RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,

KARNATAKA.

“ROLE OF MRCP IN SUSPECTED CASE OF

OBSTRUCTIVE JAUNDICE IN CORRELATION WITH
COMPUTED TOMOGRAPHY/ ULTRASONOGRAPHY”

BY

Dr. PURNIMA IROM

M.B.B.S.

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

In Partial fulfillment
of the requirements for the degree of

DOCTOR OF MEDICINE
IN
RADIO-DIAGNOSIS

Under the guidance of

Dr. J. PRAMOD SETTY M.D., F.I.C.R.
PROFESSOR AND H.O.D.,

DEPARTMENT OF RADIO-DIAGNOSIS
J.J.M. MEDICAL COLLEGE
DAVANGERE – 577 004.
2014

i
 ACKNOWLEDGEMENT

It is most appropriate that I begin by expressing my undying gratitude to

the ALMIGHTY GOD for giving me the strength both mentally and physically

to complete this task.

I would like to express my gratitude to my beloved PARENTS,

Mr. I.M. SINGH and Mrs. JALE SANYII, who are my strength, for there

efforts and hardships they have been through which make me stand where I am

today.

It gives me immense pleasure to express my deepest gratitude and

sincere thanks to my teacher and guide Dr. J. PRAMOD SETTY M.D.,

F.I.C.R., Professor and Head, Department of Radio-Diagnosis, J.J.M. Medical

College, Davangere for preparing for this task, guiding me with his superb

talent and professional expertise, showing great care and attention to details

and without his supervision and guidance this dissertation would have been

impossible.

My special thanks and gratitude to Dr. K.N. SHIVAMURTHY M.D.,

D.M.R.D., Dr. JEEVIKA M.U. M.D., Dr. KIRAN KUMAR .S. HEGDE

M.D., Dr. BHAGYAVATHI M.D., Dr. SIDDESH M.D., Dr. NAVEEN .S.

MARALAHALLI M.D., and for their timely suggestions and constant

encouragement.

My sincere thanks to Dr. MANJUNATH ALUR M.D., Principal

Dr. GURUPADAPPA, Director of Post Graduate studies, J.J.M. Medical

College, Davangere for their constant help and inspiration.

vi
 LIST OF ABBREVATIONS USED

Ca Carcinoma
CBD Common Bile Duct
CHD Common Hepatic Duct
CT Computed Tomography
ERCP Endoscopic Retrograde Cholangiopancreatography
FLASH Fast Low Angle Shot
FN False Negative
FOV Field Of View
FP False Positive
GB Gall Bladder
HASTE Half Fourier Acquisition Single Shot Turbo Spin Echo
MIP Maximum Intensity Projection
MRCP Magnetic Resonance Cholangiopancreatography
MRI Magnetic Resonance Imaging
NPV Negative Predictive Value
PPV Positive Predictive Value
RARE Rapid Acquisition With Relaxation Enhancement
SEN Sensitivity
SPE Specificity
TE Time Of Excitation
TN True Negative
TP True Positive
TR Time Of Relaxation
TSE Turbo Spin Echo
US/USG Ultrasonography

viii
 ABSTRACT
BACKGROUND & OBJECTIVE:
The main objective of the study is to determine the accuracy of MRCP over
USG and CT in the evaluation of patients with obstructive jaundice.
MATERIAL & METHODS:
The study was conducted in the department of Radio Diagnosis, for a period
of 2 years from August 2011-August 2013. Thirty six patients were included in the
study. All the patients were referred to the department of radio diagnosis with the
clinical suspicion of obstructive jaundice and elevated serum bilirubin levels.
Ultrasonography followed by CT and then MRCP were done in all the patients. Three
experienced radiologists reviewed the images separately and evaluated the cause and
site of obstruction in these patients. The accuracy of each modality was analyzed
statistically and correlation was made with the surgical findings or histopathological
reports.
RESULTS:
Of the thirty six patients, sixteen patients had benign causes of obstructive
jaundice while twenty patients had malignant causes of obstructive jaundice. For
diagnosing the cause of obstructive jaundice MRI with MRCP has a greater diagnostic
accurancy of 94.4% than helical CT with accuracy of 91.6% and USG with diagnostic
accuracy of 30.56%.The sensitivity of MRI with MRCP is greater than that of helical
CT and USG in diagnosing the cause of obstructive jaundice. In diagnosing the site of
obstruction MRCP had a accuracy of 100% while CT had 88% and USG 55%. The
performance of MRCP when compared to CT and USG was statistically more
significant (p<0.05).
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 a better
choice over other radiological procedures like USG, CT or ERCP. The only drawback
of MRCP is the cost involved and the availability. The limitation of the study is the
small sample size and that ERCP correlation for these patients was not done.

