images were added simultaneously to the MRCP. The mean serum bilirubin level on admission was 11.5 mg/ml (range, 2.8-28.5 mg/ml). The presence and extent of malignant biliary obstruction were determined with both MRCP and ERCP following the known criteria: an abrupt and irregular character of a distal narrow segment, a proportionally dilated biliary tree proximally, and an irregularly shaped intraluminal filling defect. The efficacy of the MRCP examination in detecting the presence of biliary obstruction, its anatomical extent, and the underlying cause, respectively, was compared to that of ERCP. RESULTS: MRCP examination was successfully performed on all patients, whereas ERCP examination was unsuccessful in two patients. Both MRCP and ERCP were very effective in detecting the presence of biliary obstructions (40 of 40 vs. 38 of 38, p = 1.0). MRCP was superior in its investigation of anatomical extent (34 of 40 vs. 24 of 38, p = 0.015) and the cause of the jaundice (31 of 40 vs. 22 of 38, p = 0.023) compared to ERCP. Specifically, the performance of MRCP is promising for the interpretation of cholangiocarcinoma (22 of 26) and gallbladder carcinoma (five of five), but is relatively ineffective for the interpretation of icteric HCC (two of four) and metastasis (two of five). CONCLUSION: MRCP represented an ideal noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions with reference to ERCP.     

Variations of the hilar biliary confluence from postoperative cholangiography in Chinese population

正To the Editor: Treatment of the bile ducts at the porta hepatis is a critical step for avoiding post-surgical bile leakage and atrophy of the residual liver and/or the graft during hepatobiliary surgeries, such as hemihepatectomy, surgeries for cholangiocarcinoma or procurement of graft. Precise knowledge of the bile duct anatomy in individual cases has great importance in avoiding these kinds of complications. According to the Couinaud nomenclature,     

三种非手术胆管引流方法治疗肝门部恶性胆道梗阻的疗效评估

目的探讨不同非手术胆管引流方法治疗肝门部恶性胆道梗阻（MHBO）的疗效和并发症发生率。方法245例MHBO患者分为3组,其中内镜治疗组86例、经皮治疗组104例、内镜与经皮联合组（联合治疗组）55例。245例患者中,BismuthⅠ型31例、Ⅱ型24例、Ⅲ型108例、Ⅳ型74例。对各组患者的临床资料进行回顾性分析,并对其中具有可比性的数据进行统计学处理。结果内镜治疗组、经皮治疗组和联合治疗组减黄有效率分别为82．4％（56／68,除外18例近期并发胆管炎行PTBD者）、72．1％（75／104）和89．1％（49／55）,其中Bismuth Ⅲ型患者减黄有效率分别为78．6％（22／28,除外7例近期并发胆管炎行PTBD者）、69．8％（30／43）和90．0％（27／30）,且Ⅲ型患者中双侧引流减黄有效率89．5％（34／38）明显优于单侧引流73．0％（46／63）。内镜治疗组近期并发胆管炎19例,发生率为22．1％（19／86）,明显高于经皮治疗组的5．8％（6／104）和联合治疗组的5．5％（3／55）（P均〈0．05）。Bismuth Ⅲ型及以上患者中,内镜、经皮及联合治疗组近期胆管炎发生率分别为33．3％（18／54）、6．6％（5／76）和5．8％（3／52）,内镜治疗组明显高于其他两组（P〈0．05）。结论对于不能手术的MHBO,内镜和（或）经皮方法减黄治疗有效,但内镜治疗胆管炎发生率高;Bismuth Ⅲ型及以上患者内镜与经皮联合治疗胆管炎并发症发生率低,减黄效果好。     

Endoscopic ultrasound‐guided biliary drainage of hilar biliary obstruction

Only 20–30% of patients with hilar cholangiocarcinoma (CC) are candidates for potentially curative resection. However, even after curative (R0) resection, these patients have a disease recurrence rate of up to 76%. The prognosis of hilar cholangiocarcinoma (CC) is limited by tumor spread along the biliary tree leading to obstructive jaundice, cholangitis, and liver failure. Therefore, palliative biliary drainage may be a major goal for patients with hilar CC. Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is an established method for palliation of patients with malignant biliary obstruction. However, there are patients for whom endoscopic stent placement is not possible because of failed biliary cannulation or tumor infiltration that limits transpapillary access. In this situation, percutaneous transhepatic biliary drainage (PTBD) is an alternative method. However, PTBD has a relatively high rate of complications and is frequently associated with patient discomfort related to external drainage. Endoscopic ultrasound‐guided biliary drainage has therefore been introduced as an alternative to PTBD in cases of biliary obstruction when ERCP is unsuccessful. In this review, the indications, technical tips, outcomes, and the future role of EUS‐guided intrahepatic biliary drainage, such as hepaticogastrostomy or hepaticoduodenostomy, for hilar biliary obstruction will be summarized.     

