Role of magnetic resonance cholangiopancreatography (MRCP) in the evaluation of patients with obstructive jaundice

 

 

Abstract               Background: Obstructive jaundice is a common clinical problem and the most common presentation in patients with biliary ductal obstruction. The role of imaging is crucial for detection of site and cause of obstruction and also to the differentiation of benign and malignant pathology. MRCP is used in patients with history of obstructive jaundice to identify and confirms the presence of obstruction, its location, extent, probable cause and also to obtain a map of the biliary tree that will help the surgeon or the interventionist to determine the best approach to each individual case. Aim of The Study: To determine the accuracy of MRCP in the evaluation of patients with obstructive jaundice. Methods: In the evaluation of patients with obstructive jaundice, MRCP was conducted in the Department of Radio-Diagnosis, Karpaga Vinayaga Medical College and Hospital, Madhuranthagam in 2018-2019. A total number of twenty-five patients suffering from obstructive jaundice of all age groups and either sex were included in this study. Total of Twenty five patients with clinical diagnosis of obstructive jaundice was included in the study. MRCP was done in all the patients and results were compiled and compared with Operative/ ERCP findings and histopathological reports. Results: A total of twenty-five patients suffering from obstructive jaundice underwent MRCP. Out of the twenty-five patients, ten patients had benign causes of obstructive jaundice, while fifteen patients had malignant causes of obstructive jaundice. MRCP had an accuracy of 97% in detecting the cause of obstructive jaundice. In diagnosing the site of obstruction MRCP had an accuracy of 100%.Conclusion: In the diagnosis of obstructive jaundice and to know the cause, site, and extent of the lesion MRCP being a non invasive, non ionizing procedure seems to be an accurate and better choice.

Key Words: Cholelithiasis, Choledocholithiasis, Carcinoma of Pancreas, MRCP, Obstructive Jaundice, Periampubllary Carcinoma, Stricture of CBD, Klatskin Tumour

 

 

INTRODUCTION

Obstructive jaundice is a common clinical problem. It has been documented as one of the leading cause of increased mortality and morbidity. Though clinical data such as history, physical examination, and laboratory tests can differentiate between intrahepatic and extrahepatic obstruction in 90% of patients, the cause and site of obstruction are diagnosed by imaging modalities.¹ Purpose of imaging procedure in obstructive jaundice are to identify the level of obstruction, location, and length ho fobstruction, probable cause for obstruction. ² The commonly used imaging modalities include Ultrasonography (USG), Computed Tomography (CT), Endoscopic Retrograde Cholangiopancreatography (ERCP) and Magnetic Resonance Cholangiopancreatography (MRCP). Percutaneous Tran hepatic Cholangiography (PTC) is used for drainage procedures. MRCP is a standard MR imaging technique that has revolutionized the imaging of biliary and pancreatic ducts and has emerged as an accurate, noninvasive means of visualization of the biliary tree and pancreatic duct without radiation and injection of contrast material.³ Since its introduction by Wallner et al in 1991, MRCP has undergone a wide range of changes. It relies on heavily T2-Weighted image sequences that display stationary water as a high signal. Multiplanar thin and thick section acquisitions are obtained using fast spin-echo techniques. ⁴The latest imaging techniques for MRCP are Rapid Acquisition with Relaxation Enhancement (RARE) and Half-Fourier Acquisition Single- Shot Turbo-Spin-Echo (HASTE).1 Using RARE and HASTE sequences, image acquisition is possible within a few seconds, allowing MRCP to be performed comfortably during a single breath-hold thus markedly reducing the motion artifacts and improving the quality of images Magnetic Resonance Cholangiopancreatography with its inherent high contrast resolution, rapidity, multiplanar capability and virtually artifact-free display of anatomy and pathology, is proving to be imaging of choice in these patients.⁵ MRCP shows the entire biliary tract and pancreatic duct without any intervention and use of oral or IV contrast. The quality of images obtained is comparable with those of direct cholangiography procedure like ERCP.⁶ The diagnostic accuracy of MRCP suggests that it has the potential to replace the more invasive procedures like diagnostic ERCP, which should be used only in cases where intervention is being contemplated. MRCP is very effective in diagnosing calculi within the CBD, level of stricture, Intrahepatic, extrahepatic biliary ductal dilatation. In patients with malignant obstruction or stenosis of biliary-enteric anastomosis, this non invasive imaging technique demonstrates the site and extent of the stenosis, the degree of proximal dilatation, the presence and size of biliary stones, and associated findings. ⁷Though Ultrasonography and CT are non invasive, they have their drawbacks as well. USG is ineffective in accurately diagnosing the site of obstruction in most cases. CT has an increased risk of radiation and is also not sufficiently sensitive for detecting stones. IV cholangiography has its own limitations as in 30-40 % of the cases there is incomplete opacification of the biliary passage and increased contrast reaction. ERCP and PTC are complicated procedures and require technical expertise and contrast media. Also, several complications from the procedure may arise.⁸