Key words: MRCP, CT

ix
 TABLE OF CONTENTS

TOPICS PAGE NO.

1. INTRODUCTION 01

2. OBJECTIVES 05

3. REVIEW OF LITERATURE 04

4. METHODOLOGY 30

5. PHOTOGRAPHS 35-45

6. RESULTS 46

7. DISCUSSION 59

8. CONCLUSION 64

9. SUMMARY 68

10. BIBLIOGRAPHY 70

11. ANNEXURES

• PROFORMA 78
• INFORMED CONSENT 83
• MASTER CHART 87

x
 LIST OF TABLES

SL.
TABLES PAGE
NO.

1 Table showing age distribution of Study Subjects 47

2 Table showing sex distribution of the study subjects 48

Table showing type of lesion causing obstructive jaundice
3 among the study subjects 49

Table showing benign causes for Obstructive jaundice

4 50
among the subjects

Table showing malignant causes for Obstructive jaundice

5 51
among the subjects
Table showing distribution of Benign and Malignant
6 Lesions with respect to age 52

Table showing Histopathological diagnosis among benign

7 53
cases

Table showing Histopathological diagnosis among

8 54
malignant cases

Table showing diagnosis by Helical CT scan and

9 55
Histopathological diagnosis

Table showing diagnosis by MRI with MRCP scan and

10 56
Histopathological diagnosis

Table showing diagnosis by USG and Histopathological

11 57
diagnosis

Table showing Comparison of diagnostic values of

12 Helical CT and MRI with MRCP in causes of obstructive 58
jaundice

xi
 LIST OF GRAPHS

SL.
LIST OF GRAPHS PAGE NO.
NO.

1 Pie Diagram showing Age distribution of the subjects 47

2 Pie Diagram showing sex distribution of the patients 48

Pie diagram showing type of lesion causing obstructive

3 49
jaundice

Bar diagram showing the benign causes of Obstructive

4 50
Jaundice
Bar diagram showing the malignant causes of Obstructive
5 Jaundice 51

Bar diagram showing distribution of Benign and Malignant

6 52
Lesions with respect to age

Bar diagram showing Histopathological diagnosis among

7 53
benign cases

Bar diagram showing Histopathological diagnosis among

8 54
malignant cases

Bar Diagram showing Validity of Helical CT as a

9 55
Diagnostic Test
Bar Diagram showing Validity of MRI with MRCP as a
10 Diagnostic Test 56

Bar diagram showing diagnosis by USG and

11 57
Histopathological diagnosis
Comparison of diagnostic values of Helical CT and MRI
12 with MRCP in causes of obstructive jaundice 58

xii
 LIST OF PHOTOGRAPHS

SL. PAGE
PHOTOGRAPHS
NO. NO

1 Normal anatomy of biliary tract 6

Algorithm for the management of biliary
2 69
Calculus to reduce the number of diagnostic ERCP

xiii
 INTRODUCTION

Obstructive Jaundice has been documented as one of the leading cause of

increased morbidity. It has been mainly diagnosed by imaging modalities. The

main goals of any imaging procedure in obstructive jaundice are to confirm the

presence of obstruction, its location, extent, probable cause, and it should also

attempt to obtain a map of biliary tree that will help the surgeon to determine

the best approach to each individual case. Among these Ultrasonography (USG)

and Helical Computed Tomography (CT) are initial modalities of

investigations. Recently Magnetic Resonance Imaging with Magnetic

Resonance Cholangiopancreatography (MRI with MRCP) is emerging as an

exciting tool for noninvasive evaluation of patients with obstructive jaundice.

Magnetic Resonance Cholangiopancreatography is a relatively new 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 injection of contrast materia 1 .

Since its introduction by Wallner et al in 1991, MR

Cholangiopancreatography has undergone a wide range of changes. With the

development of higher magnetic field strength and newer pulse sequences like

HASTE (Half Fourier Acquisition Single Shot Turbo Spin Echo) and RARE

(Rapid Acquisition and Relaxation Enhancement), 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. 2,3

1
 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, which

is considered as standard of reference in ductal pathologies 4 . 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.