A modern approach to malignant hilar biliary obstruction

Management of patients with malignant hilar biliary obstruction is challenging for all specialists involved in their care. Evaluation should focus on potential surgical resection, which offers the principal chance of cure; liver transplantation is offered as an experimental treatment at a few centers. Attempt at curative surgical resection is appropriate for selected tumors and often requires partial hepatectomy. Diagnosis and staging is now facilitated by the use of magnetic resonance cholangiopancreatography (MRCP), spiral computed tomography, and endoscopic ultrasonography, which should largely supplant invasive cholangiography. Use of endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography should be limited primarily to palliation of jaundice in patients with unresectable tumors and to establish tissue diagnoses in ambiguous cases. Palliation of jaundice is optimal with self-expanding metallic stents. Safe and effective drainage can be achieved by using MRCP for targeted endoscopic placement of unilateral metal stents in most cases, with bilateral stents rarely required unless undrained ducts are contaminated. Other palliative modalities for bile duct tumors include surgical bypass, intraluminal and external beam radiation therapy, chemotherapy, and photodynamic therapy.     

The role of magnetic resonance cholangiopancreatography in patients with suspected biliary obstruction

Endoscopic retrograde cholangiopancreatography (ERCP) is an accepted and accurate procedure that combines the advantage of diagnosis of biliary obstruction with possible therapeutic endobiliary intervention. However, it is an operator-dependent and invasive procedure that is associated with complications and limitations. Magnetic resonance cholangiopancreatography (MRCP) is a unique noninvasive technique for the diagnosis of biliary obstruction. It is well suited to provide the information required to plan the optimal therapeutic approach for these patients. MRCP has the potential to replace or at least precede ERCP as the first-line imaging effort in the evaluation of suspected biliary obstruction. Significant advantages and some notable limitations inherent to the modality dictate its judicious use in appropriate circumstances. The present article reviews the utility of MRCP in evaluation of biliary obstruction, with brief reference to its principles and techniques.     

Endoscopic management of hilar biliary strictures

Hilar biliary strictures are caused by various benign and malignant conditions. It is difficult to differentiate benign and malignant strictures. Postcholecystectomy benign biliary strictures are frequently encountered. Endoscopic management of these strictures is challenging. An endoscopic method has been advocated that involves placement of increasing number of stents at regular intervals to resolve the stricture. Malignant hilar strictures are mostly unresectable at the time of diagnosis and only palliation is possible.Endoscopic palliation is preferred over surgery or radiological intervention. Magnetic resonance cholangiopancreaticography is quite important in the management of these strictures. Metal stents are superior to plastic stents. The opinion is divided over the issue of unilateral or bilateral stenting.Minimal contrast or no contrast technique has been advocated during endoscopic retrograde cholangiopancreatography of these patients. The role of intraluminal brachytherapy, intraductal ablation devices, photodynamic therapy, and endoscopic ultrasound still remains to be defined.     

肝门部高位恶性胆管梗阻的多支架引流治疗

目的探讨多支架植入技术治疗肝门部高位多发性恶性胆道梗阻的治疗方法及临床应用价值。方法高位胆管梗阻127例。梗阻部位：肝总管上端距左、右肝管汇合部1cm以内66例，左、右肝管及肝总管上端同时梗阻45例．肝内右肝管多发性梗阻5例，肝内左、右肝管梗阻11例。采用五种支架植入方法。66例经右腋中线右肝管一胆总管途径植入支架；37例经腋中线和剑突下’分别穿刺左、右肝管。植入2个支架呈“Y”型排列。7例左肝管一右盯管问植入支架，再在右肝管一胆总管间植入支架．2支架呈“Г”行排列。3例右肝内肝管多发梗阻。先存右肝内盯管问放置支架，再在右肝管-肝总管问放置支架。12例右盯管放置支架．左肝管放置外引流。2例右盯内肝管多发梗阻病例，单纯放置多点位外引流。测定术前、术后血清总胆红素水平。结果127例高他胆管梗阻患者经植入支架。实现胆汁内引流。J2J例患者的总胆红素由术前平均（283．4±175．4）μmol，／L下降至（63．2±111．8）／μmol／L．差异有统计学意义（P〈0．05）。术后随访1～28个月．患者生存率大于6个月者占67．3％（85/127）。1年者占46．5％（59／127）。结论对无法手术治疗的肝门部高位多部位恶性胆管梗阻．采用双点传双通道双支架植入或单点位单通道双支架植入,能有效实现胆汁的全面充分内引流．临床效果显著。     