MATERIAL AND METHODS

In the evaluation of patients with obstructive jaundice, MRCP was conducted in the Department of Radio-Diagnosis, Karpaga Vinayaga Medical College and Hospital, Madhuranthagam in 2018-2019. A total number of twenty-five patients suffering from obstructive jaundice of all age groups and either sex were included in this study. The inclusion criteria were that the patient is clinically diagnosed as suffering from obstructive jaundice and the patient referred to the Department of Radio Diagnosis for further investigation. Patients who are not suitable for MRI study due to claustrophobia, pregnancy, etc, were excluded from the study. The study protocol was approved by the ethical committee of this institute and all the patients gave written consent to participate. All the patients were instructed to fast overnight prior to examination. All the metallic belongings removed prior to the examination and screened by using a metal detector. All the patients in the study underwent MRCP. MRCP has performed on Philips Healthcare Intera 1.5 Tesla MRI Scanner. All images were obtained with breath-holding and parameters were individualized. Detailed parameters of each sequence are summarized below. The following Parameters like level of obstruction, Presence of bile duct calculi, Status of CBD, Degree of dilatation of intrahepatic biliary radicles, Gall bladder pathology including size, wall, stones, Dilatation of pancreatic duct, Pancreaticatrophy, calcifications, and pseudocysts, Presence of masses, Invasion of viscera, fascial planes and metastasis, in case of malignant lesions were studied. Then classification of imaging findings as the benign or malignant cause of obstructive jaundice is based on following scale of confidence. Among these twenty patients under went surgery, five patients underwent cytology and remaining with other modalities of investigation. Probably benign lesions were considered as benign and similarly probably malignant lesions were considered as malignant

 

RESULTS

This study was conducted to establish the Role of MRCP in the evaluation of obstructive jaundice. A total of twenty-five patients with a clinical diagnosis of obstructive jaundice were included in the study. The age group of the patients varied from 21 to 86. The average age of the patients in the study.

 

Table 1: age group of various pathologies in studied population

AGE GROUP	No of cases	Percentage (%)
Children (0-12yrs)	0	0
Adolescent and young adults (13-30yrs)	3	12
Adults (31-60yrs)	15	60
Geriatric patient (>60yrs)	7	28
Total	25	100

 

 

 

 

 

 

 

 

 

Table 2: various causes of obstructive jaundice studied in thepopulation

 

Table 3: diagnostic values of mrcp in benign and malignant causes of obstructive jaundice

Figure 1                                                                                Figure 2                                                                                Figure 3

Figure 1: Cholelithiasis and Choledocholithiasis; Figure 2: Case of CA head of pancreas; Figure 3: Case of Klatskin’s tumour

 