It has proved effective in demonstrating bile duct dilatation, stricture

and choledocholithiasis. In patients with malignant obstruction or stenosis of

biliary-enteric anastomosis, this noninvasive 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.3,5

The principle of MRCP is based on use of heavily T2 weighted fast spin

echo sequences. As a result, stationary or slow moving fluid in biliary &

pancreatic duct gives high signal intensity, while solid organs have low signal

intensity. On these images, the fluid of the biliary and pancreatic ducts gives

the cholangiogram and pancreatogram.2,3,6,7,8

Other imaging modalities used in the diagnosis of biliary tree and

pancreatic duct are Ultrasonography, Computed Tomography, IV

cholangiography and Endoscopic Retrograde Cholangio-pancreatography

(ERCP) and Percutaneous Transhepatic Cholangiography (PTC). For patients

with suspected ductal pathology each modality offers advantages and

disadvantages that are unique to the specific technology.

2
 Drawbacks with ultrasonography and CT are, they do not accurately

define site and extent of biliary strictures. Ultrasonogrpahy has limitations in

diagnosing choledocholithiasis, where as MRCP offers diagnostic accuracy of

>90%. IV cholangiography has limitations, in 30-40% of cases there is

incomplete opacification of biliary system9 . ERCP and PTC require biliary

intervention and use of contrast media.

Magnetic Resonance Cholangiopancreatography (MRCP) has few added

advantage as follow:-

• Non-invasive imaging modality

• No ionizing radiation needed

• No need of contrast media

• Multiplanar imaging capability

• No post procedure complications

• It can be performed in critically ill patients

• It can show biliary tract proximal as well as distal to the level of

obstruction.

MRCP plays a major role in the overall evaluation of biliary &

pancreatic duct lesions and modality is expected to provide information that

will help identify the nature of the disease (infection, tumor, calculus &

others), show the location and extent of involvement, suggest the type of

pathology, guide biopsy and drainage procedures, indicate method of therapy

(medical and/or surgical), suggest surgical approach and help assess response

3
to the therapy. Rapid technical developments in coil design, gradient hardware,

and pulse sequences have continued to improve quality and diagnostic

capability while reducing the data acquisition times.

In this present study we have prospectively studied 36 patients by MR

with MRCP, Helical CT and ultrasonogrpahy who were suffering from various

diseases of biliary tract and/or pancreas and tried to evaluate the efficacy of

MR with MRCP as an imaging modality of choice.

4
 OBJECTIVES

• To establish the role of MR with MRCP over Ultrasound/Computed

Tomography in diagnosing the cause of Obstructive Jaundice.

• To compare the diagnostic yield of MR with MRCP versus Helical

CT and Ultrasonography in diagnosing the causes of Obstructive

Jaundice, extent, associated biliary tract anomalies and condition of

CBD beyond obstruction.

5
 REVIEW OF LITERATURE

Familiarity with normal gross and radiological anatomy is a prerequisite

to understand the broad spectrum of disorders that affect the biliary and

pancreatic system10 .

Fig. 1 : Normal anatomy of biliary tract.

The biliary tract consists of:

• Intra hepatic bile ducts

• Common hepatic duct

• Gall bladder

• Cystic duct

• Common bile duct

• Pancreatic duct
6
Intra hepatic bile ducts:

Normal intra hepatic bile ducts measure less than 3 mm in diameter,

fewer in number and are randomly scattered throughout the liver.11 They are

linear water density structures seen along one side of portal vein. Towards the

hilum they unite to form right and left hepatic ducts which have a constant

location just anterior to main portal vein bifurcation.12 Normally intra hepatic

bile ducts are not visualized on MR imaging.

Common hepatic duct:

Two main ducts (right & left hepatic) issue from the liver and unite near

the right end of the porta hepatis to form the common hepatic duct; this is

usually imaged as a round or elliptical structure sitting anterior and often

slightly lateral to main portal vein. The common hepatic duct lies to the right

and lateral to the proper hepatic artery ,and usually measures 3 to 6 mm in

short axis diameter. The wall of CHD is normally visualized and measures less

than 1.5 mm and enhances brightly than adjacent pancreas. The CHD passes

downward for 3cm, and is joined on its right side at an acute angle by the cystic

duct. By the union of the common hepatic duct with cystic duct the common

bile duct is formed. CECT aids in differentiating water density CHD from the

enhanced hepatic artery and portal vein.10,12

Gall Bladder:

