Search

Purpose: Ultrasound (US) is considered a first-line study for painless jaundice. However, in our hospital system, patients with new-onset painless jaundice often have a contrast-enhanced computed tomography (CECT) or magnetic resonance cholangiopancreatography (MRCP) regardless of the sonographic findings. Thus, we investigated the accuracy of US for detection of biliary dilatation in patients with new-onset painless jaundice., Methods: Our electronic medical record was searched from January 1, 2012, to January 1, 2020, for adult patients with new-onset painless jaundice. Presenting complaint/setting, laboratory values, imaging studies/findings, and final diagnoses were recorded. Patients with pain or known liver disease were excluded. A gastrointestinal physician reviewed the laboratory values/chart to classify the type of suspected obstruction. Two radiologists blindly re-reviewed the US scans, and κ between the radiologists was calculated. Fisher exact test and the 2-sample t test were used for statistical analysis., Results: Three hundred sixty patients presented with jaundice (>3 mg/dL), of whom 68 met the inclusion criteria (no pain and no known liver disease). Laboratory values had an overall accuracy of 54%, but were accurate in 87.5% and 85% for obstructing stones/pancreaticobiliary cancer. Ultrasound demonstrated overall accuracy of 78%, but only 69% for pancreaticobiliary cancer and 12.5% for common bile duct stone. Seventy-five percent of the patients underwent follow-up CECT or MRCP regardless of presenting setting. In the emergency department or inpatient setting, 92% of the patients underwent CECT or MRCP regardless of US, and 81% had follow-up CECT or MRCP within 24 hours., Conclusion: A US-first strategy in the setting of new-onset painless jaundice is accurate only 78% of the time. In practice, US was almost never a stand-alone imaging examination in patients presenting to the emergency department or inpatient setting with new-onset painless jaundice, no matter the suspected diagnosis based on clinical and laboratory grounds or on the US findings themselves. However, for milder elevations of unconjugated bilirubin (suspicious for Gilbert disease) in the outpatient setting, a US demonstrating lack of biliary dilatation was often a definitive study for exclusion of pathology., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Ectopic pancreas (EP) is defined as pancreatic tissue found outside its usual anatomical position, with no ductal or vascular communication with the native pancreas.We report the case of a 59-year-old woman with a mesenteric jejunal EP initially suspected on computed tomography and confirmed by secretin-enhanced magnetic resonance cholangiopancreatography.Mesenteric EP is a very rare finding with nonspecific clinical presentation, so that, classic radiological findings have not been well described previously.

Objectives: We evaluated prospectively the clinical use of the short-echo time (TE) Cube sequence for magnetic resonance cholangiopancreatography (MRCP) at 3 T., Methods: Using a 3-T unit, we subjected 41 consecutive patients to short-TE Cube MRCP and conventional 3-dimensional fast spin-echo (3D-FSE) MRCP. Two radiologists independently rated the image quality and the visibility of the right and left hepatic, cystic, common bile, and main pancreatic ducts and the gallbladder on a 4-point scale. The averaged visual scores by 2 readers for the image quality were calculated, and the artifacts were evaluated in cases with relatively lower (<3) score. The signal-to-noise ratio, contrast-to-noise ratio, and acquisition time were evaluated by quantitative analysis., Results: The visual scores of the common bile duct (P < 0.05), cystic duct (P < 0.01), and gallbladder (P < 0.01) were significantly higher for Cube than 3D-FSE MRCP. Signal-to-noise ratio was also significantly higher for Cube than 3D-FSE MRCP (P < 0.01). There was no significant difference in the image acquisition time (352.1 ± 93.0 vs 314.1 ± 126.2 seconds, P = 0.059). Four cases on 3D-FSE MRCP and 2 cases on Cube MRCP have relatively lower image quality; however, the difference was not significant (P = 0.18)., Conclusions: The visibility of biliary structures is significantly better on short-TE Cube MRCP than conventional 3D-FSE MRCP images at a clinically acceptable acquisition time.

Objective: The objective of this study was to evaluate the clinical utility of 3-dimensional (3D) balanced turbo-field-echo (BTFE) magnetic resonance cholangiopancreatography (MRCP) with gate and track acquisition at 3 T., Methods: Using a 3-T unit, we subjected 52 consecutive patients to 3D BTFE MRCP with the navigator-gated technique and 3D turbo-spin-echo volume isotropic T2-weighted acquisition (VISTA) MRCP with the navigator-triggered technique. Two radiologists independently rated the image quality and visibility of the right and left hepatic duct, cystic duct, common bile duct, gallbladder, and main pancreatic duct using a 4-point scale. The signal-to-noise ratio, contrast-to-noise ratio, and the acquisition time were evaluated by quantitative analysis., Results: The visual scores of the cystic duct, common bile duct, gallbladder, and overall image quality were significantly higher for BTFE than VISTA MRCP (P < 0.01). The score for the main pancreatic duct was significantly higher with VISTA MRCP (P < 0.01). The image acquisition time was significantly shorter with BTFE than VISTA MRCP (139.8 ± 45.4 vs 416.9 ± 108.3 seconds, P < 0.01). There was no significant difference in signal-to-noise ratio and contrast-to-noise ratio., Conclusions: Three-dimensional BTFE MRCP yields significantly better image quality and visibility of large biliary structures than VISTA MRCP at a significantly shorter acquisition time. Volume isotropic T2-weighted acquisition MRCP provides detailed information on the main pancreatic duct that tends to be obscure on the 3D BTFE sequence.

Objective: To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients., Material and Methods: Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings., Results: All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%., Conclusion: Gadolinium-EOB-DTPA-enhanced MR can detect bile leaks with a high sensitivity and specificity.

