MRCPMRCP vs.vs. ERCPERCP

SteveSteve Harrell,Harrell, MD,MD, MSPHMSPH AdvancedAdvanced TherapeuticTherapeutic EndoscopyEndoscopy DecemberDecember 6,6, 20072007 University of Louisville InitialInitial ThoughtsThoughts

„ ““So,So, itit isis mymy predictionprediction thatthat MRCPMRCP willwill havehave aa hugehuge effecteffect onon ERCPERCP practicepractice inin thethe UnitedUnited States.States.”” „ ““IfIf II hadhad aa pancreaticpancreatic oror biliarybiliary problemproblem II wouldwould searchsearch outout …… aa centercenter withwith thethe mostmost sophisticatedsophisticated noninvasivenoninvasive techniquestechniques…… veryvery quickly.quickly.”” „ ““WeWe allall wantwant thethe bestbest forfor ourour patients;patients; shouldshould wewe treattreat themthem differentlydifferently thanthan wewe wouldwould ourselves?ourselves?”” 5/15/985/15/98 Peter B. Cotton, MD, FRCP Medical University of South Carolina Charleston, South Carolina Universityhttp://www.ddc.musc.edu/ddc_pro/pro_development of Louisville /hot_topics/impact_MRCP-cotton.htm LearningLearning GoalsGoals

„ KnowKnow whatwhat ERCPERCP andand MRCPMRCP standstand forfor „ AdvantagesAdvantages andand disadvantagesdisadvantages ofof MRCPMRCP „ IndicationsIndications forfor ERCPERCP „ PoorPoor IndicationsIndications forfor ERCPERCP „ ClinicalClinical UseUse inin commoncommon disordersdisorders forfor MRCPMRCP „ EffectsEffects ofof MRCPMRCP onon ERCPERCP inin trainingtraining „ CasesCases University of Louisville ERCPERCP

„ EndoscopicEndoscopic retrograderetrograde cholangiopancreatographycholangiopancreatography „ (en(en--dohdoh--SKAHSKAH--pikpik „ REHREH--trohtroh--graydgrayd „ kohkoh--LANLAN--jeejee--ohoh--PANGPANG--kreekree--uhuh--TAHTAH--gruhgruh-- feefee))

University of Louisville MRCPMRCP

„ MyMy RectumRectum CanCan’’tt PoopPoop „ ““MRCPMRCP”” asas aa typetype ofof snakesnake „ MagneticMagnetic resonanceresonance cholangiopancreatographycholangiopancreatography

University of Louisville herpherp--ll--humilishumilis--athath--MRCPMRCP--hshs

„ WESTERNWESTERN THREADSNAKETHREADSNAKE

University of Louisville MRCPMRCP

„ NonNon--venomousvenomous snakesnake foundfound inin ArizonaArizona

NaeemUniversity Knows Snakes! of Louisville INTRODUCTIONINTRODUCTION

„ MagneticMagnetic resonanceresonance cholangiopancreatographycholangiopancreatography (MRCP)(MRCP) isis aa noninvasivenoninvasive techniquetechnique forfor evaluatingevaluating thethe intrahepaticintrahepatic andand extrahepaticextrahepatic bilebile ductsducts andand thethe pancreaticpancreatic duct.duct.

Barish, MA, Yucel, EK, Ferrucci, JT. Magnetic resonance Universitycholangiopancreatography. N Englof J Med Louisville1999; 341:258. IntroIntro

„ UnlikeUnlike conventionalconventional endoscopicendoscopic retrograderetrograde cholangiopancreatographycholangiopancreatography (ERCP),(ERCP), MRCPMRCP doesdoes notnot requirerequire contrastcontrast materialmaterial toto bebe administeredadministered intointo thethe ductalductal system.system. „ Thus,Thus, thethe morbiditymorbidity associatedassociated withwith endoscopicendoscopic proceduresprocedures andand contrastcontrast materialsmaterials isis avoided.avoided. „ However,However, MRCPMRCP doesdoes notnot currentlycurrently allowallow anyany interventionintervention toto bebe performed,performed, suchsuch asas stonestone extraction,extraction, stentstent insertion,insertion, oror biopsy.biopsy. University of Louisville MRCPMRCP INTROINTRO

„ FirstFirst describeddescribed byby WalnerWalner etet alal inin 19911991 „ MRCPMRCP isis basedbased onon aa heavilyheavily T2T2 weightedweighted pulsepulse sequencesequence whichwhich showsshows stationarystationary fluids,fluids, suchsuch asas bile,bile, toto appearappear atat highhigh signalsignal intensintensityity whereaswhereas thethe surroundingsurrounding liverliver andand flowingflowing bloodblood generatesgenerates littlelittle signal.signal. „ AsAs aa resultresult ofof thisthis combinationcombination ofof imagingimaging characteristics,characteristics, MRCPMRCP providesprovides optimaloptimal contrastcontrast betweenbetween thethe hyperintensehyperintense signalsignal ofof thethe bilebile andand thethe hypointensehypointense signalsignal ofof backgroundbackground tissue.tissue. University of Louisville PlainPlain EnglishEnglish