The Gall bladder is a pear shaped sac partly contained in a fossa on the

inferior surface of the right hepatic lobe. It is 7 to 10 cm long, 3 cm broad at its

widest part and 30 to 50ml in capacity. It is divided into a fundus, body and

neck. The fundus or expanded end is directed downwards, forwards and to the

7
right. The body is directed upwards, backwards and to the left, near the right

end of the porta hepatis it is continuous with the neck. The neck is narrow, it

curves upwards, forwards, and then turning abruptly backwards, becomes

continuous with the cystic duct, at this point of continuity with the cystic duct

usually there is a constriction. The mucous membrane, which lines the neck

projects into its lumen in the form of oblique ridges, forming a sort of spiral

valve. From the right wall of the neck of the Gall bladder a small pouch, often

termed Hartman’s pouch is a constant feature of normal gall bladder. Cystic

duct arises from its upper and left wall. There can be enhancement of normal

wall after intravenous contrast administration; a 20 HU increase in

enhancement is seen. The density of gall bladder lumen is that of water (0 to 20

HU). Increase in density of lumen seen normally after post contrast. Signal

intensity of gall bladder content appear hyper intense on T2 and variable on

T1. Gallbladder wall appears thin and hypo intense relative to retroperitoneal

fat on non-fat-suppressed snapshot T2 weighted images. 10,12,13

Cystic duct:

The cystic duct is 3 to 4 cm long, with average diameter of 1.8 mm and

has serpigenous course with tight S-shaped bends, passes backward,

downwards and to the left from the neck of the gall bladder and joins the

common hepatic duct to form the common bile duct; it runs parallel with and

adheres to the common hepatic duct for a short distance before joining with it.

The junction is situated immediately below the porta hepatis. Normally it is

seen as small tubular fluid containing structure between gall bladder and bile

duct.10,13

8
Common bile duct:

Bile duct (CBD) is formed near the porta hepatis by the junction of the

cystic and common hepatic ducts; it is usually about 7.5cm long and about

6mm in diameter, and usually measures upto 8mm in short axis and the wall

shows normal enhancement on CECT and measures 1.5mm. In post

cholecystectomy patients CBD diameter can go upto 10mm. It runs at first

downwards, backwards and slightly to the left & then it passes behind the

superior part of duodenum and then runs in a groove on the upper and lateral

part of the posterior surface of the head of the pancreas. At the left side of the

descending part of the duodenum the bile duct comes in contact with the

pancreatic duct and accompanies it into the wall of second part of duodenum

and there the two ducts usually unite to form hepatopancreatic ampulla, the

distal constricted end of this ampulla opens into the descending part of the

duodenum on the summit of the major duodenal papilla. 10,13

Pancreatic duct:

The main pancreatic duct courses cephalad, takes a 45-90 degree turn in

the neck and continues horizontally in the body and in the tail of the gland the

normal diameter is between 2 to 3mm. it unites with CBD to form

hepatopancreatic ampulla.10,13

The basic principle of MRCP is visualization of static fluid structures

like Gall bladder, cystic duct, hepatic duct, bile duct and pancreatic duct using

heavily T2 weighted spin echo images and gradient echo images with fat

saturation technique.

9
 Fluid appears hyper intense on these sequences because of its long T2

relaxation time. Hence hepatobiliary tree including pancreatic duct will appear

bright within background of low signal intensity liver and other structures.

10
 PATHOPHYSIOLOGY

Obstructive jaundice is the commonest presentation in patients with

biliary obstruction. The role of imaging is crucial for detection of site and

cause of obstruction. In case of malignant obstruction, characterization of the

lesion and staging of the tumor is crucial to decide optimal management of the

disease. These patients in general are subjected to diagnostic US followed by

CECT. It has been proposed that when complete MR imaging is performed

including T1 and T2 weighted images and Gadolinium enhanced MR along

with MRCP, it has the capacity to provide all in one evaluation of the suspected

obstructive lesions, obviating the need for any other investigation such as

CT/PTC/ERCP.

Aberrant Bile Ducts:

Aberrant duct is the only bile duct draining a particular hepatic segment.

