Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging modality that has high diagnostic accuracy for a wide range of bile duct and pancreatic duct pathologies. Endoscopic retrograde cholangiopancreatography (ERCP) is still the gold standard for the exploration of the biliopancreatic region.

The aim of the study was to compare the diagnostic accuracy of MRCP with that of ERCP in the diagnosis of bile duct and pancreatic duct pathologies.

A total of 60 patients with common bile duct (CBD) and pancreatic duct pathologies detected on MRCP were subsequently evaluated by ERCP in this observational study. A comparison of MRCP findings with ERCP was made.

MRCP had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 88.1%, 94.4%, 97.3%, 72.7%, and 90%, respectively, in diagnosing choledocholithiasis in comparison to ERCP. For CBD dilation, the sensitivity was 90.91%, specificity was 93.75% and the PPV, NPV, and accuracy were 97.56%, 78.95%, and 91.67%, respectively, for MRCP. In CBD stricture, MRCP showed a sensitivity, specificity, PPV, NPV, and accuracy of 83.33%, 97.92%, 90.91%, 95.92%, and 95%, respectively. In pancreatic duct dilatation, the sensitivity, specificity, PPV, NPV, and accuracy were all 100%. Pancreatic duct stricture showed a sensitivity, specificity, PPV, NPV, and accuracy of 80%, 98%, 88.89%, 96.08%, and 95%, respectively. For the diagnosis of periampullary carcinoma, the sensitivity, specificity, PPV, NPV, and accuracy rate of MRCP were 80%, 98%, 88.89%, 96.08%, and 95%, respectively.

No significant difference was found between MRCP and ERCP in diagnosing those six pathologies.

Chronic pancreatitis is characterized by irreversible destruction of pancreatic parenchyma and its ductal system resulting from longstanding inflammation, leading to fibrosis and scarring due to genetic, environmental, and other risk factors. The diagnosis of chronic pancreatitis is made based on a combination of clinical features and characteristic findings on computed tomography or magnetic resonance imaging. Abdominal pain is the most common symptom of chronic pancreatitis. The main aim of treatment is to relieve symptoms, prevent disease progression, and manage complications related to chronic pancreatitis. Patients who do not respond to medical treatment or not a candidate for surgical treatment are usually managed with endoscopic therapies. Endoscopic therapies help with symptoms such as abdominal pain and jaundice by decompression of pancreatic and biliary ducts. This review summarizes the risk factors, pathophysiology, diagnostic evaluation, endoscopic treatment of chronic pancreatitis, and complications. We have also reviewed recent advances in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided therapies for pancreatic duct obstruction due to stones, strictures, pancreatic divisum, and biliary strictures.

In daily routine, every radiologist is confronted with a variety of questions concerning the biliary tract and pancreatic system.

Today, besides sonography, magnetic resonance cholangiopancreatography (MRCP) is considered the method of choice in the investigation of many disorders of the hepatobiliary and pancreatic system and is commonly preferred over invasive ERCP in a mere diagnostic setting.

Since its introduction in 1991, MRCP has constantly evolved. Major innovations have been the reduction of acquisition time by using fast spin echo (FSE) sequences, the use of respiratory gating and contrast-enhanced imaging of the bile ducts with hepatobiliary-specific MRI contrast agents.

Many diagnoses may already be made with noncontrast enhanced images. By supplemental administration of a hepatobiliary-specific contrast agent, it is also possible to evaluate the flow dynamics of the bile. This is of additional value especially in patients who underwent surgery of the biliodigestive system or endoscopic interventions.

Aside from robustness and reproducibility, a major advantage of this technique is the modular design of imaging protocols, which can easily be adapted to the clinical question.

MRCP is a reliable and low-risk imaging method for primary diagnosis and follow-up of biliary and pancreatic pathologies.

Differentiation of the benign and malignant etiology of biliary obstruction is difficult. We studied the diagnostic accuracy of MRCP (Magnetic Resonance Cholangio-pancreatography) in differentiating between benign and malignant causes of biliary obstruction.

To evaluate the role of Magnetic Resonance Cholangio-Pancreatography in differentiating benign from malignant causes of biliary obstruction using surgical, ERCP or histopathological findings as gold standard.

Seventy five patients with clinical and laboratory finding suggestive of biliary obstruction underwent MRI/MRCP. The final diagnosis was based on either surgical findings, histopathology of resected specimen or ERCP findings. Diagnostic effectivity of MRCP was calculated which included sensitivity, specificity and accuracy. Statistical analysis was done by using chi-square test and p value was calculated.

Out of 75 cases, there were 54 benign and 21 malignant cases. Mean age of patients with malignant obstruction was more than benign with slight male preponderance. The diagnostic accuracy of MRCP in differentiating benign from malignant biliary obstructive diseases in correlation with surgical, ERCP and histopathological outcome was 93.3%, sensitivity 85.7%, specificity 96.3%. It was found that irregular, asymmetric and long segment narrowing was more common in malignant stricture.

MRCP is the investigation of choice for suspected choledocholithiasis, choledochal cyst and primary sclerosing cholangitis. A benign stricture can be differentiated from a malignant one if it shows regular, symmetric and short segment narrowing. Irregular, asymmetric and long segment narrowing was more commonly found in malignant stricture.

Gd-EOB-DTPA-enhanced magnetic resonance (MR) could be used for preoperative evaluation of bile duct anatomy in addition to conventional information of focal hepatic lesions.

To evaluate accuracy of contrast-enhanced MR cholangiography (CE MRC) reconstructed from Gd-EOB-DTPA-enhanced MR images for depicting biliary anatomy with intraoperative cholangiography.