„ StationaryStationary oror slowslow--flowingflowing fluidfluid withinwithin thethe bilebile andand pancreaticpancreatic ductsducts appearappear veryvery brightbright relativerelative toto thethe lowlow signalsignal intensityintensity producedproduced byby adjacentadjacent solidsolid tissuestissues darkdark „ WithWith thethe specificspecific imageimage acquisitionacquisition sequencessequences used,used, flowingflowing bloodblood hadhad littlelittle oror nono measurablemeasurable signal;signal; asas aa result,result, bloodblood vesselsvessels werewere notnot mistakenmistaken forfor bilebile oror pancreaticpancreatic ducts.ducts. „ TheThe ductsducts couldcould bebe visualizedvisualized fromfrom multiplemultiple projections,projections, therebythereby duplicatingduplicating cholangiographiccholangiographic imagesimages noninvasively.noninvasively. Bret, PM,University Reinhold, C. Magnetic resonance cholofangiopancreatography. Louisville Endoscopy 1997; 29:472. ExampleExample MRCPMRCP

University of Louisville LimitationsLimitations

„ TheThe mainmain potentialpotential problemsproblems withwith MRCPMRCP areare imageimage artifactsartifacts andand difficultydifficulty inin patientpatient compliance.compliance. „ ImageImage artifactsartifacts cancan bebe producedproduced byby aa brightbright signalsignal arisingarising fromfrom stationarystationary fluidfluid withinwithin thethe adjacentadjacent duodenum,duodenum, duodenalduodenal diverticulaediverticulae,, andand asciticascitic fluid.fluid. „ InIn addition,addition, locallocal areasareas ofof dropoutdropout ofof signalsignal cancan bebe causedcaused byby metallicmetallic clipsclips followingfollowing cholecystectomy,cholecystectomy, crossingcrossing defectsdefects inducedinduced byby ththee rightright hepatichepatic artery,artery, oror fromfrom severelyseverely narrowednarrowed ducts,ducts, suchsuch asas occursoccurs withwith primaryprimary sclerosingsclerosing cholangitischolangitis (PSC).(PSC). „ TheThe presencepresence ofof metalmetal leadsleads oror fragmentsfragments precludesprecludes anyany MRMRUniversity imagingimaging study.study. of Louisville LimitationsLimitations

„ Currently, MRCP has lower resolution than direct cholangiography and can miss small stones (<4 mm), small ampullary lesions, primary sclerosing cholangitis, and strictures of the ducts. „ MRCP also has difficulty visualizing small stones in the pancreatic duct. „ Certain anatomic characteristics or disorders can mimic bile duct obstruction or common bile duct stones. „ Obstructing stones are generally easier to identify than nonobstructing stones (especially if smaller than the thickness of the acquired image slices). „ Small stones may not be distinguishable from sludge, mucin, or even blood. University of Louisville AdvantagesAdvantages andand DisadvantagesDisadvantages MRCPMRCP

University of Louisville AdvantagesAdvantages ofof MRCP:MRCP:

„ NonNon invasiveinvasive (avoids(avoids complicationscomplications ofof diagnosticdiagnostic ERCPERCP oror PTC)PTC) „ NoNo sedationsedation usuallyusually requiredrequired „ NoNo iodinatediodinated intravenousintravenous contrastcontrast (avoids(avoids iodineiodine anaphylaxisanaphylaxis andand contrastcontrast nephropathy)nephropathy) „ RapidRapid scanscan timetime „ NoNo ionizingionizing radiationradiation (safe(safe inin pregnancypregnancy andand children)children) „ DelineatesDelineates ductalductal anatomyanatomy proximalproximal toto obstructionsobstructions „ DelineatesDelineates anatomyanatomy postpost biliarybiliary--entericenteric anastomosisanastomosis „ T1T1 imagesimages definedefine extraductalextraductal structuresstructures (useful(useful inin stagingstagingUniversity malignancy)malignancy) of Louisville http://www.ddc.musc.edu/ddc_pro/pro_development/hot_topics/impact_MRCP.htm DisadvantagesDisadvantages ofof MRCP:MRCP:

„ AddedAdded costcost toto therapuetictherapuetic ERCPERCP (but(but maymay preventprevent diagnosticdiagnostic studies)studies) „ DuctDuct imagesimages maymay bebe obscobscuredured byby otherother fluidfluid filledfilled structuresstructures (renal(renal cysts,cysts, ascites,ascites, pseudocysts)pseudocysts) „ ContraindicatedContraindicated afterafter ferromagneticferromagnetic implantsimplants ((eg.pacemakereg.pacemaker,, anuerysmanuerysm clips)clips) „ ArtifactsArtifacts fromfrom implantsimplants (metal(metal stents,stents, TIPS,TIPS, surgicalsurgical clips)clips) „ ClaustrophobiaClaustrophobia inin somesome patientspatients „ ?? LackLack ofof standardizedstandardized scanningscanning protocolsprotocols http://www.ddc.musc.edu/ddc_pUniversityro/pro_development/hot_t of Louisville opics/impact_MRCP.htm IndicationsIndications forfor ERCPERCP

University of Louisville University of Louisville http://www.askasge.org/uploadedFiles/Publications_and_Products/Practice _Guidelines/2000_appropriate.pdf ERCPERCP IndicationsIndications contd.contd.