The direct drainage of the right posterior duct into the common hepatic duct,

right or left sided, is a variant also known as the aberrant hepatic duct and is

present in approximately 5% and less than 1% of the population respectively.24

It is the most common anatomic variation of biliary tree and constitutes the

cause of the major risk factors for bile duct injuries.14

Choledochal Cyst:

It is the cystic dilatation of the extrahepatic bile duct, with or without

dilation of the intrahepatic bile ducts. It is uncommon and is 3 to 4 times more

common in female than male patients. The precise origin of this abnormality is

unknown. CECT appearances of choledochal cysts depends upon the extent of

11
ductal involvement and degree of dilatation, and it can be mild dilatation or a

large water density mass in the region of porta hepatic or adjacent to the head

of pancreas 60% of patients will have associated central IHBR dilatation.

Direct communication of cystic duct with the dilated duct is a must for

diagnosing choledochal cyst which is often difficult on CT , unless the cyst is

large enough.MR imaging shows it as markedly dilated extrahepatic bile duct

saccular in configuration with no or mild IHBR dilatation, with a long

common channel being hallmark of it.12,13,16,17

Classification of Alonzo-lej modified by Todani et al 18 :

Type IA : Cystic dilatation of the CBD

Type IB : Focal segmental dilatation of the distal CBD

Type IC : Fusiform dilatation of both the CHD & CBD

Type II : True diverticula arising from the CBD

Type III : Cystic dilatation involving only the intraduodenal portion of

the CBD (Choledochocoele)

Type IVA : Multiple intra and extra hepatic cysts

Type IVB : Multiple extra hepatic cysts

Type V : Single or multiple intrahepatic cysts (Caroli’s Disease)

Type VI : Cystic dilation of cystic duct.

12
Caroli’s Disease:

Caroli’s disease is segmental, saccular dilatation of the intrahepatic bile

ducts. It is associated with high incidence of bile duct stones, ascending

cholangitis, liver abscesses and renal cystic disease. On CT and MR images it

appears as saccular cystic dilatation of the IHBDs. The cystic areas often

shown to be communicating with the bile ducts ‘CENTRAL DOT SIGN’

suggested as the pathagonomic of Carolis disease. This sign consists of cystic

dilatation of IHBDs with a small focus or ‘DOT’ of increased density lying

within dilated duct. ‘DOT’ represents portal radicle which enhances on post

contrast.12,13

Cholecystolithiasis:

It is common in female in age group of 20-40 years. it is divided into

three types as follows.

a) Pigment stone – 20%

b) Cholesterol stone
80%
c) Mixed stone

On CT calcified stones appear hyperdense, cholesterol stones appear

hypodense, stones isodense to bile are undetectable by CT. On MR stones will

be hypointense on T1 and T2 weighted images, cross sectional T2 weighted

images are more sensitive than T1 weighted images. Dehydration of older

stones leads to internal shrinkage due to nitrogen gas filling (“crow-foot” or

“Mercedes-Benz” sign) sharing a hypointense central core.12,13

13
Mirizzi Syndrome:

It is an uncommon disease in which obstruction is caused by extrinsic

compression of the CHD from an impacted stone in the gallbladder neck or

cystic duct or by associated periductal inflammation. Two types , simple and

fistulous type. On CT dilated bile ducts may be seen with the CHD dilated to

the level of gallbladder neck or cystic duct.CHD diameter abruptly decreases

below the level of stone at neck or cystic duct. On MRCP simple type shows

smooth focal laterally scalloped narrowing of CHD caused by stone in

gallbladder neck or cystic duct and in fistulous type there will be no smooth

lateral compression.12,13,19

Extrahepatic biliary atresia:

It is a rare disease associated with atresia of CBD and patent

intrahepatic bile ducts. Two subtypes, subtype1- perinatal type, subtype 2- fetal

type. Frequency of biliary atresia is less than 10 in 1 lakh live births. Obviously

there is no role of CT, and it is used to detect associated anomalies. On MRCP

there will be nonvisualisation of extrahepatic bile duct, atrophic gall bladder,

periportal thickening. 12,13

Chronic Pancreatitis:

Chronic Pancreatitis is an irreversible inflammatory disease of pancreas.

The size of pancreas is variable; atrophy of whole gland is common.