We retrospectively identified 71 patients who underwent both preoperative Gd-EOB-DTPA-enhanced MR imaging (MRI) and intraoperative cholangiography for hepatic resections. Two readers independently analyzed biliary anatomy using CE MRC reconstructed from transverse and coronal images separately in 4 weeks. The accuracy and diagnostic confidence were evaluated in correlation with intraoperative cholangiography. The accuracy and confidence score (3-point scale) were compared on CE MRCs from transverse versus coronal images.

CE MRCs correctly depicted biliary anatomy in 91.5% and 88.7% with coronal images and in 81.7% and 73.2% with transverse images for readers 1 and 2, respectively. CE MRCs from coronal images tended to show greater accuracy (P = 0.12 and 0.01, for readers 1 and 2) and higher confidence score (P = 0.11 and P = 0.04, for readers 1 and 2) than those from transverse images.

Accurate preoperative biliary mapping can be achieved on CE MRC reconstructed from Gd-EOB-DTPA-enhanced MR images. The diagnostic performance was better on CE MRC reconstructed from coronal than those from transverse images.

The aim of this study was to compare the image quality of magnetic resonance Cholangiopancreatography (MRCP) using Pineapple Juice (PJ) or ranitidine as negative oral contrast agents and no agent.

MRCP images of patients administered PJ (n = 117) or Ranitidine (n = 110) at random, and patients without an agent (n = 50) were evaluated. The subjective image quality of the overall, extra hepatic bile duct and pancreatic duct and the degree of elimination of gastrointestinal fluid were scored by two blinded radiologists. RESULTS were compared using Mann-Whitney's U-test.

The degrees of elimination of gastro duodenal fluid of PJ and ranitidine were significantly better than those without an agent (p < 0.01 and p < 0.01, respectively). The subjective image quality of PJ of the overall and extra hepatic bile duct were significantly better, although no significant differences for ranitidine were observed compared with those without an agent (p < 0.01 and p =0.23, p = 0.025 and p = 0.18). There were no significant differences for the pancreatic duct (p = 0.13 and p = 0.20), nor were there any significant differences in the evaluations between PJ and ranitidine (p = 0.21 and p = 0.96).

PJ showed better performance compared to that of conventional ranitidine in terms of pancreatic and biliary depiction and safety.

To evaluate the usefulness of magnetic resonance cholangiopancreatography (MRCP) in patients referred for assessment of the cause of elevated liver enzymes.

The MRCP scans of 170 patients between 2009 and 2011 with elevated liver enzyme levels were blindly and independently rereviewed by two experienced radiologists. Biochemical data were collected from the medical records. Receiver operating characteristics curve analyses were carried out. Cutoff levels of the enzymes to predict pathological MRCPs were determined by the area under the curve (AUC). Sensitivity, specificity, negative predictive value, and positive predictive value were calculated.

MRCP scans of 134 patients were identically diagnosed by the two reviewers as nonpathological and 22 as pathological and 14 as uncertain. The agreement between the two reviewers was κ=0.62, indicating good agreement. The percentage of pathological MRCP performed because of elevated liver enzymes was only 14%. For patients with inflammatory bowel disease, the frequency was 36%. On receiver operating characteristics curve analysis, Az values were high for alkaline phosphatase 160 U/l (AUC=0.725) and γ-glutamyl transferase 270 U/l (AUC=0.617). Alkaline phosphatase and γ-glutamyl transferase had a high negative, but low positive predictive value for distinguishing pathological from normal scans.

MRCP does not contribute markedly toward the evaluation of the cause of elevated enzyme levels, except in patients with inflammatory bowel disease. These findings can provide practical guidelines for evaluation of patients with abnormal liver enzymes and for alleviation of the financial burden from health providers.

To assess the feasibility of a comprehensive MRI protocol using intrabiliary contrast medium (gadolinium-EOB-DTPA) for evaluation of living liver donors.

In this prospective study, 30 donor candidates for living-related liver transplantation (17 men; 13 women, mean age 37 ± 10.9 years) underwent MRI including MR-angiography (MRA) as well as a conventional T2-weighted MR-cholangiography (MRC) and a contrast-enhanced sequence for depiction of the biliary structures. MRC and MRA images were evaluated for quality on a four-point-scale (score of 0 indicated poor and a score of 3, excellent image quality). Anatomic variants of the arterial, venous, portal venous, and biliary structures were identified.

Image quality was diagnostic in all examinations except for 4 of 30 MRA data sets. Intrahepatic biliary structures, especially with regard to the intrahepatic bile ducts of 2nd and 3rd order could be identified with significantly increased image quality than in conventional T2-weighted MRC sequences (P = 0.005 and P = 0.035). A high percentage rate of anatomic variants regarding the biliary, arterial, venous, and portal venous anatomy was found.

This protocol allows the evaluation of liver donors especially with regard to the biliary structures. However, the depiction of the arterial anatomy requires further technical developments.

The purpose of this study was to compare the biliary enhancement dynamics of gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic-acid (Gd-EOB-DTPA) and mangafodipir trisodium (Mn-DPDP) for contrast-enhanced MR cholangiography (MRC) in healthy subjects.

15 healthy volunteers underwent MRI at 1.5 T with volumetric interpolated breath-hold examination sequence. Each volunteer was scanned once for each contrast agent. The signal-to-noise ratio (SNR) of the liver parenchyma and common hepatic duct (CHD) and the contrast-to-noise ratio (CNR) of CHD to liver parenchyma were evaluated and compared before and at several time points (5, 15, 30, 45, 60, 90, and 120 min) after injection of each agent.