University of Louisville University of Louisville ClinicalClinical UseUse

„ MRCPMRCP providesprovides accurateaccurate depictiondepiction andand measurementsmeasurements ofof thethe bilebile andand pancreaticpancreatic ductsducts inin 9595 percentpercent ofof examinations;examinations; associatedassociated anatomicanatomic variants,variants, suchsuch asas pancreaspancreas divisumdivisum andand choledochalcholedochal cysts,cysts, cancan alsoalso bebe visualized.visualized. „ TheThe techniquetechnique isis usefuluseful forfor documentingdocumenting communicationcommunication betweenbetween pancreaticpancreatic cystscysts andand ducts,ducts, andand forfor evaluatingevaluating thethe naturenature ofof pancreaticpancreatic cysts.cysts. „ However,However, sincesince itit isis fluidfluid withinwithin ductsducts thatthat isis depicted,depicted, MRCPMRCP cannotcannot differentiatedifferentiate betweenbetween focalfocal stricturesstrictures andand spasmspasm ofof thethe commoncommon bilebile duct.duct. Bret, PM,University Reinhold, C. Magnetic resonance cholofangiopancreatography. Louisville Endoscopy 1997; 29:472. CommonCommon DisordersDisorders

University of Louisville BileBile ductduct obstructionobstruction

„ MRCPMRCP cancan identifyidentify thethe largerlarger intrahepaticintrahepatic ductsducts andand thethe extrahepaticextrahepatic ductsducts inin 8383 toto 100100 percentpercent ofof patientspatients withwith normalnormal calibercaliber ductsducts „ ItIt hashas aa greatergreater abilityability toto depictdepict abnormalabnormal dilateddilated ducts,ducts, andand providesprovides diagnosticdiagnostic cholangiogramcholangiogram inin 9090 toto 100100 percentpercent ofof patients;patients; itit alsoalso revealsreveals thethe levellevel ofof obstructionobstruction inin 8080 toto 100100 percentpercent ofof casescases „ MayMay havehave aa rolerole inin thethe diagnosisdiagnosis ofof postcholecystectomypostcholecystectomy biliarybiliary complicationscomplications Hintze,University RE, Adler, A, Veltzke, W, et al. The ofsignificance Louisville of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1997; 29:182. BileBile ductduct obstructionobstruction

„ A systematic review that included a total of 67 studies found that the overall sensitivity and specificity of MRCP for the diagnosis of biliary obstruction werewere 9595 andand 9797 percent,percent, respectively.respectively. „ Sensitivity was lower for stones (92 percent) and for malignant conditions (88 percent). „ In a prospective double-blind study MRCP had a high sensitivity, but lower specificity for identifying post-transplant biliary strictures. „ However, MRCP is a passive anatomic technique that does not display functional information, such as the degree of obstruction to flow, which can be seen by conventional cholangiography.

Romagnuolo, J, Bardou, M, Rahme, E, et al. Magnetic resonance cholangiopancreatography:University a meta-analysis of test performance Louisville in suspected biliary disease. Ann Intern Med 2003; 139:547. BiliaryBiliary obstructionobstruction pitfallspitfalls

„ ThereThere areare somesome technicaltechnical pitfallspitfalls thatthat cancan interfereinterfere withwith thethe interpretationinterpretation ofof MRCPMRCP inin bilebile ductduct obstruction.obstruction. „ ForFor example,example, lowlow unionunion ofof thethe cysticcystic ductduct withwith thethe commoncommon hepatichepatic ductduct withwith bothboth ductsducts runningrunning inin parallelparallel forfor aa significantsignificant distancedistance maymay resultresult inin aa combinedcombined imageimage suggestivesuggestive ofof commoncommon bilebile ductduct dilation.dilation. David, V, Reinhold, C, Hochman, M, et al. Pitfalls in the interpretation of MR cholangiopancreatography.University AJR Am J Roentgenol of 1998; Louisville 170:1055. BileBile ductduct obstructionobstruction