Most of the patients affected with obstructive jaundice are over the age of 30 yrs. More than 60% of the patients affected were over the age of 50 yrs. The average age of patients with benign lesions was 53 years while that of malignant lesions was 52.8 years (Table-1). There was no obvious sex predilection the patients affected with obstructive jaundice. In the diagnosis of the site of obstruction, MRCP was accurate in all twenty-five patients. Out of twenty-five patients with history of obstructive jaundice, 60 percent (15 patients) were diagnosed to be having malignant pathology, among this Carcinoma of head of pancreas constituted the most common malignant pathology in our study population, comprising 16% of the study population. Next common malignant pathologies are Periambullary carcinoma and klaskins tumor comprising 12 % of study population each. (Table No:2) Total of 40 % study population had benign pathology as a cause of obstructive jaundice, Out of these benign lesions, Calculus in the common bile duct constituted the most common cause of obstruction in our study, comprising 24% of study population. Even though the malignant cases were outnumbering the benign causes, most common single lesion causing obstructive jaundice in our study is Calculus in the common bile duct, comprising 24% of our study population (Table No:2) MRCP has the highest accuracy for detecting cause of obstruction in both and malignant lesions. The sensitivity of MRCP is 94% but the specificity is high as 100%. In spite of the high sensitivity for USG, the specificity for the same is very low at 69% when compared to that of CT’s 69% and MRCP’s 100%. Thus MRCP is a specific investigation for level and cause of obstruction in patients with obstructive jaundice. (Table No:3)

 

DISCUSSION

Diagnosing patients with suspected biliary or pancreatic pathologies in their early stage is almost importance in patient care and management. The imaging technique is needed to determine the required and appropriate work up of patients with obstructive jaundice. With the introduction of MR.⁹ Cholangiopancreatography for the diagnosis of biliary and pancreatic ductal pathologies, an invasive procedure like ERCP can be avoided solely for the purpose of diagnosis. In our study twenty-five, patients with a clinical diagnosis of obstructive jaundice were studied. Most of the patients presented with jaundice and abdominal pain. Icterus was the most common sign followed by passing of white stools and itching. The youngest patient in the study was twenty-seven years old female who was suffering from Carcinoma of pancreatic head with pancreatic ductdilatation.¹⁰ The oldest patient was seventy-five years old and was suffering from periampullary carcinoma. The average age of patients with benign lesions and malignant lesions was in the fifth decade (Table No-2). MRCP was done for all patients. Of the six patients diagnosed with CBD and GB calculi MRCP had accurately diagnosed all the six cases.(Figure No:1).¹¹ Stricture disease was diagnosed in three patients. MRCP clearly showed benign nature of stricture in all three cases approaching 100 % accuracy. MRCP with MRI images differentiated the benign and malignant lesions and MRCP also assessed the length of stricture. Histopathology examination of the resected specimen revealed benign nature of obstruction.¹² Our study is in concordance with Singh A al; In their study they found 100% accuracy for MRCP in diagnosing benign CBD stricture. One case of anatomical variant, a case of choledochal cysts present in our study. It was diagnosed correctly by MRCP. ¹³ Among the malignant lesions there were 4 cases of Head of Pancreas tumor and 3 cases of Periampullary Ca. MRCP accurately diagnosed all the 7 cases. Though MRCP alone could not clinch the diagnosis a few sequences of MRI was required to diagnose accurately the malignant lesions. On MR it is invariably hypointense on T1 weighted images and variable on T2 weighted images due to the desmoplastic reaction.(figure:2)Our study is in concordance with Upadhyaya Vet al; in their study they found 90% accuracy for MR in diagnosing periampullary growth and carcinoma pancreas. In 2 patients with extra hepatic Cholangiocarcinoma MRCP diagnosed all cases with a 100% accuracy with the help of conventional MRI, thus approaching 100% accuracy for MR with MRCP. Two patients with Ca of Gallbladder were diagnosed accurately by MRCP and confirmed by histopathological examination after surgery.¹⁴ ERCP is the standard imaging study for patients with obstructive jaundice, who needed intervention. and its great advantage is, in its ability to perform therapeutic interventional procedures, like stone removal, stricture dilatation, and stent placement which will relieve obstruction. It requires a highly skilled and experienced endoscopist.¹⁵

 

CONCLUSION

In the diagnosis of obstructive jaundice and to know the cause, site, and extent of the lesion MRCP being a noninvasive, nonionizing procedure seems to be a better choice. The drawback of MRCP is its limited availability and its high cost. The limitation of the study is the small sample size and that ERCP correlation for these patients was not done.

 

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