SNR was significantly higher for Gd-EOB-DTPA than for Mn-DPDP in liver parenchyma after 5 min and in CHD after 15 min (p<0.05). CNR of CHD to liver parenchyma using Gd-EOB-DTPA showed an initial decrease at 5 min post-injection followed by a steep increase to a peak at 15 min post-injection. CNR using Mn-DPDP showed a steady increase to a peak at 15 min post-injection without an initial decrease. At 15 min, the value of CNR was significantly higher for Gd-EOB-DTPA than for Mn-DPDP (p<0.05).

For both contrast agents, CNR reached a peak at 15 min after contrast injection. At this time point, CNR of Gd-EOB-DTPA was significantly higher than that of Mn-DPDP. Therefore, Gd-EOB-DTPA may provide better contrast-enhanced MRC than Mn-DPDP at 15 min after contrast administration.

Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article (1) reviews the imaging features of the common cystic pancreatic lesions, including serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor, and including the less common lesions such as cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas; and (2) provides comprehensive algorithms on how to manage the individual lesions, with recommendations on when to reimage patients.

Cholecystectomy is one of the common surgical procedure performed across the world and bile duct injury is a dreaded complication. The present review addresses the classification of injuries, preoperative preparation and evaluation of these patients and appropriate timing of surgery. A detailed preoperative evaluation combined with a meticulous wide anastomosis by experienced surgeons is the key in achieving long term success. Vascular injuries and its consequences on repair and outcome is also reviewed. Long term results of surgical repair and quality of life in these patients are excellent.

Magnetic resonance (MR) cholangiopancreatography is useful in humans to diagnose biliary and pancreatic diseases. Some of these protocols incorporate the use of secretin, which stimulates the exocrine pancreas to release bicarbonate with secondary dilation of the pancreatic duct. We compared the utility and quality of multiple hepatic-pancreaticobiliary MR imaging sequences before and after secretin stimulation of the pancreatic duct in five healthy cats. Multiple MR sequences were evaluated, including fast Spoiled Gradient Recalled in- and out-of-phase, Single Shot Fast Spin Echo (SSFSE), T2 Fast Spin Echo, MR cholangiopancreatography (pre- and postsecretin administration), and Fast Acquisition with Multiphase Efgre (FAME) (postsecretin and before and after gadolinium administration). The MR cholangiopancreatography protocol with secretin stimulation was feasible and yielded high-contrast maps of the biliary ductal anatomy but the pancreactic duct was seen inconsistently. The FAME series most consistently provided visualization of biliary and postsecretin pancreatic ductal anatomy, combined with very good depiction of the liver and pancreas. The remaining sequences each had satisfactory utility and diagnostic quality, with the exception of the SSFSE sequences. Secretin improved the conspicuity of the pancreatic duct.

Recent progress of the data processing applied to ultrasonographic (US) examination has made it possible to develop new software. The US workstation of the last generation thus incorporated in their center a computer allowing a precise treatment of the US image. This advancement has made it possible to work out new images such as 3-dimensional (3D) US, contrast harmonic US associated with the intravenous injection of contrast agents, and even more recently, elastography. These techniques, quite elaborate in percutaneous US at present, are to be adapted and evaluated with endoscopic US (EUS). The contribution of contrast agents of US to pancreatic EUS and then 3D EUS are successively approached in this article.

The place of endoscopic ultrasound (EUS) in malignant pathology of the pancreas is two-fold: (1) EUS is the best examination for the diagnosis of small tumours (<3cm in diameter). Its sensitivity is greater than that of CT scan, percutaneous ultrasound or magnetic resonance imaging (MRI) and is equal to that of endoscopic retrograde cholangiopancreatography (ERCP) without sharing its invasive character; (2) EUS is also indicated in the assessment of locoregional extension of tumours judged resectable by tomodensitometric (TDM) (scanner) data. The performance of EUS seems to be greater than other imaging techniques for the diagnosis of vascular and lymph node invasion although recent studies report less good results than those of studies in 1992 to 1994, particularly for vascular involvement. Nevertheless, EUS cannot affirm the malignant or benign character of these pancreatic masses. The development over the last 20 years of linear sector-based EUS has enabled us to perform guided biopsies of such lesions. EUS-guided biopsy is today the best technique for obtaining the histology of a pancreatic mass, with a sensitivity of 85 to 87%. Furthermore, it also has a non-negligible impact on the deciding the treatment particularly in the case of adenocarcinomas (ADKP) not visible to TDM (scanners). This is currently of importance because trials are being developed of preoperative radio-chemotherapy for resectable lesions. probably in the next future, contrast-enhanced EUS (CE-EUS) and elastography will improve the results of EUS and will be necessary for a precise local staging before treatment.

We evaluate the effectiveness of the Amazonian fruit pulp from Euterpe olerácea (popularly named Açaí) as a negative oral contrast agent applied to clinical routine. The use of such contrasts is particularly important in magnetic resonance cholangiopancreatography (MRCP) to reduce overlapping.

We administered Açaí pulp to 5 nonsymptomatic subjects and 35 patients submitted to unspecific abdominal MR imaging, intending to set up optimal protocol. In 8 MRCP examinations, contrast and image effects were assessed and graded blindly by 2 independent radiologists. Quantitative analysis was performed by Wilcoxon test as to verify the potential of the Açaí to eliminate overlap signal over the pancreaticobiliary tract. Adverse effects and subject tolerance were also addressed.

The Açaí pulp elicited a local brightness decrease in T2-weighted images. The depiction of gallbladder, common bile duct, ampulla of Vater, and pancreatic duct was markedly improved after Açaí ingestion because of the suppression of the overlapping from bowel loops and gastric content (P < 0.01). All patients considered Açaí palatable, and no side effect was registered.

The Açaí pulp can be used routinely in MRCP studies as a natural, safe, and inexpensive negative oral contrast agent with high efficacy and patient acceptance.

