Role of magnetic resonance cholangiopancreatography in diagnosing choledochal cysts: Case series and review

Abstract

AIM:To determine the merits of magnetic resonance cholangiopancreatography (MRCP) as the primary diagnostic test for choledochal cysts (CC's). METHODS:Between 2009 and 2012, patients who underwent MRCP for perioperative diagnosis were identified. Demographic information, clinical characteristics, and radiographic findings were recorded. MRCP results were compared with intraoperative findings. A PubMed search identified studies published between 1996-2012, employing MRCP as the primary preoperative imaging and comparing results with either endoscopic retrograde cholangiopancreatography (ERCP) or operative findings. Detection rates for CC's and abnormal pancreaticobiliary junction (APBJ) were calculated. In addition detection rates for clinically related biliary pathology like choledocholithiasis and cholangiocarcinomas in patients diagnosed with CC's were also evaluated. RESULTS:Eight patients were identified with CC's. Six patients out of them had type Ⅳ CC's, 1 had type I and 1 had a new variant of choledochal cyst with confluent dilatation of the common bile duct (CBD) and cystic duct. Seven patients had an APBJ and 3 of those had a long common-channel. Gallstones were found in 2 patients, 1 had a CBD stone, and 1 pancreatic-duct stone was also detected. In all cases, MRCP successfully identified the type of CC's, as well as APBJ with ductal stones. From analyzing the literature, we found that MRCP has 96%-100% detection rate for CC's. Additionally, we found that the range for sensitivity, specificity, and diagnostic accuracy was 53%-100%, 90%-100% and 56%-100% in diagnosing APBJ. MRCP's detection rate was 100% for choledocholithiasis and 87% for cholangiocarcinomas with concurrent CC's. CONCLUSION:After initial ultrasound and computed tomography scan, MRCP should be the next diagnostic test in both adult and pediatric patients. ERCP should be reserved for patients where therapeutic intervention is needed.© 2013 Baishideng. All rights reserved.Key words: Magnetic resonance cholangiopancreatography; Choledochal cyst; Abnormal pancreaticobiliary junction; Diagnostic test; Choledocholithiasis; Cholangiocarcinomas Core tip: Magnetic resonance cholangiopancreatography (MRCP) is used as primary diagnostic approach in various biliary pathologies. This is the first literature review of published studies discussing MRCP as a diagnostic modality for choledochal cysts. This review further outlines how recent imaging techniques have improved diagnostic accuracy of MRCP in diagnosing choledochal cysts and their associated anatomic variants. Advantages, disadvantages and contraindication for MRCP with respect to endoscopic retrograde cholangiopancreatography are also discussed.

Caso Clínico: Quiste de Colédoco Tipo IA, Resolución Quirúrgica

“…El riesgo de malignidad aumenta con la edad. [6][7][8].De acuerdo a la clasificación de Todani y col, el quiste de colédoco se divide en 5 tipos [7][8][9][10]: Tabla 1. Clasificación de Todani y cols.…”

“…En la ecografía se visualiza como una lesión anecóica que contiene líquido y refuerzo acústico, a veces se confunde con una vesícula biliar dilatada o un quiste hepático a menos que se trace toda la ruta de los conductos biliares [3,4,8,11]. La TAC de abdomen con contraste evidencia lesiones fusiformes, quísticas, hipodensas y sin realce; las imáge-nes multiplanares resultan ideales para mejorar su valoración.…”

“…En la RM se observan imágenes hiperintensas y fusiformes; al realizar la Colangio RM, que constituye el método no invasivo de elección para el diagnóstico, la bilis aparece hiperintensa en contraste con la vena porta, por lo que se consigue caracterizarla de acuerdo a la clasificación de Todani antes mencionada. A su vez la CPRE permite la visualización detallada de la anatomía de vía biliar y pancreática, así como su extensión [4,8,11].…”

“…El examen inicial para la valoración de la vía biliar debe ser una ecografía, la cual sugiere el diagnóstico de quiste del colédoco, no obstante, la resonancia magnética (RM) con contraste es el estudio de elección para valorar estas estructuras [3,8]. Se asocia a varias complicaciones, la más grave es la transformación maligna a colangiocarcinoma, riesgo que aumenta con la edad del paciente (1 %≤ 10 años, 15 % hasta los 20 años, 26 % >40 años y 45.5 % > 70 años),y ocurren con más frecuencia en los tipo I (68 %) y tipo IV (21 %) [2,[6][7][8].Actualmente la clasificación más aceptada es la propuesta por Todani y col, que describe 5 tipos: I al V [7][8][9][10].…”

Choledochal cysts in children: Intrahepatic ductal dilatation does not indicate true intrahepatic biliary duct disease

“…However, more evaluation methods need to be performed to assess the MRCP ability to detect abnormal pancreaticobiliary junctions (APBJs) and choledochoceles. ERCP should be used when MRCP inadequately visualizes the terminal common bile duct or pancreaticobiliary duct junction or when a therapeutic procedure is anticipated (13). Additionally, we performed CT and an upper gastrointestinal contrast study in 1 patient to rule out a duodenal duplication cyst.…”