„ Once ductal dilation is established by ultrasonography, the next step is to fully image the biliary tree via ERCP or percutaneous transhepatic cholangiography (PTC). „ These procedures can exclude choledocholithiasis and define the location and extent of the biliary lesion. „ ERCP is preferred in patients with primary sclerosing cholangitis (a major predisposing factor to cholangiocarcinoma), since the marked stricturing of the intrahepatic biliary tree makes a percutaneous approach difficult. „ Conversely, PTC is preferred to image the more proximal biliary system if there is complete obstruction of the distal biliary tree. University of Louisville CholangiocarcinomaCholangiocarcinoma

„ The role of MRCP in the diagnosis and management of bile duct malignancy is not yet defined. „ It will probably prove to be a useful noninvasive adjunct to present techniques, since it has the capability to evaluate the bile ducts both above and below a stricture while also identifying any intrahepatic mass lesions). „ One series evaluated MRCP in 126 patients with suspected bile duct obstruction. „ Fourteen had malignant obstruction that was diagnosed by MRCP in 12; the positive predictive value was 86 percent and the negative predictive valuevalue 9898 percent.percent.

Guibaud,University L, Bret, PA, Reinhold, C, et al. Bile ductof obstruction Louisville and choledocholithiasis: Diagnosis with MR cholangiography. Radiology 1995; 197:109. CholangiocarcinomaCholangiocarcinoma

„ This MRCP image, obtained without having to opacify the bile ducts, demonstrates a circumferential narrowing of the distal common bile duct (CBD, arrow) due to a focal cholangiocarcinoma. „ The obstructing tumor is causing dilation of the CBD. University of Louisville MalignantMalignant HilarHilar andand PerihilarPerihilar ObstructionObstruction „ MRCPMRCP appearsappears toto bebe usefuluseful inin delineatingdelineating thethe anatomicalanatomical extentextent ofof perihilarperihilar obstructionobstruction andand interpretinginterpreting itsits etiology.etiology. „ OneOne study,study, forfor example,example, includedincluded 4040 patientspatients withwith malignantmalignant perihilarperihilar biliarybiliary obstructionobstruction whowho underwentunderwent ERCPERCP andand MRCP.MRCP. „ BothBoth teststests werewere equallyequally effectiveeffective inin detectingdetecting thethe biliarybiliary obstruction.obstruction. „ However,However, MRCPMRCP waswas superiorsuperior inin thethe investigationinvestigation ofof thethe anatomicalanatomical extentextent andand thethe typetype ofof tumor.tumor. SimilarSimilar conclusionsconclusions havehave beenbeen reachedreached inin otherother reports.reports.

Yeh, TS, Jan, YY, Tseng, JH, et al. Malignant perihilar biliary obstruction: Magnetic resonance cholangiopancreatographic findings. Am J Gastroenterol 2000; 95:432. Lopera, JE,University Soto, JA, Munera, F. Malignant hilar and perihilar biliary obstruction: of Use of LouisvilleMR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions. Radiology 2001; 220:90. MalignantMalignant HilarHilar ObstructionObstruction

„ MRCPMRCP depictsdepicts anan intrabiliaryintrabiliary fillingfilling defectdefect (arrow)(arrow) duedue toto aa hilarhilar papillarypapillary cholangiocarcinoma.cholangiocarcinoma.

University of Louisville MalignantMalignant HilarHilar ObstructionObstruction

„ MRCPMRCP demonstratingdemonstrating aa hilarhilar cholangiocarcinoma.cholangiocarcinoma. „ ThereThere isis aa stricturestricture andand obstructionobstruction atat thethe hilumhilum withwith intrahepaticintrahepatic biliarybiliary dilatation.dilatation.

University of Louisville PatientsPatients withwith knownknown oror suspectedsuspected PSCPSC „ InIn patientspatients withwith knownknown oror suspectedsuspected PSC,PSC, MRCPMRCP isis performedperformed alongalong withwith routineroutine MRMR imagesimages toto documentdocument thethe segmentalsegmental extentextent ofof ductalductal involvementinvolvement toto helphelp planplan forfor surgery,surgery, searchsearch forfor intrahepaticintrahepatic metastases,metastases, andand identifyidentify aberrantaberrant ductalductal anatomy.anatomy. „ RoutineRoutine MRMR imagesimages areare obtainedobtained toto documentdocument thethe extentextent ofof extrahepaticextrahepatic involvement,involvement, includingincluding nodesnodes atat thethe portaporta hepatis.hepatis. University of Louisville PatientsPatients withwith knownknown oror suspectedsuspected PSCPSC „ Characteristic changes of PSC are visible on MRCP „ MRCP provides less spatial resolution than ERCP and lower sensitivity for detecting subtle peripheral ductal abnormalities in the liver. „ Peripheral ducts may not be visualized because imaging is performed when ducts are in their physiologic, nondistended state. „ In addition, the subtle mural irregularities see on ERCP may not be detected with MRCP. „ MRCP does not permit therapeutic intervention. „ The accuracy of MRCP for diagnosis or screening of cholangiocarcinoma in patients with PSC has not been well established. Ernst, O, Asselah, T, Sergent, G, et al. MR cholangiography in primary sclerosing cholangitis.University AJR Am J Roentgenol 1998; 171:1027. of Louisville PSCPSC

