Role of Magnetic Resonance Cholangiopancreatography in Evaluation of Choledocholithiasis in Patients with Suspected Cholecystitis

Myung-Won You; Yoon Young Jung; Ji-Yeon Shin

doi:10.3348/jksr.2018.78.3.147

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You, Jung, and Shin: Role of Magnetic Resonance Cholangiopancreatography in Evaluation of Choledocholithiasis in Patients with Suspected Cholecystitis

Original Article

J Korean Soc Radiol 2018;78(3):147-156.

Published online: 20 January 2018

DOI: https://doi.org/10.3348/jksr.2018.78.3.147

Role of Magnetic Resonance Cholangiopancreatography in Evaluation of Choledocholithiasis in Patients with Suspected Cholecystitis

Myung-Won You, MD¹, Yoon Young Jung, MD^1,^∗, Ji-Yeon Shin, MD²

¹Department of Radiology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea

²Department of Preventive Medicine, School of Medicine, Eulji University, Seoul, Korea

^∗Corresponding author: Yoon Young Jung, MD Department of Radiology, Nowon Eulji Medical Center, Eulji University, 68 Hangeulbiseok-ro, Nowon-gu, Seoul 01830, Korea. Tel. 82-2-970-8290 Fax. 82-2-970-8346 E-mail: jyy@eulji.ac.kr

Received 12 May 2017 Revised 28 August 2017 Accepted 13 September 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To determine the role of magnetic resonance cholangiopancreatography (MRCP) in evaluation of choledocholithiasis in patients with suspected cholecystitis.

Materials and Methods

A total of 78 patients (mean age: 66.06 ± 15.63 years; range: 21–94 years, Male:Female = 31:47) who had experienced symptoms of cholecystitis and who underwent computed tomography (CT), MRCP, and endoscopic retrograde cholangiopancreatography from January 2013 to February 2015 were included in this study. Two reviewers independently interpreted CT and MRCP images to determine the presence or absence of choledocholithiasis and cholelithiasis. Diagnostic performance (sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) was compared between CT and MRCP. Interobserver agreement was also evaluated.

Results

Forty-three patients underwent cholecystectomy. The accuracy of CT and MRCP for detection of gallbladder stones showed no significant difference. The sensitivity and accuracy of MRCP for detection of extrahepatic duct stones were superior to those of CT for both reviewers (reviewer 1: MRCP: sensitivity, 73.3%; accuracy, 76.9%; CT: sensitivity, 50%, accuracy 59%; p = 0.01; reviewer 2: MRCP: sensitivity, 75%; accuracy, 73.1%; CT: sensitivity, 50%; accuracy, 56.4%; p = 0.018). The interobserver agreement was consistent for both CT (k-value: 0.738) and MRCP (k-value: 0.701).

Conclusion

MRCP showed superior diagnostic performance for the detection of choledocholithiasis with reliable interobserver agreement. Considering the lack of radiation and contrast enhancement, MRCP would be an appropriate first-line modality in evaluation of common bile duct stones in patients with suspected cholecystitis.

Keywords: Index terms Magnetic Resonance Cholangiopancreatography Choledocholithiasis Multidetector Computed Tomography Endoscopic Retrograde Cholangiopancreatography Sensitivity and Specificity

References

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Fig. 1.

Flow chart of patient selection. Among 313 patients who underwent magnetic resonance cholangiopancreatography for suspected cholecystitis, 235 patients were excluded. Finally, total 78 patients were included in this study. CT = computed tomography, ERCP = endoscopic retrograde cholangiopancreatography, MRCP = magnetic resonance cholangiopancreatography

Fig. 2.

A 91-year-old female patient, suspected with cholecystitis and true positive MRCP findings for choledocholithiasis. A, B. Subtle high-attenuating intraductal lesion in far distal CBD is detected retrospectively on unenhanced axial (A) and coronal (B) CT images (white arrows). Both reviewers interpreted CT as negative for CBD stone. C, D. Heavily T2-weighted TSE fat-saturated axial (C) and triggered 3-dimensional TSE MRCP (D) images reveal a visible distal CBD stone (white arrows), which was confirmed with endoscopic retrograde cholangiopancreatography. Both reviewers interpreted MRCP as positive for CBD stone. CBD = common bile duct, CT = computed tomography, MRCP = magnetic resonance cholangiopancreatography, TSE = turbo spin echo

Fig. 3.

A 81-year-old male, suspected with cholecystitis and false positive MRCP findings of choledocholithiasis. A. Unenhanced axial computed tomography image shows no radiopaque bile duct stone in the extrahepatic duct (arrows). B, C. T2-weighted TSE axial (B) and triggered 3-dimensional TSE MRCP (C) images shows suspicious intraductal focal signal void in distal CBD (white arrows). Reviewer 2 interpreted MRCP as positive for biliary stone. Small periampullary diverticulum with air fluid level is seen next to distal CBD (arrow with dotted line). D. Heavily T2-weighted TSE fat-saturated axial image shows no intraductal signal void (arrows), indicating flow artifact rather than true CBD stones. Endoscopic retrograde cholangiopancreatography revealed no presence of CBD stones (not shown). CBD = common bile duct, MRCP = magnetic resonance cholangiopancreatography, TSE = turbo spin echo

Fig. 4.