Objective: The objective of this study was to describe the imaging findings for intraductal tubulopapillary neoplasms of the pancreas., Methods: Eleven pancreatic tumors pathologically confirmed as intraductal tubulopapillary neoplasm were retrospectively collected. The dynamic contrast-enhanced computed tomography (CT), magnetic resonance (MR) imaging including MR cholangiopancreatography (MRCP), ultrasound, and endoscopic retrograde cholangiopancreatography (ERCP) results were reviewed. The 2-tone duct sign and cork-of-wine-bottle sign were reviewed as indicators of intraductal tumor growth on CT/MR and MRCP/ERCP images, respectively., Results: A 2-tone duct sign was noted on the dynamic CT images (7/10, 70%) and on the MR imaging (5/8, 63%). The distal main pancreatic duct was dilated in all the patients except one, who had a branch duct lesion. A cork-of-wine-bottle sign was observed on the MRCP image (3/8, 38%) and on the ERCP image (3/6, 50%)., Conclusions: Intraductal tubulopapillary neoplasms are rare tumors showing characteristic imaging findings such as the 2-tone duct sign and the cork-of-wine-bottle sign that represent their intraductal growth.

Objective: To evaluate cystic duct patency on hepatobiliary-phase magnetic resonance (MR) images after intravenous gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) administration., Methods: A radiology information system search identified patients with gallbladders that had MR imaging after intravenous Gd-EOB-DTPA injection. No patients had acute cholecystitis. Magnetic resonance image findings were correlated with clinical notes, other imaging studies, time of contrast injection, and serum laboratory tests., Results: Contrast accumulated in the gallbladder in 80% of patients (n = 100) with hepatobiliary-phase MR imaging at a median of 22 minutes (range, 15-83 minutes). Absence of contrast accumulation in the gallbladder (n = 20) was associated with hepatobiliary imaging less than 30 minutes after contrast administration, gallbladder contraction, cholelithiasis, elevated liver function tests, elevated bilirubin, and cirrhosis., Conclusions: Functional assessment of cystic duct patency by Gd-EOB-DTPA-enhanced liver MR is best conducted when hepatobiliary-phase T1-weighted imaging is delayed by more than 30 minutes after contrast injection. Hepatobiliary dysfunction is associated with nonfilling of the gallbladder.

We report a case of an endoscopically confirmed biliary leak of the common hepatic duct after laparoscopic cholecystectomy that was prospectively diagnosed on gadoxetate disodium-enhanced magnetic resonance cholangiography. Whereas dynamic contrast-enhanced magnetic resonance images during the early vascular phases helped to rule out the causes of possible complications such as seroma, hematoma, or abdominal abscess, delayed hepatobiliary phase imaging was crucial for unequivocal diagnosis and location of the biliary leak. The diagnosis prompted therapeutic endoscopic retrograde cholangiography whereby a polytetrafluoroethylene-covered nitinol stent graft was successfully placed to repair the biliary injury.

Background: 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., Materials and Methods: 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., Results: 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., Conclusions: 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.

Objective: To determine the diagnostic accuracy of combined magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) for preoperative diagnosis of Mirizzi syndrome., Materials and Methods: Fifty-two patients with surgically proven Mirizzi syndrome (n = 13) and cholecystitis without evidence for Mirizzi syndrome (n = 39) underwent both MRCP using single-shot turbo spin echo and 3-dimensional turbo spin echo sequences and CT. Two blinded observers independently and retrospectively reviewed the combination of MRCP and CT images and CT images alone. Diagnostic accuracy for a combined protocol and CT was evaluated., Results: The overall sensitivity, specificity, positive and negative predictive values, and accuracy of the combination of MRCP and CT were 96.0%, 93.5%, 83.5%, 98.5%, and 94.0%, respectively. Corresponding values of CT were 42.0%, 98.5%, 93.0%, 83.5%, and 85.0%, respectively. The sensitivity, negative predictive value, and accuracy of combined protocol were significantly higher than those of CT alone (P = 0.000, 0.001, and 0.042, respectively). Interobserver agreement was better for combined images (kappa = 0.906) than for CT images alone (kappa = 0.812)., Conclusions: A combination of MRCP and CT is useful for preoperative diagnosis of Mirizzi syndrome.

Choledochal cyst and anomalous pancreaticobiliary ductal union (APBDU) are considered to be embryologically related to each other, and their complications are clinically important. This article illustrates the key imaging features of choledochal cysts and APBDU and their various associated abnormalities and complications. Complications of common bile duct are more common in APBDU with choledochal cyst, and complications of gallbladder are more common in APBDU without choledochal cyst.

Primary sclerosing cholangitis is a progressive cholestatic disease of unknown etiology leading to cirrhosis and liver failure. Several imaging modalities have been used to study this disease, including ultrasonography, computed tomography and hepatobiliary scintigraphy, but accurate diagnosis was found to be best made with endoscopic retrograde cholangiopancreatography or direct cholangiography. However, these 2 methods are invasive and may produce serious complications. Magnetic resonance cholangiopancreatography is a noninvasive imaging technique that has become very useful for diagnosing primary sclerosing cholangitis. Contrast enhanced magnetic resonance imaging provides pertinent information of extraductal abnormalities in addition to biliary ductal changes.

Liver transplant patients who present with abdominal pain after removal of the T-tube can be initially evaluated by contrast-enhanced magnetic resonance cholangiography (CEMRC) instead of abdominal computed tomography and hepatobiliary scintigraphy. In this article, 3 liver transplant patients who were evaluated by CEMRC after removal of the T-tube. CEMRC successfully identified the presence, location and extent of bile duct leaks, and can be performed as a diagnostic study in patients with suspected bile duct leaks.