Adel Hasanin, MRCP (UK), MS (Cardiology) Adel Hasanin, MRCP (UK)
The accuracy of MRCP in a District General Hospital.
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The accuracy of MRCP in a District General Hospital. Authors: Dr Nicolas Ellerby, Dr Rosalind Joseph, Dr Chew Tan, Dr John Whalley Figures 1-8 are all images collected from our cohort of patients. Figure 1: Normal ductal anatomy demonstrated on a heavy T2 weighted MIP MRCP pinwheel reconstruction. Figure 2: Normal ductal anatomy demonstrated with ERCP. The arrow is pointing to the dilated balloon. Figure 3: Calculus in the distal Common bile duct. Coronal T2. Figure 4: The same calculus as figure 3 in the distal Common bile duct on an Axial T2. Figure 5: The calculus from the previous figures seen with ERCP. Background: Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive, low risk, well tolerated investigation to investigate biliary disease. The main indications are: biliary obstruction, stone disease, biliary or pancreatic malignancy. However, the more invasive and higher risk Endoscopic Retrograde Cholangiopancreatography (ERCP) has long been considered the gold standard in imaging for diagnosis of the cause of biliary obstruction as well as subsequent intervention (1). The accuracy and role of MRCP has been comprehensively studied in the literature compared with ERCP. Its non- invasive method of imaging compared with ERCP combined with the high accuracy of identifying the cause of biliary obstruction, whilst also allowing for assessment of the patient’s biliary tree anatomy add value in later management (1). This audit assessed the accuracy of MRCP compared with ERCP findings. These findings where then compared with the previous cycle of this audit, which was performed in 2015. The referenced standard from the literature is 91% sensitivity and 91% specificity for biliary obstruction, 80% and 82% for calculi and 70% and 82% for malignancy. Methods: A cohort of 27 patients in the first cycle in 2016 and 50 patients in 2017-19 were selected at Warrington district general hospital, whom had an MRCP then went on to have an ERCP. The sensitivity and specificity were calculated by assessing the MRCP reports on CRIS and comparing the ERCP report findings documented on the gastroenterologist notes via UNISOFT software. Results: In 2016, there was a sensitivity of 75% and a specificity of 67% for obstruction, 88% and 33% for calculi and a specificity of 93% for strictures, although no patients were identified with malignancy or strictures in this cycle. This led to the additional of an axial T1 sequence to the MRCP protocol. In 2019, there was a sensitivity of 81% and a specificity of 75% for obstruction, 94% and 12.5% for calculi and 100% and 100% for a stricture. Conclusions: The introduction of axial T1 sequence to the MRCP protocol at this DGH appears to have markedly improved sensitivity in regard to identifying ductal calculi, however the specificity of the examination in this DGH remains low. Possible solutions to this involve; the formation of a local MRCP discrepancy meeting, double reporting Figure 6: Same sequence as Figure 1, demonstrating beading (right arrow) a long stricture (left arrow) and left hepatic duct dilatation, these findings are typical of Primary sclerosing cholangiitis. References. Figure 7: T2 coronal demonstrating a stricture caused by a mass. Figure 8: ERCP of the same patient in figure 7 with a mass causing a long stricture in the common bile duct. Later proven to be cholangiocarcinoma. of MRCPs or GI Specialist MRCP reporters only. 1. Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 2003;139:547-57)
Transcript of The accuracy of MRCP in a District General Hospital.
The accuracy of MRCP in a District General Hospital. Authors: Dr Nicolas Ellerby, Dr Rosalind Joseph, Dr Chew Tan, Dr John Whalley
Figures 1-8 are all images collected from our cohort of patients.
Figure 1: Normal ductal anatomy demonstrated on a heavy T2 weighted MIP MRCP pinwheel reconstruction.
Figure 2: Normal ductal anatomy demonstrated with ERCP. The arrow is pointing to the dilated balloon.
Figure 3: Calculus in the distal Common bile duct. Coronal T2. Figure 4: The same calculus as figure 3 in the distal Common bile duct on an Axial T2.
Figure 5: The calculus from the previous figures seen with ERCP.
Background: Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive, low risk, well tolerated investigation to investigate biliary disease. The main indications are: biliary obstruction, stone disease, biliary or pancreatic malignancy. However, the more invasive and higher risk Endoscopic Retrograde Cholangiopancreatography (ERCP) has long been considered the gold standard in imaging for diagnosis of the cause of biliary obstruction as well as subsequent intervention (1). The accuracy and role of MRCP has been comprehensively studied in the literature compared with ERCP. Its non- invasive method of imaging compared with ERCP combined with the high accuracy of identifying the cause of biliary obstruction, whilst also allowing for assessment of the patient’s biliary tree anatomy add value in later management (1). This audit assessed the accuracy of MRCP compared with ERCP findings. These findings where then compared with the previous cycle of this audit, which was performed in 2015. The referenced standard from the literature is 91% sensitivity and 91% specificity for biliary obstruction, 80% and 82% for calculi and 70% and 82% for malignancy. Methods: A cohort of 27 patients in the first cycle in 2016 and 50 patients in 2017-19 were selected at Warrington district general hospital, whom had an MRCP then went on to have an ERCP. The sensitivity and specificity were calculated by assessing the MRCP reports on CRIS and comparing the ERCP report findings documented on the gastroenterologist notes via UNISOFT software. Results: In 2016, there was a sensitivity of 75% and a specificity of 67% for obstruction, 88% and 33% for calculi and a specificity of 93% for strictures, although no patients were identified with malignancy or strictures in this cycle. This led to the additional of an axial T1 sequence to the MRCP protocol. In 2019, there was a sensitivity of 81% and a specificity of 75% for obstruction, 94% and 12.5% for calculi and 100% and 100% for a stricture. Conclusions: The introduction of axial T1 sequence to the MRCP protocol at this DGH appears to have markedly improved sensitivity in regard to identifying ductal calculi, however the specificity of the examination in this DGH remains low. Possible solutions to this involve; the formation of a local MRCP discrepancy meeting, double reporting
Figure 6: Same sequence as Figure 1, demonstrating beading (right arrow) a long stricture (left arrow) and left hepatic duct dilatation, these findings are typical of Primary sclerosing cholangiitis.
References.
Figure 7: T2 coronal demonstrating a stricture caused by a mass.
Figure 8: ERCP of the same patient in figure 7 with a mass causing a long stricture in the common bile duct. Later proven to be cholangiocarcinoma.
of MRCPs or GI Specialist MRCP reporters only. 1. Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a meta-analysis of test performance in suspected biliary disease. Ann Intern Med 2003;139:547-57)