Until recently, there was no contrast harmonic imaging technique available for EUS examination. Second-generation US contrast agents produce harmonic signals at lower acoustic powers and, therefore, are suitable for EUS imaging at low acoustic powers. CE-EUS could provide a contribution to the differential diagnosis between a primary pancreatic carcinoma, chronic pancreatitis and a pancreatic metastasis, and therefore can have a decisive influence on the selection of appropriate therapeutic strategies (follow-up, chemotherapy or surgery, for example). However, histology remains the standard in the differential diagnosis of pancreatic tumours. Regarding lymph nodes, CE-EUS cannot replace EUS-guided fine-needle aspiration. Elastography examines the elastic properties of tissues by applying a slight compression to the tissue and comparing an image obtained before and after this compression. EUS elastography is a new application in the field of endosonography and seems to be able to differentiate fibrous and benign tissue from malignant lesions. While our results are very encouraging, further research will be needed to further define the place of this new technique and should be aimed at further defining criteria for accurate elastography as well as subsequently assessing the technique using multiple operators in a blinded setting. EUS-guided sonoelastography has the potential for further guiding the diagnosis and therapy of gastrointestinal-related tumours.

The hepatocyte-specific contrast agent gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) was developed to improve the detection and characterization of focal liver lesions at magnetic resonance (MR) imaging. Approximately 50% of the injected dose is taken up into the functional hepatocyte and is excreted via the biliary system. Because of this property, Gd-EOB-DTPA has the potential to be a biliary contrast agent. When combined with T2-weighted MR cholangiography, Gd-EOB-DTPA-enhanced MR imaging can allow morphologic and functional assessment of the biliary system. Gd-EOB-DTPA-enhanced MR cholangiography could be effective in evaluation of biliary anatomy, differentiation of biliary from extrabiliary lesions, diagnosis of cholecystitis, assessment of bile duct obstruction, detection of bile duct injury including leakage and stricture, evaluation of biliary-enteric anastomoses, postprocedure evaluation, differentiation of biloma from other pathologic conditions, and evaluation of sphincter of Oddi dysfunction. However, the clinical applications of this imaging technique have not yet been fully explored, and further investigations are needed to determine the utility of Gd-EOB-DTPA-enhanced MR cholangiography in a clinical setting.

The purpose of this study was to investigate the effectiveness of the combined use of intravenous morphine and intramuscular glucagon in improving magnetic resonance cholangiopancreatography (MRCP) image quality in donors for living-related liver transplantation. Sixteen healthy donor candidates underwent an MRCP study. Coronal, single-shot, fast spin-echo, heavily T2-weighted dynamic MRCP images were obtained before and 3 minutes after the intravenous administration of morphine HCl with a dose of 0.04 mg/kg. Thirty minutes after the injection of morphine, intramuscular glucagon was used. Another MRCP image of the same pulse sequence was generated 15 minutes after the injection of glucagon with a dose of 1 mg. The diameter, signal intensity, and number of branches of bile ducts in MRCP images taken immediately before and after the injection of morphine and after the injection of glucagon (plus delayed morphine effects) were compared and analyzed. In all 16 donor candidates, the diameters of the right and left hepatic ducts, common bile duct, and main pancreatic duct were significantly increased (P < 0.05) in the MRCP images taken 3 minutes after the injection of morphine and 15 minutes after the injection of glucagon (plus delayed morphine effects) in comparison with MRCP images taken before any drug administration. The qualitative grading scores of the signal intensity and order of branches of bile ducts revealed improvements in the MRCP images after the injection of glucagon (plus delayed morphine effects; P < 0.05). In conclusion, combining the intravenous administration of low-dose morphine and the intramuscular use of glucagon before MRCP examination improves the visualization of the nondilated biliary ductal anatomy, which is important for the preoperative biliary evaluation of donor candidates for living-related liver transplantation.

An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreaticography (ERCP). Although early cholecystectomy is advised, there is no consensus about the time interval between LC and ERCP. The aim of this study is to evaluate the effects of the time interval between ERCP and ERCP on operation outcomes.

Patients with cholelithiasis and a risk of choledocholithiasis underwent ERCP. Patients were grouped as those operated on between 24 and 72 h after ERCP (group 1) and those operated on more than 72 h after ERCP (group 2). Patients' age, gender, body mass index, American Society of Anesthesiologists Physical Status, abdominal ultrasonography findings, white blood cell count, total serum bilirubin, ALP, amylase, ALT, AST, GGT levels, ERCP findings, time interval between ERCP and LC, conversion rate, median postoperative hospital stay, median operation time, intraoperative complication and postoperative complication rates were collected.

There was no significant difference between the demographics of the patients in both groups. The median operation time, median postoperative hospital stay and conversion rate in group 2 were significantly higher than those of group 1. More postoperative complications were seen in group 2.

Early cholecystectomy after ERCP, within 72 h, has better outcomes, probably due to the inflammatory processes.

Magnetic resonance pancreatography (MRCP) is now established as a robust noninvasive tool for the evaluation of biliary and pancreatic pathology. Its diagnostic performance is comparable with endoscopic retrograde cholangiopancreatography without the associated risks. This article aims to familiarize the reader with the technique, clinical indications, and limitations of the investigation. Common pitfalls in interpretation also are addressed. Emerging applications and techniques are discussed that include recent advances in technology and the development of functional imaging.

Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article aims to review the histopathologic and imaging findings of the relatively common lesions (serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor) and uncommon lesions (cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas) in this group.

