Comparative evaluation of magnetic resonance cholangiopancreatography and perioperative cholangiography in patients with suspect choledocholithiasis / Avaliação comparativa da colangiopancreatografia por ressonância magnética e da colangiografia peroperatória na suspeita de coledocolitíase

ABSTRACT Background: Cholelithiasis is a highly prevalent condition, and choledocholitiasis is a high morbidity complication and requires accurate methods for its diagnosis. Aim: To evaluate the population of patients with suspected choledocholitiasis and check the statistical value of magnetic resonance cholangiopancreatography, ultrasonography, the laboratory and the clinic of these patients comparing them to the results obtained by perioperative cholangiography. Methods: This is a retrospective cohort study, which were evaluated 76 patients with cholelithiasis and suspected choledocholithiasis. Results: It was observed that the presence of dilatation of the biliary tract or choledocholithiasis in the ultrasonography was four and eight times increased risk of perioperative cholangiography for positive choledocholithiasis, respectively. For each unit increased in serum alkaline phosphatase was 0.3% increased the risk of perioperative cholangiography for positive choledocholithiasis. In the presence of dilatation of the bile ducts in the ultrasonography was four times greater risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. In the presence of pancreatitis these patients had five times higher risk of positive magnetic resonance cholangiopancreatography for choledocholithiasis. On the positive magnetic resonance cholangiopancreatography presence to choledocholithiasis was 104 times greater of positive perioperative cholangiography for choledocholithiasis. Conclusions: The magnetic resonance cholangiopancreatography is a method with good accuracy for propedeutic follow-up for the diagnosis of choledocholithiasis, consistent with the results obtained from the perioperative cholangiography; however, it is less invasive, with less risk to the patient and promote decreased surgical time when compared with perioperative cholangiography.

RESUMO Racional: A colelitíase é afecção de alta prevalência, sendo a coledocolitíase complicação de elevada morbidade e que necessita de métodos acurados para seu diagnóstico. Objetivo: Avaliar o perfil populacional de pacientes com suspeita de coledocolitíase e verificar o valor estatístico da colangiopancreatografia por ressonância magnética, da ultrassonografia, dos exames laboratoriais e da clínica desses pacientes e compará-los aos resultados obtidos pela colangiografia peroperatória. Métodos: Trata-se de estudo longitudinal, de coorte, retrospectivo, no qual foram avaliados 76 pacientes com diagnóstico de colelitíase e suspeita de coledocolitíase. Resultados: Observou-se que na presença de dilatação das vias biliares ou coledocolitíase na ultrassonografia havia risco quatro e oito vezes maior, respectivamente, de colangiografia peroperatória positiva para coledocolitíase. Para cada unidade de aumento na fosfatase alcalina sérica houve aumento em 0,3% no risco de colangiografia peroperatória positiva para coledocolitíase. Na presença de dilatação das vias biliares na ultrassonografia ou clínica de pancreatite havia risco quatro e cinco vezes maior, respectivamente, de colangiopancreatografia por ressonância magnética positiva para coledocolitíase. Na presença de colangiopancreatografia por ressonância magnética positiva para coledocolitíase o risco foi 104 vezes maior de colangiografia peroperatória positiva para coledocolitíase. Conclusão: A colangiopancreatografia por ressonância magnética para seguimento propedêutico tem boa acurácia para o diagnóstico de coledocolitíase, e concordante com os resultados obtidos na colangiografia peroperatória. O método é menos invasivo, com menores riscos ao paciente e com diminuição do tempo cirúrgico dispendido para realização da colangiografia peroperatória.