University of Louisville CommonCommon ductduct stonesstones

„ Common duct stones are readily ddisplayedisplayed by MRCP as a signal void within the bright signal arising from bile „ Multiple studies have compared test characteristics of MRCP with other imaging modalities in detection of choledocholithiasis. „ As a general rule, test characteristics of MRCP appear to be similar to ERCP for detecting choledocholithiasis (sensitivity 80 to 100 percent, sspecificitypecificity 85 to 100 percent) „ In an illustrative study (involving 32 patients with suspected biliary pancreatitis), the sensitivity of transabdominal ultrasonography, CT, MRCP, ERCP and intraductal ultrasonography was 20, 40, 80, 90, and 95 percent, resrespectivelypectively compared with ERCP plus sstonetone extraction as the reference standard. „ The overall agreement between MRCP and ERCP was 91 percent. Varghese, JC, Farrell, MA, Courtney, G, et al. A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patientsUniversity with suspected biliary tract disease. Clin Radiolof 1999; Louisville 54:513. Moon, JH, Cho, YD, Cha, SW, et al. The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US. Am J Gastroenterol 2005; 100:1051. CommonCommon ductduct stonesstones

„ However,However, asas notednoted above,above, tetestst characteristicscharacteristics dependdepend inin partpart uponupon thethe imagingimaging techniques,techniques, experience,experience, sizesize ofof thethe stone,stone, andand anatomyanatomy surroundingsurrounding biliarybiliary tree.tree. „ SensitivitySensitivity ofof MRCPMRCP decreaseddecreased withwith dilateddilated bilebile ductsducts (73(73 percentpercent forfor aa bilebile ductduct diameterdiameter >10>10 mmmm versusversus 8989 percentpercent forfor smallsmall diameterdiameter bilebile ducts)ducts) inin oneone ofof thethe reportsreports above.above. „ InIn thethe presencepresence ofof aa dilateddilated CBD,CBD, MRCPMRCP hashas aa 9090 toto 9595 percentpercent concordanceconcordance withwith ERCPERCP inin diagnosingdiagnosing CBDCBD stonesstones overover 44 mmmm inin diameterdiameter

Chan, YL, Chan, AC, Lam, WW, et al. Choledocholithiasis: Comparison of MR cholangiographyUniversity and endoscopic retrograde cholangiography.of Louisville Radiology 1996; 200:85. NonNon--obstructingobstructing calculuscalculus

University of Louisville „ MRCPMRCP imageimage showsshows twotwo smallsmall stonesstones inin thethe distaldistal commoncommon bilebile ductduct (arrows)(arrows) immediatelyimmediately adjacentadjacent toto thethe duodenalduodenal bulbbulb (Duo).(Duo). „ NoteNote thethe normalnormal appearing,appearing, nondistendednondistended pancreaticpancreatic ductduct (small(small whitewhiteUniversity arrows).arrows). of Louisville StonesStones

„ StonesStones largerlarger thanthan 44 mmmm areare readilyreadily seenseen butbut cannotcannot bebe differentiateddifferentiated fromfrom fillingfilling defectsdefects suchsuch asas bloodblood clots,clots, tumor,tumor, sludge,sludge, oror parasites.parasites. „ OtherOther mimickersmimickers ofof choledocholithiasischoledocholithiasis includeinclude flowflow artifacts,artifacts, biliarybiliary air,air, andand aa pseudostonepseudostone atat thethe ampulla.ampulla.

Barish, MA, Yucel, EK, Soto, JA, et al. MR cholangiopancreatography: Efficacy of three-dimensional turbo spin-echo technique. AJR Am J Roentgenol 1995; 165:295. University of Louisville StonesStones

„ MRCPMRCP study,study, obtainedobtained inin aa 6060--yearyear--oldold womanwoman withwith recurrentrecurrent rightright upperupper quadrantquadrant painpain andand anan unremarkableunremarkable ultrasoundultrasound examination,examination, showsshows smallsmall stonesstones (arrows)(arrows) inin thethe gallbladdergallbladder (GB)(GB) andand thethe commoncommon bilebile ductduct University(CBD).(CBD). of Louisville StonesStones

„ The choice of procedure varies with the clinical setting and local availability. „ In patients with cholangitis, for example, ERCP is preferred because it permits therapeutic drainage of the obstruction. „ However, MRCP may be performed if cholangitis is not severe and the risks of ERCP are high. „ MRCP may also be useful after unsuccessful or incomplete ERCP and in imaging the CBD in patients undergoing laparoscopic cholecystectomy. „ Endoscopic ultrasound may also be an option in individuals considered at increased risk for ERCP.

