Pitfalls of MRCP in the diagnosis of pancreaticobiliary maljunction.
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CONTEXT: Magnetic resonance cholangiopancreatography (MRCP) is useful for examining the pancreatic duct system in patients with acute pancreatitis instead of using endoscopic retrograde cholangiopancreatography (ERCP), as ERCP-induced pancreatitis represents a serious problem. However, we present here a case of idiopathic acute pancreatitis in which MRCP suggested pancreaticobiliary maljunction, but ERCP indicated normal pancreaticobiliary union. CASE REPORT: A 22-year-old male was urgently admitted complaining of upper abdominal and back pain. He had no history of alcohol or drug intake. Serum amylase levels were elevated to 880 U/mL (reference value: less than 158 U/mL). Abdominal ultrasound demonstrated only a slight swelling of the pancreas, but no abnormal findings for the bile duct or gallbladder. Symptoms and hyperamylasemia improved with supportive therapy. Coronal heavily T2-weighted single-shot rapid acquisition with relaxation enhancement MRCP indicated a markedly long common channel, and pancreaticobiliary maljunction without biliary dilatation was diagnosed. Under the diagnosis of idiopathic acute pancreatitis associated with pancreaticobiliary maljunction without biliary dilatation, prophylactic laparoscopic cholecystectomy was planned. However, ERCP demonstrated a narrow main pancreatic duct and a normal common bile duct without the formation of a common channel. In a supine position, after withdrawal of the scope, the narrow main pancreatic duct at the head of the pancreas overlapped the lower common bile duct, giving the appearance of a long common channel as indicated by MRCP. CONCLUSIONS: In MRCP of cases with a narrow main pancreatic duct, there is a possibility for false-positive indications of pancreaticobiliary maljunction. MRCP with secretin stimulation or ERCP should be performed in such cases. (+info)
Unilocular extrahepatic biliary cystadenoma mimicking choledochal cyst: a case report.
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We report here on a case of extrahepatic biliary cystadenoma arising from the common hepatic duct. A 42-year-old woman was evaluated by us to find the cause of her jaundice. Ultrasonography and CT showed a cystic dilatation of the common hepatic duct and also marked dilatation of the intrahepatic duct. Direct cholangiography demonstrated a large filling defect between the left hepatic duct and the common hepatic duct; dilatation of the intrahepatic duct was also demonstrated. Following excision of the cystic mass, it was pathologically confirmed as a unilocular biliary mucinous cystadenoma arising from the common hepatic duct. (+info)
A case of acute pancreatitis possibly associated with combined salicylate and simvastatin treatment.
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CONTEXT: Drug-induced acute pancreatitis is a rather rare clinical entity. From time to time, several cases have been reported in which statins or salicylates have been associated with the development of acute pancreatitis. There is only one report which implies the involvement of both drugs in pancreatic inflammation. CASE REPORT: A 58-year-old Caucasian male with a history of coronary heart disease and hypercholesterolemia, under treatment with acetyl-salicylate for 6 years and simvastatin for 2 months, presented to the Emergency Department of our hospital with epigastric pain and vomiting of 24-hour duration. The clinical and laboratory investigation led to the diagnosis of acute pancreatitis. Conservative and rich-in-fluid treatment resulted in clinical and laboratory amelioration, and the patient was discharged on day 15, after full restoration of his health. In our patient, all possible common causes of acute pancreatitis were excluded. CONCLUSION: Conclusion It is a rational assumption to connect this case to the co-administration of simvastatin and acetyl-salicylate. However, the pathophysiological mechanism behind the onset of acute pancreatitis due to a statin, or, even more, due to its combination with salicylate, remains vague. (+info)
Preoperative evaluation of pancreaticobiliary tumor using MR multi-imaging techniques.
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AIM: To evaluate the clinical value of MR multi-imaging techniques in diagnosing and preoperative assessment of pancreaticobiliary tumor. METHODS: MR multi-imaging techniques, including MR cross-sectional imaging, MR cholangiopancreatography (MRCP) and 3D dynamic contrast-enhanced MR angiography (3D DCE MRA), were performed to make prospective diagnosis and preoperative evaluation in 28 patients with suspected pancreaticobiliary tumors. There were 17 cases of pancreatic adenocarcinoma, 8 cases of biliary system carcinoma and 3 cases of non-neoplastic lesions. RESULTS: Using MR multi-imaging techniques, the accuracy in diagnosing the patients with pancreaticobiliary tumors was 89.3% (25/28). The accuracy in detecting the range of tumor invasion was 80.3% (57/71). The sensitivity, specificity, accuracy, positive and negative predictive value of MR multi-imaging techniques in preoperative assessment of the resectability of pancreaticobiliary tumor were 83.3%, 89.5%, 88.0%, 71.4%, and 94.4%, respectively. There was well diagnostic consistency between MR multi-imaging techniques and CT (kappa = 0.64, P<0.01). The fusion image could be made from MRCP and 3D DCE MRA images. CONCLUSION: MR multi-imaging techniques can integrate the advantages of various MR images. The non-invasive "all-in-one" MR imaging protocol is the efficient method in diagnosing, staging and preoperative assessment of pancreaticobiliary tumor. (+info)
Magnetic resonace appearance of gall bladder ascariasis.