Endoscopic retrograde cholangiography (ERC) is a well-established modality for diagnostic and therapeutic maneuvers in pancreaticobiliary disorders. However, it is technically more challenging in patients with postsurgical anatomy like Roux-en-Y anastomoses. Its effectiveness in post-orthotopic liver transplantation (OLT) patients with Roux-en-Y biliary reconstruction has not been reported. We sought to assess the efficacy and safety of ERC in this patient population. A total of 132 OLTs with Roux-en-Y biliary reconstruction were performed at our institution from June 1998 to August 2005. Data from consenting patients who underwent ERC were reviewed once they were identified through computerized medical index system. Of 132 OLT patients with Roux-en-Y biliary reconstruction, 31 patients (9 female and 22 male subjects ranging in age from 11 months to 70 years) underwent ERC. The indication for liver transplant was end-stage liver disease or occurrence of cholangiocarcinoma from primary sclerosing cholangitis in 28 patients and a case each of chronic hepatitis C, alcoholic liver disease, and metastatic islet cell carcinoma. A variable-stiffness pediatric colonoscope was used in most cases. ERC indications were both diagnostic and therapeutic and included the following: evaluation of increased liver biochemistries and fever in 12 patients, dilation of anastomotic biliary strictures in 10 patients, removal of fractured biliary tube or retained biliary stent in 6 patients, and in 1 patient each, biliary stone removal, management of bile leak, and jejunal tube extension placement for nutritional purpose. ERC was successful in 22 patients (71%). There were no postprocedural complications. Although ERC is technically more difficult and time-consuming in OLT patients with Roux-en-Y anastomoses, these data suggest that ERC is an effective and safe diagnostic and therapeutic modality with few or no complications when performed by experienced endoscopists. ERC was successful in most patients and allowed therapeutic interventions that obviated the need for percutaneous radiological intervention or surgery.

The purpose was to retrospectively compare two-dimensional (2D) magnetic resonance cholangiography (MRC) including breath-hold single-shot rapid acquisition with relaxation enhancement (RARE) and multislice half-Fourier RARE versus navigator-triggered 3D-RARE MRC in the evaluation of biliary malignancy. MRC findings were evaluated in 31 patients with malignant biliary obstruction, including biliary malignancy, gallbladder carcinoma, and ampullary cancer. Two observers independently reviewed the images to assess the overall image quality, artifacts, ductal conspicuity, extent of disease, diagnostic confidence of tumor extent, and origin of tumor. The results were compared with surgical and histopathologic findings. Studies obtained with 3D-MRC were of significantly higher technical quality than those obtained with 2D-MRC. However, the accuracy between two sequences for classification of tumor showed no statistical significance. There was no significant difference between the Az values of 2D- and 3D-MRC for overall tumor extent in bilateral second order branch, intrapancreatic common bile duct (CBD) involvement (Az = 0.889, 0.881 for 2D and Az = 0.903, 0.864 for 3D). Nor was there a significant difference between two sequences in the assessment of the origin of tumor. Although 3D-MRC has superior image quality over 2D-MRC, 3D-MRC showed no statistically significant difference in accuracy compared with 2D-MRC for evaluating the extent of disease in malignant biliary obstructions.

Bile duct strictures are a common complication in patients with advanced chronic pancreatitis and have a variable clinical presentation ranging from an incidental finding to overt jaundice and cholangitis. The diagnosis is mostly made during investigations for abdominal pain but jaundice may be the initial clinical presentation. The jaundice is typically transient but may be recurrent with a small risk of secondary biliary cirrhosis in longstanding cases. The management of a bile duct stricture is conservative in patients in whom it is an incidental finding as the risk of secondary biliary cirrhosis is negligible. Initial conservative treatment is advised in patients who present with jaundice as most will resolve once the acute on chronic attack has subsided. A surgical biliary drainage is indicated when there is persistent jaundice for more than one month or if complicated by secondary gallstones or cholangitis. The biliary drainage procedure of choice is a choledocho-jejunostomy which may be combined with a pancreaticojejunostomy in patients who have associated pain. Since many patients with chronic pancreatitis have an inflammatory mass in the head of the pancreas, a Frey procedure is indicated but a resection should be performed when there is concern about a malignancy. Temporary endoscopic stenting is reserved for cholangitis while an expandable metal stent may be indicated in patients with severe co-morbid disease.

Magnetic resonance cholangiopancreatography (MRCP) is an alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP) for investigating biliary obstruction. The use of MRCP, a non-invasive procedure, may prevent the use of unnecessary invasive procedures. The aim of the study was to compare the findings of MRCP with those of ERCP by the computation of accuracy statistics.

Thirteen electronic bibliographic databases, covering biomedical, science, health economics and grey literature were searched. A systematic review of studies comparing MRCP to diagnostic ERCP in patients with suspected biliary obstruction was conducted. Sensitivity, specificity, likelihood ratios, acceptability and adverse events were reported.

25 studies were identified reporting several conditions including choledocholithiasis (18 studies), malignancy (four studies), obstruction (three studies), stricture (two studies) and dilatation (five studies). Three of the 18 studies reporting choledocholithiasis were excluded from the analysis due to lack of data, or differences in study design. The sensitivity for the 15 studies of choledocholithiasis ranged from 0.50 to 1.00 while specificity ranged from 0.83 to 1.00. The positive likelihood ratio ranged: from 5.44-47.72 and the negative likelihood ratio for the 15 studies ranged from 0.00-0.51. Significant heterogeneity was found across the 15 studies so the sensitivities and specificities were summarised by a Receiver Operating Characteristic (ROC) curve. For malignancy, sensitivity ranged from 0.81 to 0.94 and specificity from 0.92 to 1.00. Positive likelihood ratios ranged from 10.12 to 43 and negative likelihood ratios ranged from 0.15 to 0.21, although these estimates were less reliable.

MRCP is a comparable diagnostic investigation in comparison to ERCP for diagnosing biliary obstruction.