Soto, JA, Yucel, EK, Barish, MA, et al. MR cholangiopancreatography Universityafter unsuccessful or incomplete ERCP.of Radiology Louisville 1996; 199:91. AcuteAcute cholecystitischolecystitis

„ TheThe rolerole ofof MRCPMRCP forfor thethe diagnosisdiagnosis ofof acuteacute cholecystitischolecystitis waswas evaluatedevaluated inin aa seriesseries thatthat includedincluded 3535 patientspatients withwith symptomssymptoms ofof acuteacute cholecystitischolecystitis whowho underwentunderwent bothboth ultrasoundultrasound andand MRMR cholangiographycholangiography priorprior toto cholecystectomy.cholecystectomy. „ MRCPMRCP waswas superiorsuperior toto ultrasoundultrasound forfor detectingdetecting stonesstones inin thethe cysticcystic ductduct (sensitivity(sensitivity 100100 versusversus 1414 percent)percent) butbut waswas lessless sensitivesensitive thanthan ultrasoundultrasound forfor detectingdetecting gallbladdergallbladder wallwall thickeningthickening (sensitivity(sensitivity 6969 versusversus 9696 percent).percent). „ AtAt thethe presentpresent timetime itsits rolerole inin thethe diagnosisdiagnosis ofof acuteacute cholecystitischolecystitis shouldshould remainremain withinwithin clinicalclinical trials.trials. UniversityPark, MS, Yu, JS, Kim, YH, et al. Acute cholecystitis:of Louisville Comparison of MR cholangiography and US. Radiology 1998; 209:781. PancreatitisPancreatitis andand pancreaticpancreatic cancercancer

„ MRCP has been evaluated in both acute and chronic pancreatitis. In patients with acute pancreatitis, MRCP is useful for evaluating the bile ducts and cystic duct remnants for stones, for evaluating the pancreatic ducts, and for documenting the presence of cysts in or around the pancreas. „ However, ERCP is often preferred in patients with gallstone pancreatitis since endoscopic papillotomy performed during the same procedure may be beneficial in patients with obstructive jaundice (with a serum bilirubin concentration above 5 mg/dL) or biliary sepsis. „ In patients with failed ERCP and in those with biliary-enteric anastomoses with which ERCP may be contraindicated, MRCP can be used to image the ducts and evaluate the anastomosis, respectively. UniversitySoto, JA, Barish, MA, Yucel, EK, et al. Pancreaticof Louisville duct: MR cholangiopancreatography with a three-dimensional fast spin-echo technique. Radiology 1995; 196:459. PancreasPancreas divisumdivisum

„ MRCPMRCP cancan alsoalso detectdetect pancreaspancreas divisum.divisum. „ However,However, thethe possiblepossible associationassociation ofof thisthis variantvariant withwith thethe developmentdevelopment ofof eithereither acuteacute oror chronicchronic pancreatitispancreatitis remainsremains controversial.controversial.

Bret, PM, Reinhold, C, Taourel, P, et al. Pancreas divisum: Evaluation with MR cholangiopancreatography. Radiology 1996; 199:99. University of Louisville PancreaticPancreatic CancerCancer vs.vs. CPCP

„ MRCP appears to be as accurateaccurate asas ERCPERCP forfor distinguishingdistinguishing pancreatic cancer from chronic pancreatitis. „ Prospective study involving 124 patients who were suspected of having pancreatic cancer and underwent a number of diagnostic studies, including ERCP and MRCP. „ The correct diagnosis was confirmed histologically and clinically. „ A diagnosis of pancreatic cancer was established in 37 patients (30 percent); the others had chronic pancreatitis (46 percent) or other causes. „ The sensitivity and specificity of MRCP for diagnosing pancreatic cancer were 84 and 97 percent, which was similar to ERCP 70 and 94 percent, respectively UniversityAdamek, HE, Albert, J, Breer, H, et al. Pancreaticof Louisville cancer detection with magnetic resonance cholangioopancreatography and endoscopic retrograde cholangiopancreatography: A prospective controlled study. Lancet 2000; 356:190. ChronicChronic PancreatitisPancreatitis

„ MRCPMRCP demonstratingdemonstrating featuresfeatures ofof chronicchronic pancreatitis.pancreatitis. „ ThereThere isis aa dilateddilated mainmain pancreaticpancreatic duct,duct, aa psuedocystpsuedocyst inin thethe headhead ofof thethe pancreaspancreas andand prominentprominent sideside branches.branches. University of Louisville SecretinSecretin--enhancedenhanced MRCPMRCP

„ SecretinSecretin--enhancedenhanced MRCPMRCP isis beingbeing increasinglyincreasingly studiedstudied forfor evaluationevaluation ofof pancreaticpancreatic exocrineexocrine functionfunction andand inin thethe earlyearly diagnosisdiagnosis ofof chronicchronic pancreatitis.pancreatitis. „ ItIt isis usedused mostmost commonlycommonly inin patientspatients withwith chronicchronic pancreatitis,pancreatitis, aa settingsetting inin whichwhich itit cancan helphelp characterizecharacterize subtlesubtle pancreaticpancreatic diseasedisease byby improvingimproving thethe depictiondepiction ofof thethe pancreaticpancreatic ductduct anatomy.anatomy. „ SecretinSecretin stimulationstimulation isis notnot usedused forfor imagingimaging bilebile ducts.ducts.