Posttraumatic biloma formation: diagnosis and management

One of the rarest complications of the hepatic trauma is a biloma, defined as an abnormal bile collection outside the biliary tree, with intra or extrahepatic localization. Patients with biloma do not present with specific clinical features, which demands a challenging radiological diagnosis. In this report, we present a case of biloma due to blunt hepatic trauma, in which the patient experienced a changing symptomatic spectrum after surgery and had an interesting radiological investigation. The clinical course, imaging features, and management of this case are discussed. (AU)

Diagnosis of Proximal Biliary Strictures: Role of serum bilirubin, alkaline phosphatase and abdominal ultrasound

To determine the role of serum bilirubin, alkaline phosphatase and abdominal ultrasound in the diagnosis of proximal biliary strictures. Cross sectional Place and Duration: Surgical Unit IV, Civil Hospital Karachi, from Jan 2007 to August 2008. A total of 407 patients with obstruction of the biliary tree on ultrasound and raised serum levels of alkaline phosphatase had ERCP performed on them. Serum bilirubin and alkaline phosphatase levels were recorded prior to the procedure. A total of 75 patients with strictures on ERCP were included in the study. Jaundice and abdominal pain were present in 68 [90.6%] and 41 [54.6%] of the total 75 patients respectively. A statistically significant difference was present in the mean bilirubin levels of different stricture groups [p=.024]]. Receiver Operator Curve analysis of serum bilirubin level of 19.2gm/dl showed a sensitivity of 43% and specificity of 77% with area under curve= 0.6. Abdominal ultrasound was found to be 31.8% sensitive and 79.2% specific in predicting the presence of proximal biliary strictures. Serum levels of total bilirubin and alkaline phosphatase and abdominal ultrasound have minor role in the diagnosis of proximal biliary strictures

Application of ursodeoxycholic acid in hepatobiliary scintigraphy for neonatal hyperbilirubinemia: comparison with phenobarbital

Early differentiation of biliary atresia from neonatal hepatitis is of utmost importance, since on time surgery of biliary atresia significantly improves the outcome. Hepatobiliary scintigraphy is an integral part of diagnosis work-up of these patients; however its specificity for diagnosis of biliary atresia is suboptimal. In this study we evaluated the value of ursodeoxycholic acid pre-treatment for improvement of hepatobiliary scintigraphy specificity. Thirty consecutive infants with direct heperbilirubinemia were included into the study. All infants underwent hepatobiliary scintigraphy with [99m]Tc-bromo iminodiacetic acid [[99m]Tc-BRIDA] twice [first after pre-treatment with phenobarbital and the other time after pre-treatment with ursodeoxycholic acid]. Of 30 patients included into our study 13 had final diagnosis of extrahepatic biliary atresia and 17 had neonatal hepatitis. Bowel was visualized in 11 patients with neonatal hepatitis after phenobarbital pre-treatment and in 16 after ursodeoxycholic acid pretreatment which amounts to 80% and 96.6% specificity for diagnosis of biliary atresia with phenobarbital and ursodeoxycholic acid respectively. All patients had complications of phenobarbital administration [lethargy, poor feeding, irritability, hypotonia, etc] to some extent. These findings decreased significantly after discontinuation of phenobarbital and were not present with ursodeoxycholic acid. Ursodeoxycholic acid is a safe and efficient drug for pre-treatment of patients with neonatal cholestasis syndrome who are going to undergo hepatobiliary scintigraphy. Compared to phenobarbital, this drug has fewer complications and is more efficient

Ultrasound findings in acute viral hepatitis.

AIM: Serological markers for the virus remain mainstay of diagnosis of acute viral hepatitis. However, it is not available in all part of our country. The aim of this study is to find out the sonological findings of the hepatobiliary system that may aid to clinch the diagnosis of acute viral hepatitis. MATERIALS AND METHODS: One hundred seventy seven consecutive patients with clinical diagnosis of acute viral hepatitis from June 2004 to June 2006 attending liver clinic were enrolled in this study. After exclusion of 32 patients 145 patients with definitive diagnosis by serological confirmation were studied. RESULT: Hepatitis E (85%) was most common followed by B (10%) and A (5%). Gall bladder finding was more common than hepato-splenomegaly. Collapsed gall bladder with increased wall thickness and pericholecystic oedema was present in more than 50% of the patient. In HAV hepatitis it was present in all patients while in HEV hepatitis it was present in 84% patients. CONCLUSIONS: Gall bladder findings in ultrasound are present in over 80% of enterically transmitted hepatitis virus. Thus, it can be used to diagnose acute hepatitis when serological tests are not available.