To compare the efficacy of Mangafodipir trisodium (Mn-DPDP)-enhanced MR cholangiogrphy (MRC) and Gadobenate dimeglumine (Gd-BOPTA)-enhanced MRC in visualizing a non-dilated biliary system.

Eighty-eight healthy liver donor candidates underwent contrast-enhanced T1-weighted MRC. Mn-DPDP and Gd-BOPTA was used in 36 and 52 patients, respectively. Two radiologists reviewed the MR images and rated the visualization of the common duct, the right and left hepatic ducts, and the second-order branches using a 4-point scale. The contrast-to-noise ratio (CNR) of the common duct to the liver in the two groups was also compared.

Mn-DPDP MRC and Gd-BOPTA MRC both showed similar visualization grades in the common duct (p=.380, Mann-Whitney U test). In the case of the proximal bile ducts, the median visualization grade was significantly higher with Gd-BOPTA MRC than with Mn-DPDP MRC (right hepatic duct: p=0.016, left hepatic duct: p=0.014, right secondary order branches: p=0.006, left secondary order branches, p=0.003). The common duct-to-liver CNR of the Gd-BOPTA MRC group was significantly higher (38.90+/-24.50) than that of the Mn-DPDP MRC group (24.14+/-17.98) (p=.003, Student's t test).

Gd-BOPTA, as a biliary contrast agent, is a potential substitute for Mn-DPDP.

A newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors.

Fourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels.

In 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas.

MENBI has the ability and potential to predict histological characteristics of ampullary lesions.

Echo-enhanced ultrasound is a newly available mode of imaging for differential diagnosis of pancreatic tumours. Ductal carcinomas are often hypovascularised compared with the surrounding tissue. Neuroendocrine tumours, on the other hand, are hypervascularised lesions. Tumours associated with pancreatitis have a different vascularisation pattern depending on inflammation and necrosis. Cystadenomas frequently have many vessels along the fibrotic strands.

Data from prospective studies have demonstrated, on the basis of these imaging criteria, that the sensitivity and specificity of echo-enhanced sonography for differentiation of pancreatic masses are >or=85 and >or=90%, respectively.

Pancreatic tumours have a different vascularisation pattern in echo-enhanced ultrasound. These characteristics can be used with high diagnostic accuracy for differential diagnosis.

The objective was the evaluation of minimum intensity projections (MinIP) of 16-channel multidetector computed tomography (MDCT) data for the visualization of biliary ducts with magnetic resonance cholangiopancreatography (MRCP) as reference method. Twenty-five patients with biliary obstruction who received MDCT of the abdomen and MRCP without subsequent interventions were analysed. Coronal and axial MinIP were reconstructed from the MDCT-data. The evaluation of image quality and the quantitative comparison to MRCP was performed by two observers in consensus. The additional diagnostic value of MinIP compared with conventionally visualised MDCT was assessed by three independent observers. With MRCP as the reference method, MinIP was superior to conventional MDCT concerning the visualization of the extent of bile duct dilatation (r, 1.000 vs 0.699) and the correlation of diameter measurement (r, 0.979 vs 0.942). Subsidiary to conventional MDCT, MinIP revealed an improvement of visualization of the biliary system in 73% of cases. Concerning the additional diagnostic value, MinIP allowed for a better definition of the obstruction site in 13% of patients, and in one patient a change of diagnosis was observed. Thus, MinIP can improve the diagnostic assessment of biliary obstructions in MDCT imaging.

Drugs such as secretin and morphine have been used to augment the visualization of magnetic resonance cholangiopancreatography (MRCP). This study investigated the effectiveness of intravenous administration of a synthetic opioid, fentanyl, in improving the MRCP image quality.

Thirty consecutive patients with a provisional diagnosis of benign biliary and/or pancreatic disease underwent MRCP. Coronal single-shot fast spin-echo heavily T2-weighted dynamic MRCP images were generated before and at every minute for 10 min after intravenous administration of fentanyl citrate at a dose of 1.0 mug/kg. Pre- and postinjection images were compared and analyzed qualitatively and quantitatively.

Qualitatively, visualization of intrahepatic bile ducts, common bile duct, and main pancreatic duct improved after fentanyl injection in five (16%), 11 (37%), and 19 (63%) patients, respectively. The pancreatobiliary junction and common channel were visualized better after fentanyl injection in eight of the 18 patients (44%). Quantitatively, signal intensity and diameters of the intrahepatic ducts, common bile duct, and main pancreatic duct measured at corresponding points on pre- and postinjection images showed an increase above preinjection values in 28 (93%), 27 (90%), and 21 (70%) and in 18 (60%), 26 (86%), and 22 (73%), respectively, and these changes were highly significant at all sites (p < 0.001).

Intravenous administration of fentanyl before MRCP improves qualitative and quantitative visualization of the ductal system anatomy that may be of value in clinical diagnosis and management.

This paper reports a series of patients with Mirizzi's syndrome (MS) who were managed at our institution over an 11-year (1994-2005) period.

Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospital's radiology computer coding system.

33 patients were identified with a median age of diagnosis of 70 (35-90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1-7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2).

Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.

Magnetic resonance cholangio-pancreaticograpy (MRCP) is a non-invasive imaging modality of the pancreatico-biliary system which plays an increasingly important role in the clinical and diagnostic workup of patients with biliary or pancreatic diseases. The present review is designed to give an overview of the currently available and appropriate sequences, their technical background, as well as new developments and their relevance to the various clinical issues and challenges. The impact of the latest technical innovations, such as integrated parallel imaging techniques and navigator-based respiratory triggering, on the diagnostic capacities of MRCP is discussed. In this context, the individual value of RARE, T2w single shot turbo/fast spin echo (SSFSE) and the recently introduced 3D T2w turbo/fast spin echo sequences (T2w 3D-T/FSE) is reviewed. RARE imaging may be preferred in severely ill patients with limitations in cooperation, SSFSE is particularly effective in differentiating benign and malignant stenosis, and 3D-FSE offers additional advantages in the detection of small biliary concrements.