全国酒精性肝病的多中心调查分析

目的对全国酒精性肝病发病情况、临床特征等进行多中心回顾研究。方法按酒精性肝病诊疗指南标准，将全国7家医院2000—2004年902例确诊为酒精性肝病患者纳入研究。回顾调查酒精性肝病患者占同期住院肝病患者的构成比，分析酒精性肝病的易感因素。结果2000-2004年,酒精性肝病患者占同期住院肝病患者的病例构成比分别为2．4％、2．7％、2．8％、3．4％和4．3％；酒精性肝病以40～49岁者居多，每日摄入乙醇量为80～159g。饮酒年限以20～29年者居多；轻症酒精性肝病101例（11．2％）。酒精性脂肪肝204例（22．6％），酒精性肝炎260例（28．8％），酒精性肝硬化337例（37．4％）。酒精性肝硬化组的饮酒量、饮酒年限与其他三组差异有统计学意义（P〈0．05）。酒精性肝病患者常见临床表现为乏力、纳差、黄疸、腹胀、腹痛等；血清学改变以天冬氨酸转氨酶、丙氨酸转氨酶、了谷氨酰转肽酶、胆红素升高为主。约19．7％患者出现乙醇相关性精神障碍表现，11．9％出现乙醇戒断综合征．10．8％有乙醇性肌病表现；乙醇性心肌和胰腺损害分别占4．6％和3．1％；0．3％有乙醇性性功能障碍表现。结论酒精性肝病占同期住院肝病患者构成比呈逐年上升趋势,肝脏损害程度与饮酒量、饮酒年限相关．长期大量饮酒可造成多器官功能受损。     

Postoperative biliary adverse events following orthotopic liver transplantation: Assessment with magnetic resonance cholangiography

Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings makes the diagnosis challenging. Moreover, direct cholangiographic procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography present an inadmissible rate of adverse events to be utilized in clinically low suspected patients. Magnetic resonance (MR) maging with MR cholangiopancreatography is crucial in assessing abnormalities in the biliary system after liver surgery, including liver transplant. MR cholangiopancreatography is a safe, rapid, non-invasive, and effective diagnostic procedure for the evaluation of biliary adverse events after liver transplantation, since it plays an increasingly important role in the diagnosis and management of these events. On the basis of a recent systematic review of the literature the summary estimates of sensitivity and specificity of MR cholangiopancreatography for diagnosis of biliary adverse events following OLT were 0.95 and 0.92, respectively. It can provide a non-invasive method of imaging surgical reconstruction of the biliary anastomoses as well as adverse events including anastomotic and non-anastomotic strictures, biliary lithiasis and sphincter of Oddi dysfunction in liver transplant recipients. Nevertheless, conventional T2-weighted MR cholangiography can be implemented with T1-weighted contrast-enhanced MR cholangiography using hepatobiliary contrast agents (in particular using Gd-EOB-DTPA) in order to improve the diagnostic accuracy in the adverse events’ detection such as bile leakage and strictures, especially in selected patients with biliary-enteric anastomosis.     

Choledochocele imaged with magnetic resonance cholangiography

Choledochal cysts are rare developmental malformations of the biliary tree. Percutaneous and endoscopic ultrasound, as well as endoscopic retrograde cholangiopancreatography, are recommended diagnostic tools. Magnetic resonance cholangiography may also contribute to the workup and treatment plan of patients with choledochal cysts. We report a 25-yr-old white woman with episodic nausea and moderate epigastric discomfort. Magnetic resonance cholangiography showed a rather spherical, cyst-like, fluid-filled structure in continuity with the prepapillary segment of the common bile duct, thus making a choledochocele (type III choledochal cyst) likely. The patient was treated by endoscopic sphincterotomy and, after a 6-month follow-up, is without complaints.     

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

OBJECTIVES: The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP. METHODS: A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. RESULTS: At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. CONCLUSIONS: Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.