A 58-year-old male, suspected with cholecystitis and false negative MRCP findings for choledocholithiasis. A. Unenhanced axial CT image shows no radiopaque stone in the extrahepatic duct (arrow). B. Focal intraductal signal void in the distal CBD (arrow) is suspected on T2-weighted half-Fourier acquisition single-shot turbo spin-echo axial image. C, D. This lesion is not visible on other MRCP sequences such as heavily T2-weighted turbo spin-echo fat-saturated (C, arrow) and maximal intensity projection reconstruction (D) images. Both reviewers interpreted CT and MRCP images as negative for CBD stones. However, cholangiopancreatography revealed a CBD stone, which was removed (not shown). CBD = common bile duct, CT = computed tomography, MRCP = magnetic resonance cholangiopancreatography

Table 1.

MRCP without Enhancement Protocol

Type of Sequence	Pulse Sequence	Repetition Time (msec)	Echo Time (msec)	Focus of View (mm)	Section Thickness (mm)	Matrix
Axial T2-weighted	HASTE	800	92.0	360 × 270	4	320 × 240
Coronal T2-weighted	HASTE FS	1500	112.0	340 × 340	2	320 × 259
Axial T1-weighted	CAIPIRINHA	3.9 FA: 9	1.9	360 × 270	4	384 × 202
Axial heavily T2-weighted	FSE FS	2400	162.0	350 × 262	4	384 × 202
Oblique	Thick slab 2D SSFSE	4500	665.0	270 × 270	50	348 × 230

CAIPIRINHA = controlled aliasing in parallel imaging results in higher acceleration, FA = flip angle, FS = fat saturation, FSE = fast spin echo, HASTE = half-Fourier acquisition single shot turbo spin echo, MRCP = magnetic resonance cholangiopancreatography, SSFSE = single shot fast spin echo, 2D = two-dimensional

Table 2.

Characteristics of Study Population

Characteristics of Patients (n = 78)
Age (yr)	66.06 ± 15.63 (range 21–94)
Sex	M:F = 31:47
MRCP-ERCP interval (day)	1.63 ± 2.82 (range 0–13)
CT-ERCP interval (day)	5.70 ± 10.98 (range 0–85)
CT-MRCP interval (day)	4.08 ± 10.44 (range 0–83)

CT = computed tomography, ERCP = endoscopic retrograde cholangiopancreatography, F = female, M = male, MRCP = magnetic resonance cholangiopancreatography

Table 3.

Comparison of Diagnostic Performance of CT and MRCP without Enhancement for Detecting Biliary Stones

	Reviewer 1			Reviewer 2
	CT (95% CI)	MRCP (95% CI)	p-Value	CT (95% CI)	MRCP (95% CI)	p-Value
Sensitivity (%)	50.0 (30/60) (43.4–52.7)	73.3 (44/60) (66.8–76.1)	< 0.001	50.0 (30/60) (43.1–54.4)	75.0 (45/60) (68.2–80.3)	< 0.001
Specificity (%)	88.9 (16/18) (66.8–0.98)	88.9 (16/18) (67.1–0.98)	^1.000	77.8 (14/18) (54.9–92.3)	66.7 (12/18) (44.1–84.4)	^0.625
PPV (%)	93.8 (30/32) (81.3–98.9)	95.7 (44/46) (87.1–99.2)		88.2 (30/34) (76.1–95.9)	88.2 (45/51) (80.3–94.5)
NPV (%)	34.8 (16/46) (26.1–38.4)	50.0 (16/32) (37.7–55.1)		31.8 (14/44) (22.4–37.8)	44.4 (12/27) (29.4–56.3)
Accuracy (%)	59.0 (46/78) (48.8–63.2)	76.9 (60/78) (66.8–81.1)	0.01	56.4 (44/78) (45.8∼63.1)	73.1 (57/78) (62.7–81.3)	0.018

CI = confidence interval, CT = computed tomography, MRCP = magnetic resonance cholangiopancreatography, NPV = negative predictive value, PPV = positive predictive value

Table 4.

Comparison of Diagnostic Performance of CT and MRCP without Enhancement for Detecting Gallbladder Stones

	Reviewer 1			Reviewer 2
	CT	MRCP	p-Value	CT	MRCP	p-Value
Sensitivity (%)	86.0 (37/43)	95.3 (41/43)	0.219	81.4 (35/43)	97.7 (42/43)	0.016
Specificity (%)	65.4 (17/26)	50 (13/26)	0.219	61.5 (16/26)	57.7 (15/26)	1.000
PPV (%)	80.4 (37/46)	75.9 (41/54)		77.8 (35/45)	79.2 (42/53)
NPV (%)	73.9 (17/23)	86.7 (13/15)		66.7 (16/24)	93.8 (15/16)
Accuracy (%)	78.2 (54/69)	78.2 (54/69)	1.000	73.9 (51/69)	82.6 (57/69)	0.216

CT = computed tomography, MRCP = magnetic resonance cholangiopancreatography, NPV = negative predictive value, PPV = positive predictive value

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