Applications of Multidetector-row CT for the Imaging Diagnosis of Liver Disease / 대한소화기학회지

Owing to the development of multidetector-row CT (MDCT), capability in the imaging diagnosis of liver disease has increased surprisingly. First, a marked decrease in scan duration of the liver enables us to select the accurate scan time optionally. Secondly, a marked decrease in slice thickness enables us to render isotropic and three-dimensional images completely. In this pictorial review, we described the optimal contrast enhancement of the liver on MDCT and its significance as well as the applications of isotropic and three-dimensional images obtained by MDCT.

Comparison of preoperative ultrasonographic findings with operative finding in hepatobiliary surgery

To compare preoperative ultrasonographic findings with operative findings in hepatobiliary surgery. Design and Place of study: A descriptive study was conduced at Unit II, Dept. of Surgery, CHK. Place and Duration: The study was conducted in Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Centre, Karachi, Pakistan between February, 2000 to January, 2004. Patient And Hundred patients admitted over a period of two years from January, 2002 to December 2003, for hepatobiliary diseases were included in the study. Ultrasonography for their basic problem was done. All these patients underwent surgery. Operative findings were compared with preoperative ultrasonography findings and the accuracy of ultrasonography in hepatobiliary diseases was evaluated. In 34 cases, ultrasonographic findings as compared to operative findings were inaccurate while in 55 patients these were comparable to operative findings. Generally accepted overall accuracy rate of ultrasonography in hepatobiliary diseases is 86%. Accuracy rate in this study was only 66% showing that ultrasonography is an operator dependant procedure

Pretreatment with Ursodeoxycholic Acid (UDCA) as a Novel Pharmacological Intervention in Hepatobiliary Scintigraphy

The purpose of this volunteer study was to investigate whether pretreatment with UDCA before the administration of 99mTc DISIDA affects the biliary excretion of the DISIDA, and whether it can shorten the total imaging time. Ten young, healthy volunteers (eight males, two females, mean age: 26.3 +/- 2.1 years) participated in the study. Hepatobiliary scintigraphies were performed twice per volunteer within three days, for the control and the UDCA-pretreated studies. In the control study, the gallbladder (GB) was observed first in four cases and the intestine was observed first in another four cases; in contrast, in the UDCA challenge study, the GB was observed first in eight cases. The quantitative results for the factors related to the GB differed significantly between the control and challenge studies. When the subjects were pretreated with UDCA, the time duration until visualization of the GB was shortened, and the maximum activity of the GB became more intense. In conclusion, UDCA pretreatment before hepatobiliary scintigraphy can shorten the total imaging time for evaluating functional obstructions of the cystic duct and increase the specificity of the process.

Techniques, Clinical Applications and Limitations of 3D Reconstruction in CT of the Abdomen

Enhanced z-axis coverage with thin overlapping slices in breath-hold acquisitions with multidetector CT (MDCT) has considerably enhanced the quality of multiplanar 3D reconstruction. This pictorial essay describes the improvements in 3D reconstruction and technical aspects of 3D reconstruction and rendering techniques available for abdominal imaging. Clinical applications of 3D imaging in abdomen including liver, pancreaticobiliary system, urinary and gastrointestinal tracts and imaging before and after transplantation are discussed. In addition, this article briefly discusses the disadvantages of thin-slice acquisitions including increasing numbers of transverse images, which must be reviewed by the radiologist.