This article evaluates the feasibility of single-dose gadobenate dimeglumine-enhanced MRI as both an angiographic and biliary contrast medium for making a preoperative evaluation of the donor candidates for a living-donor-related liver transplantation.

Eleven right hepatic lobe donors underwent MRI examinations using T1- and T2-weighted imaging and T2-weighted MR cholangiography (MRC). The MR angiography (MRA) and contrast-enhanced (CE) T1-weighted MRC images then were obtained after injecting a single dose of gadobenate dimeglumine. One radiologist and one surgeon prospectively reviewed all the MRI examinations for hepatic vascular and biliary abnormalities and compared them with the surgical findings and intraoperative cholangiograms. In addition, two blinded reviewers evaluated the two sets of MRC (T2-weighted MRC set and T2-weighted MRC plus CE-T1-weighted MRC set) retrospectively and recorded the anatomic types of the hilar biliary branching pattern along with their confidence in the interpretation.

Prospective analysis detected the following vascular variants: hepatic arterial variation in two patients, portal venous variation in one, and a significantly large accessory hepatic vein (> 5 mm) in one. Biliary variants also were identified in two patients. All the MRI findings on the vascular and biliary anatomy were corroborated intraoperatively. Retrospective analysis showed that the mean diagnostic confidence in the combined set was significantly higher than that of the T2-weighted MRC alone by both reviewers (p < 0.05).

Obtaining both MRA and CE-T1-weighted MRC is feasible using a single dose of gadobenate dimeglumine. Therefore, gadobenate dimeglumine-enhanced MRI might play a role as a preoperative imaging technique for the vascular and biliary evaluation of potential living donors.

Biliary secretion of antibiotic agents into the bile is considerably compromised by biliary obstruction, a precondition of bacterial cholangitis. Moxifloxacin may be advantageous according to secretion and antimicrobial spectrum.

To establish the secretion of moxifloxacin into obstructed and non-obstructed bile.

Biliary excretion of moxifloxacin was determined in plasma and bile of 10 patients with biliary obstruction and cholangitis and 10 patients without biliary obstruction 30 min after administration of 400 mg of moxifloxacin intravenously.

The plasma concentration of moxifloxacin was similar in both groups (4.45 +/- 1.58 microg/mL; 4.33 +/- 1.23 microg/mL). The concentration of moxifloxacin in the bile was significantly lower in patients with biliary obstruction than without (4.63 +/- 3.94 microg/mL; range 0.71-14.40; vs. 16.90 +/- 13.77 microg/mL; range 1.79-42.50; P = 0.043). Although significantly different, the penetration index was extensively high in those without biliary obstruction (4.41 +/- 4.40; range 0.35-14.45) but still sufficient in those patients with obstructive cholangitis (1.02 +/- 0.74; range 0.29-2.83; P = 0.035).

These findings are suggestive of an active secretion mechanism for moxifloxacin into the obstructed bile, producing a biliary concentration sufficiently above the minimal inhibitory concentrations for most of the expected bacteria.

The quality of magnetic resonance cholangiopancreatography (MRCP) images is frequently degraded by high signal from the gastrointestinal tract. The aim of this study is to evaluate pineapple juice (PJ) as an oral negative contrast agent in MRCP. Preliminary in vitro evaluation demonstrated that PJ shortened T(2) relaxation time and hence decreased T(2) signal intensity on a standard MRCP sequence to a similar degree to a commercially available negative contrast agent (ferumoxsil). Electrothermal atomic absorption spectrometry assay demonstrated a high manganese concentration in PJ of 2.76 mg dl(-1), which is likely to be responsible for its T(2) imaging properties. MRCP was subsequently performed in 10 healthy volunteers, before and at 15 min and 30 min following ingestion of 400 ml of PJ. Images were assessed blindly by two Consultant Radiologists using a standard grading technique based on contrast effect (degree of suppression of bowel signal), and image effect (diagnostic quality). There were statistically significant improvements in contrast and image effect between pre and post PJ images. There was particularly significant improvement in visualization of the pancreatic duct, but no significant difference between 15 min and 30 min post PJ images. Visualization of the ampulla, common bile duct, common hepatic and central intrahepatic ducts were also significantly improved at 15 min following PJ. Our results demonstrate that PJ, may be used as an alternative to commercially available negative oral contrast agent in MRCP.

The optimal treatment for bile duct stones (in terms of cost, complications and accuracy) is unclear. The aim of our study was to determine the predictive factors for preoperative endoscopic retrograde cholangiopancreatography (ERCP).

Patients undergoing preoperative ERCP (< or =90 d before laparoscopic cholecystectomy) were evaluated in this retrospective study from the 1st of January 1996 to the 31st of December 2002. The indications for ERCP were elevated serum bilirubin, elevated liver function tests (LFT), dilated bile duct (> or =8 mm) and/or stone at US examination, coexisting acute pancreatitis and/or acute pancreatitis or jaundice in patient's history. Suspected prognostic factors and the combination of factors were compared to the result of ERCP.

Two hundred and six preoperative ERCPs were performed during the observed period. The rate of successful cannulation for ERC was (97.1%). Bile duct stones were detected in 81 patients (39.3%), and successfully removed in 79 (97.5%). The number of prognostic factors correlated with the presence of bile duct stones. The positive predictive value for one prognostic factor was 1.2%, for two 43%, for three 72.5%, for four or more 91.4%.