Fukukura,University Y, Fujiyoshi, F, Sasaki, M, Nakajo, M.of Pancreatic Louisville duct: morphologic evaluation with MR cholangiopancreatography after secretin stimulation. Radiology 2002; 222:674. MRCPMRCP AdvantagesAdvantages

„ GastricGastric outletoutlet oror duodenalduodenal stenosisstenosis „ SurgicalSurgical rearrangementrearrangement (eg,(eg, BillrothBillroth II)II) oror ductalductal disruption,disruption, resultingresulting inin ductsducts whichwhich cannotcannot bebe assessedassessed byby ERCP.ERCP. „ CanCan detectdetect bilebile ductduct obstructionobstruction occurringoccurring asas aa complicationcomplication ofof chronicchronic pancreatitis.pancreatitis. „ PostPost--ERCPERCP pancreatitispancreatitis correlatescorrelates withwith thethe extentextent ofof pancreaticpancreatic ductalductal fillingfilling furtherfurther underscoringunderscoring anan advantageadvantage ofof MRCPMRCP forfor pancreaticpancreatic ductalductal imaging.imaging.

Cheon, YK, Cho, KB, Watkins, JL, et al. Frequency and severity of post-ERCP pancreatitisUniversity correlated with extent of pancreatic of ductal Louisville opacification. Gastrointest Endosc 2007; 65:385. EffectEffect ofof MRCPMRCP IntroductionIntroduction onon ERCPERCP Practice:Practice: AreAre ThereThere ImplicationsImplications forfor ServiceService andand Training?Training?

J T Jenkins1, G Glass1, S Ballantyne2, G M Fullarton3 Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, UK Gut 2006;55:1365-1366; doi:10.1136/gut.2006.097055 University of Louisville EffectsEffects ofof MRCPMRCP onon ERCPERCP PracticePractice

„ ERCPERCP requiresrequires considerableconsiderable trainingtraining „ ConsensusConsensus suggestssuggests 180180––200200 diagnostic/therapeuticdiagnostic/therapeutic ERCPsERCPs areare requiredrequired toto obtainobtain competencecompetence withinwithin aa trainingtraining facilityfacility withwith sufficientsufficient casecase volumevolume forfor viableviable trainingtraining opportunities.opportunities. „ SelectiveSelective cannulationcannulation ofof thethe bilebile ductduct hashas beenbeen usedused asas aa benchmarkbenchmark forfor technicaltechnical success.success. „ Moreover,Moreover, multivariatemultivariate analysesanalyses findfind casecase volumevolume toto independentlyindependently predictpredict ERCPERCP relatedrelated complicationscomplications American Society for Gastrointestinal Endoscopy. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1999;49:845–53.[ Freeman ML. Procedure-specific outcomes assessment for endoscopic retrograde Universitycholangiopancreatography. Gastrointest Endoscof Clin Louisville N Am 1999;9:639–47. EffectsEffects ofof MRCPMRCP onon ERCPERCP PracticePractice

„ "Diagnostic""Diagnostic" ERCPERCP shouldshould rarelyrarely bebe requiredrequired withwith thethe increasingincreasing accessibilityaccessibility toto newernewer imagingimaging modalities.modalities. „ MagneticMagnetic resonanceresonance cholangiopancreatographycholangiopancreatography (MRCP)(MRCP) hashas beenbeen foundfound toto bebe ofof equivalentequivalent diagnosticdiagnostic utilityutility asas ERCP.ERCP. „ SuchSuch developmentsdevelopments maymay reducereduce ERCPERCP casecase volumevolume andand potentiallypotentially increaseincrease procedureprocedure complexitycomplexity withwith implicationsimplications forfor serviceservice andand training.training. „ FewFew studiesstudies havehave reportedreported potentialpotential changeschanges toto ERCPERCP practicepractice followingfollowing MRCPMRCP introduction.introduction. University of Louisville MethodsMethods

„ 542542 consecutiveconsecutive ERCPsERCPs duringduring aa 2828 monthmonth periodperiod fromfrom NovemberNovember 20012001 toto FebruaryFebruary 20042004 fromfrom aa prospectiveprospective database.database. „ TheThe effecteffect ofof MRCPMRCP introductionintroduction onon ERCPERCP practicepractice waswas assessedassessed 1414 monthsmonths afterafter thethe additionaddition ofof MRCPMRCP facilitiesfacilities toto ourour unitunit andand comparedcompared withwith thethe 1414 monthmonth periodperiod priorprior toto MRCPMRCP introduction.introduction. University of Louisville MethodsMethods