Evaluation of different techniques for localization of biliary tract injury

The present study was designed to evaluate the results of different preoperative techniques for accurate localization of biliary tract injury. Thirty patients [21 females and 9 males] were included in this study. The clinical diagnosis was post operative bile duct injury. They presented mainly with jaundice, pain, dyspepsia, intermittent fever and other symptoms. Ultrasonography done to all patients, intrahepatic biliary radicle dilation, common bile duct dilatation and bile collection were evident findings. The accurate site of pathology was not clear in most of the cases. Percutaneous transhepatic [PTC] done for three patients with high serum bilirubin, after drainage PTC done. Intrahepatic biliary dilatation, proximal segment accurately localized. One patient developed biliary leakage. Retrograde cholangiopancreatography [ERCP] done for twenty patients, it clearly visualized the distal segment of the biliary tract. ERCP was helpful in diagnosis strictures. Failed cannulation occurred in five patients. Two patients developed cholangitis after ERCP. Magnetic resonance cholangiopancreatography [MRCP] done to ten patients. The findings was clear where proximal and distal segments were delineated as well as the intrahepatic dilated biliary radicles. From this study it was concluded that diagnosis of biliary tract injury could start with ultrasonography examination, followed by MRCP to localize the site of the pathology and the proximal segment before biliary reconstruction

Biliary scintigraphy versus ultrasonography in the etiological diagnosis of neonatal jaundice

Twenty-five patients complaining of neonatal jaundice was studied using biliary scintigraphy with Tc-99-HIDA and ultrasonography to evaluate the cause of jaundice. The aim of the study is the differentiation between biliary atresia and with a surgical emergency and other causes of jaundice especially hepatitis. Hepatobiliary scintigraphy showed a sensitivity, specificity and accuracy of 95.83%, 93.33% and 92% respectively. While ultrasonography showed 92.85, 73.62 and 80% respectively. In conclusion, combination of both modalities is more beneficial in differentiation of etiology of neonatal jaundice

Hepatobiliary scintigraphy in the diagnosis of choledochal cysts in children

The objective is to present the usefulness of hepatobiliary scintigraphy in the investigation of children with suspected choledochal cysts through our experience in King Khalid University Hospital at King Saud University, Riyadh. Seven patients aged between 1 and 10 years [average 4.8 yrs] comprising six females and one male were investigated. Laboratory tests, abdominal Ultrasound and/or CT, and cholangiography were performed whenever indicated, Persistent activity in a dilated common bile duct, with or without dilatation of intrahepatic bile ducts, was considered a positive indicator for choledochal cyst disease. Four children with cystic dilatation [type I] were diagnosed by hepatobiliary scintigraphy, one saccular [type II], and two cases of Caroli's disease [type V]. The diagnosis of choledochal cyst was proven by surgery with histological confirmation. Visualization of the gallbladder occurred in one case only. The common bile duct was seen in four cases. Late activity in the bowel was noted in two cases

Radionuclide imaging for evaluation of biliary tract after hepatobiliary surgery

Thirty patints with biliary enteric bypass have been evaluated with serial hepatobiliary scintigraphy for detection of any possible complication. The study included 19 females and 11 males. Their age ranged from 32 to 72 years with mean age of 51 years. Normal biliary enteric bypass was recorded in 40%, while 60% had complications [partial obstruction 20%, complete obstruction 16.6%, biliary leakage 10%, gastric reflux 6.7% ascending cholangitis 6.7%]. Ultrasound showed a sensitivity of 60% compared to 100% in Tc - 99m HIDA scintigraphy. So, HIDA scanning is a simple, non - invasive technique for follow up of biliary enteric bypass for detection of subtle deterioration of biliary drainage or serious complications as leakage or obstruction

Experimental and clinical evaluation of new hepatobiliary imaging agent Tc99m bromide

To optimize the hepatobiliary imaging techniques by radionuclides, kit procedure for the preparation of Tc-99m labelled BROMIDA [2, 4, 6 trimethyl bromo- IDA] is described. Different parameters effecting the yield [%] of the final product were evaluated. The maximum labelling efficiency of radiopharmaceutical recorded was 99%. The amount of free TCCH and hydrolysed fraction was less than 1%. The radiochemical purity checked by T.L.C method showed more than 96% labelled complex upto 6 hours. In vivo distribution studies demonstrated excellent uptake of Tc-99m BROMIDA by the hepatocytes and no artifacts were seen on scintigraphic images