Based on our data preoperative ERCP is highly recommended in patients with three or more positive factors (high risk patients). In contrast, ERCP is not indicated in patients with zero or one factor (low risk patients). Preoperative ERCP should be offered to patients with two positive factors (moderate risk patients), however the practice should also be based on the local conditions (e.g. skill of the endoscopist, other diagnostic tools).

Investigations examining the use of magnetic resonance cholangiography (MRC) for the diagnosis of primary sclerosing cholangitis (PSC) have described comparable accuracy when compared to endoscopic retrograde cholangiopancreatography (ERCP). The effectiveness of MRC based on overall cost, however, remains unknown. Our aim was to determine the average cost per correct diagnosis using MRC or ERCP as the initial testing strategy for the diagnosis of PSC. A decision analysis model was constructed employing diagnostic test parameters prospectively determined among 73 patients with clinically suspected biliary disease. ERCP was performed within 24 hours after MRC. Cost data were derived from average Medicare reimbursement fee schedules. The prevalence of PSC in the study cohort was 32%. The sensitivity and specificity of MRC for the diagnosis of PSC were 82% and 98%, respectively. The average cost per correct diagnosis of PSC was 724.00 US dollars for initial MRC (including the cost of ERCP following a negative MRC examination) versus 793.17 US dollars for initial ERCP. In the absence of biliary obstruction, the average cost per correct diagnosis of PSC was 549.64 US dollars with MRC versus 623.25 US dollars or ERCP. The average cost of managing post-ERCP-related complications among patients with PSC was 2902.20 US dollars (range, 1915.40-5031.54 US dollars). For ERCP to be the optimal initial test strategy, a prevalence rate of PSC greater than 45%, MRC specificity less than 85%, or reduction in the average cost per diagnosis to 538.30 US dollars would be required. In conclusion, MRC has comparable accuracy to ERCP and results in cost savings when used as the initial test strategy for diagnosing PSC.

To evaluate the value of magnetic resonance cholangiography (MRC) as a systematic first-line investigation in the management of patients with suspected common bile duct stones.

Ninety-nine consecutive patients with clinical suspicion of choledocolithiasis were prospectively explored by MRC. All MRCs were interpreted by two radiologists with knowledge of the patient's clinical condition and laboratory results. In case of discrepancy, a third opinion was obtained to reach consensus. The definitive diagnosis was established on the basis of endoscopic exploration of the common bile duct (n=40), clinical and biological follow-up at 6 Months (n=55) or other investigations (n=4). The clinician's level of confidence, management options implemented, and impact of management decisions were used to assess the contribution of MRC. The diagnostic accuracy of MRC for common bile duct stones was also determined.

At the observed level of confidence (85.9%), MRC identified a differential diagnosis in 7.1% of patients avoiding unnecessary endoscopic exploration in 59.6%. Systematic first-line MRC enabled appropriate management in 83.8% of patients. The sensitivity, specificity, and positive and negative predictive values of MRC for the diagnosis of common bile duct stones were 95.7%, 98.7%, 95.7% and 98.7%, respectively, with excellent inter-observer agreement (kappa=0.915).

Magnetic resonance cholangiography can be used to efficiently screen patients who may need further invasive exploration of the common bile duct. It specifically identifies patients requiring therapeutic ERCP.

To determine the diagnostic performance of functional magnetic resonance cholangiography (fMRC) for the evaluation of anatomic and functional biliary disorders.

At 1.5 T, 39 MR examinations with conventional MRC and mangafodipir trisodium-enhanced fMRC were retrospectively reviewed by three observers who recorded anatomic (duct dilation, stricture, filling defects) and functional (cholecystitis, obstruction) abnormalities in three modes: MRC alone, fMRC alone, and MRC and fMRC images together (combined-MRC). Performance was determined by comparing findings with each mode to findings of invasive cholangiography (IC) and surgery.

Among 75 biliary segments (correlated with IC), the sensitivity/specificity for diagnosing dilation (N = 41) with MRC was 95%/97%; with fMRC, 90%/100%; with combined-MRC, 100%/97%. For stricture (N = 7), the sensitivity/specificity of MRC was 86%/98%; of fMRC, 43%/100%; of combined-MRC, 86%/100%. For filling defects (N = 9), the sensitivity/specificity of MRC was 91%/98%; of fMRC, 82%/100%; of combined-MRC, 91%/100%. For diagnosing obstruction (N = 9), the sensitivity/specificity of MRC, fMRC, and combined-MRC were 89%/100%, 100%/100%, and 100%/100%, respectively. For surgically proven cholecystitis (N = 13), positive predictive values for diagnosing acute/chronic cholecystitis for MRC were 33%/40%; for fMRC, 100%/50%; for combined-MRC, 100%/50%.

Although single-shot fast spin echo (SSFSE)-MRC is valuable, the addition of fMRC increased diagnostic performance for functional biliary disorders.

To evaluate the accuracy of MR cholangiography to differentiate between the benign and malignant etiology of biliary strictures, excluding bilioenteric anastomoses.

49 patients (26 males, 23 females) with suspected biliary stricture underwent MR cholangiography at 1.5T (Siemens Symphony). RARE and HASTE sequences were acquired in the coronal, oblique and axial planes. MR cholangiography findings were reviewed by two independent radiologists and correlated with the final histological diagnosis. Sensitivity, specificity, and agreement were calculated with a 95% confidence interval.

Benign stenosis was identified in 23 patients (47%) and malignant stenosis in 26 (53%). The sensitivity of MR cholangiography was 64% and the specificity was 96%. The agreement between results at MR cholangiography and histology was moderate. The inter-observer agreement for MR cholangiography was good with a Kappa value of 0.61.

MR cholangiography has the potential to replace diagnostic cholangiography in patients with suspected biliary stricture. Direct cholangiography could be reserved for patients where a therapeutic procedure is anticipated.