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Ascariasis is a common disease in many developing countries and is a common cause of biliary and pancreatic diseases in endemic areas. Numerous studies have been published on biliary tract ascariasis. All these have documented ultrasonography as the primary imaging modality for biliary tract ascariasis. Magnetic Resonance Cholangiopancreatography (MRCP) has been the latest entrant for the study of bilary tract. MRCP findings of biliary tract ascariasis have been scarcely documented. MRCP is a unique non-invasive investigation for demonstrating ascariasis in gall bladder and bilary tract clearly. We present MR appearances of gall bladder and biliary tract in a proven case of biliary ascariasis. (+info)
Dynamic MR cholangiography after fatty meal loading: cystic contractility and dynamic evaluation of biliary stasis.
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PURPOSE: Dynamic MR cholangiography was conducted on patients with cholelithiasis or choledocholithiasis who had consumed a fatty test meal (Molyork) and the cystic contractility and dynamics of biliary stasis was evaluated. SUBJECTS AND METHOD: The subjects were 25 with intracystic cholelithiasis, 10 with choledocholithiasis and 10 normal controls. For an imaging sequence, the rapid acquisition with relaxation enhancement (RARE) method was employed and imaging was conducted for 40 min (every 30 s following Molyork administration) without breath-holding. The gallbladder contraction ratio was computed and the contractile ratio for the common bile duct was calculated. To determine the bile flow to the duodenum, the high-intensity signal, indicating the flow from the lower common bile duct, and perfusion of the duodenum were observed in dynamic mode on the monitor with the naked eye and interpreted as positive bile flow. The frequency of this flow was visually monitored. RESULTS: The gallbladder contractile ratio was significantly reduced in patients with cholelithiasis or choledocholithiasis compared with the controls. In a comparison with the normal controls, no sequential changes were noted in the mean contractile ratio of the common bile duct of the patients with cholelithiasis or choledocholithiasis. The mean frequency of bile flow observed for each 40 min period was 13+/-2.4, 6+/-2.2, and 4+/-1.3 times for the controls, those with intracystic cholelithiasis, and those with choledocholithiasis, respectively. Compared with the controls, the latter two patient groups showed evident reductions in the frequency of bile flow to the duodenum (p<0.001). CONCLUSION: Dynamic MRC combined with Molyork loading makes it possible to compute cystic contractile ratios and perform a dynamic examination of bile flow under non-invasive, near-physiological conditions. (+info)
Adenomyomatosis with marked subserosal fibrosis and lipomatosis of the gallbladder: mural stratification demonstrated with MR.
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The authors reported a case of fundal-type adenomyomatosis in which mural stratification corresponding to histopathological findings was clearly demonstrated with MR imaging. Single-shot fast spin echo images for MR cholangiopancreatography clearly visualized Rokitansky-Aschoff sinuses (RAS), which are a diagnostic clue for this disease. However, mural stratification comprising RAS with muscular proliferation, massive fibrosis and subserosal fat deposition was more precisely demonstrated in T(2)-weighted images obtained with fast spin echo. (+info)
Complications of endoscopic retrograde cholangiography in the post-MRCP era: a tertiary center experience.
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AIM: To evaluate our experience in endoscopic retrograde cholangio-pancreatography (ERCP) in terms of fulfilling the ASGE guidelines in indications, positive findings, and complications in the post-magnetic resonance cholangiopancreatography (MRCP) era. METHODS: Between November 2001 and February 2003, consecutive ERCP cases were prospectively evaluated with regard to the indications, findings, cannulation techniques, devices used during the procedure, sedation given, duration of procedure, and complications. These data were entered in a database for subsequent processing and analysis. RESULTS: Of 336 cases, 21.4% were diagnostic and 78.6% therapeutic ERCP. The indications for ERCP fulfilled the ASGE guidelines in 323 cases (96.1%). Suspected bile duct stone was the most frequent indication (26.8%), and this was followed by cholangitis (24.4%), dilated common bile duct (14.9%), and cholestatic jaundice (13.4%). Cannulation success rate was 94%. Biliary sphincterotomy was performed in 175 (52.1%) patients. Repeated ERCP was performed on 31.5% of the patients. Overall, the complication rate was 9.8% with 0.3% being procedure-related mortality. The complications were pancreatitis (5.4%), bleeding (0.8%), cholangitis (2.4%) and others (1.5%). No significant difference was observed between the complication rate and the type of ERCP performed. CONCLUSION: Our study showed that post-ERCP complication rate was comparable with the other large prospective studies and there was no difference in the complication between the diagnostic and therapeutic ERCP. (+info)