„ PrePre--MRCPMRCP introduction,introduction, 310310 ERCPsERCPs (298(298 withwith completecomplete data)data) werewere performedperformed andand 232232 werewere performedperformed inin thethe postpost--MRCPMRCP period.period. „ IndicationsIndications forfor ERCPERCP werewere categorizedcategorized byby clinical,clinical, biochemical,biochemical, andand ultrasoundultrasound (USS)(USS) findingsfindings andand thethe likelihoodlikelihood ofof therapeutictherapeutic interventionintervention forfor eacheach indicationindication assessedassessed beforebefore andand afterafter MRCPMRCP introduction.introduction. „ FailedFailed cannulationcannulation waswas defineddefined byby thethe inabilityinability toto cannulatecannulate thethe papillapapilla andand opacifyopacify thethe requiredrequired duct.duct. University of Louisville Figure 1 Indications for endoscopic retrograde cholangiopancreatography (ERCP) in pre- magnetic resonance cholangiopancreatography (MRCP) and post-MRCP introduction periods. CBD, common bile duct; LTFS, liver function tests.

Jenkins, J T et al. Gut 2006;55:1365-1366 TheUniversity ERCP indication profile changed littleof following Louisville MRCP introduction.

Copyright ©2006 BMJ Publishing Group Ltd. ResultsResults

„ AA 25%25% reductionreduction inin totaltotal ERCPERCP numbersnumbers waswas foundfound inin thethe postpost--MRCPMRCP periodperiod andand thethe monthlymonthly meanmean numbernumber ofof ERCPsERCPs performedperformed waswas reducedreduced fromfrom 2222 toto 1717 perper month.month. „ CannulationCannulation failurefailure ratesrates prepre--MRCPMRCP andand postpost-- MRCPMRCP werewere 8.7%8.7% (26(26 ERCPsERCPs)) andand 14.2%14.2% (33(33 ERCPsERCPs),), respectively.respectively. University of Louisville DiscussionDiscussion

„ WeWe havehave encounteredencountered alterationsalterations inin ERCPERCP practicepractice followingfollowing MRCPMRCP introductionintroduction withwith fewer,fewer, potentiallypotentially moremore complex,complex, proceduresprocedures beingbeing performed.performed. „ SubsetSubset analysisanalysis foundfound changechange onlyonly inin thethe groupgroup withwith pain,pain, biliarybiliary dilatation,dilatation, withwith abnormalabnormal LFTsLFTs±±CBDCBD stonestone onon USS,USS, potentiallypotentially reflectingreflecting improvedimproved identificationidentification ofof ductduct stonesstones byby MRCP.MRCP. „ ObjectiveObjective assessmentassessment ofof technicaltechnical difficultydifficulty waswas notnot easy,easy, asas bothboth traineestrainees andand traitrainersners werewere bothboth involvedinvolved inin performingperforming ERCPsERCPs andand nono validatedvalidated criteriacriteria toto assessassess ERCPERCPUniversity difficultydifficulty werewere availableavailable of duringduringLouisville thethe studystudy period.period. ConclusionsConclusions ofof StudyStudy

„ MRCPMRCP introductionintroduction hashas anan impactimpact onon ERCPERCP practice.practice. ERCPERCP servicesservices andand trainingtraining maymay requirerequire redirectionredirection towardstowards fewerfewer butbut moremore complexcomplex procedures.procedures. „ TheseThese changeschanges maymay necessitatenecessitate aa reductionreduction inin thethe numbernumber ofof casescases performedperformed onon aa list,list, maymay resultresult inin fewerfewer traineestrainees embarkingembarking onon ERCPERCP trainingtraining and,and, asas endoscopyendoscopy centerscenters requirerequire thresholdthreshold numbersnumbers ofof casescases toto ensureensure competencycompetency inin techniquetechnique andand adequacyadequacy ofof training,training, maymay reducereduce thethe numbernumber ofof centerscenters ableable toto offerofferUniversity viableviable trainingtraining opportunities.opportunities. of Louisville KeyKey PointsPoints

„ KnowKnow abbreviationsabbreviations (nurses(nurses willwill ask!!!)ask!!!) „ ERCPERCP andand MRCPMRCP areare bothboth greatgreat diagnosticallydiagnostically „ MRCPMRCP hashas fewerfewer complicationscomplications „ ERCPERCP cancan performperform therapeuticstherapeutics „ NaeemNaeem doesndoesn’’tt likelike snakessnakes

University of Louisville CASECASE 11

4646 yoyo wmwm cc chronicchronic abdabd painpain

University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville CaseCase #2#2

6969 yoyo s/ps/p ““surgerysurgery””

University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville CaseCase 33

2525 yoyo cc chronicchronic abdabd painpain

University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville University of Louisville THETHE ENDEND

University of Louisville