Calcification of the gland & duct can be seen along with dilatation of the duct

beyond its normal limits. Duct also shows multifocal stenosis, intraductal

filling defects representing proteins plugs & narrowing of intrapancreatic

segment of CBD. Loss of normal high signal on T1weighted MR images and

14
decreased enhancement on contrast enhanced one. Helical CT shows pancreatic

atrophy, dilatation of pancreatic duct, calcifications within pancreas, and focal

enlargement.12,13

Choledocholithiasis:

Passage of gallstone in CBD occurs in 10 to 15% of patients with

cholelithiasis. Majority of bile duct stones are cholesterol or mixed stones

formed in Gall bladder. Primary calculi arising de novo in the ducts are

pigment stones developing in patients with,

1. Chronic haemolytic disease

2. Hepatobiliary parasitism

3. Congenital anomalies of the bile ducts

4. Dilated sclerosed or strictured ducts.

On CT appears as radio opaque filling defect, with appreciation of

‘TARGET SIGN’ .Secondary signs on CT include abrupt termination of CBD,

rim of increased density around a lower density and associated inflammation of

CBD wall shows thickening and enhancement on post contrast images. On

MRCP it appears as a hypo intense structure surrounded by hyper intense

bile. 12,13,16,17

Cholangiocarcinoma:

Cholangiocarcinoma can be classified into three types according to the

anatomical location: 1) peripheral type, originating from peripheral bile ducts

in the liver. 2) hilar type (Klatskin tumor), originating from the confluence of

right & left hepatic duct. It constitutes 45% to 60% of cases 3) extra hepatic

15
type, originating form main hepatic ducts, common hepatic duct or CBD. It

may appear as unifocal, large mass, multifocal or diffuse infiltrative. Most are

adenocarcinomas, about 95%. The average age at the time of diagnosis is 60 to

65 years. Frequency in men is 1.5 times greater than in women. CECT has been

more helpful for tumor depiction in case of cholangiocarcinoma. On MR, the

mass located at hilum shows IHBD,with varying signal intensities on T2

weighted images.

According to Bismuth Classification of hilar obstruction:

Type I involves the main hepatic duct only

Type II lesion extends into both hepatic ducts

Type III stricture involves segmental biliary ducts in one lobe

Type IV lesion invades bile duct branches in both lobes. 20,21

Ca Head of the pancreas:

Partial or complete obstruction of the duct can be produced by

carcinoma of the head of the pancreas. Risk factors are smoking and alcohol

consumption. It occurs in sixth to eighth decade. Mostly they are

adenocarcinoma. CECT shows mass effect, morphologic contour changes,

density changes, enhancement pattern, duct changes, and some secondary

changes. On MR invariably hypointense on T1 weighted images iso to

hypointense on T2 weighted images.12,13

16
Ampullary Carcinoma :

It is adenocarcinoma that arises from the intestinal type mucosa lining

the ampulla. They account for 4% of periampullary tumors. It occurs in sixth to

seventh decade of life and is two times more common in men than in women.

Patients with Gardner syndrome are at risk. Ascaris infestation also

predisposes to the development of ampullary carcinoma.

Carcinoma of Gall bladder:

It is the most common malignant neoplasm of the biliary tract. The peak

incidence is in sixth and seventh decades. It is 3 to 5 times more common in

women than in men. The tumor is adenocarcinoma in 80% to 90% of cases.

CECT clearly shows invasion of adjacent structures. On MR images mass

replacing gallbladder, with focal, asymmetric wall thickening ,and mass shows

hypointensity on T1 and moderately hypointense on T2.12,13.

Cesar S. et al (1981) 22 in their study of Obstructive Jaundice with 67

patients analysed the value of CT in detecting the level of obstruction. The

cases were divided into four groups by anatomical segments. According to the

number of visualized hypo dense ring like structure produced by the dilated

bile duct as seen in axial sections made 1cm apart, Gall bladder size, dilation of

IHBR, and the pancreatic duct. Visualization of tumor masses and condition

like duct below the obstruction were other variable used to determine the level

of obstruction. Overall accuracy of CT has been detected and has excellent

correlation with result of direct cholangiography.

17
 Gibson N. Robert et al (1986) 23 in prospective study of 15 patients

with bile duct obstruction with various radiologic modalities, were compared

for their capability to demonstrate the level and cause of obstruction, and found

that US appears to be the single most useful modality in evaluation of bile duct

obstruction, compared to CT & Direct cholangiography.

Reiman H. Threasa et al (1987) 24 in their study of 92 patients with

biliary obstruction proximal to the panacreatic segment with CT. They

concluded that CT is the most valuable as a non-invasive means of narrating

surgical or radiologic drainage procedure in patients with biliary obstruction.

Wallner et al in (1991) 25 introduced MR cholangiography. Authors

used the rapid sequence gradient echo acquisition with three-dimensional post

processing technique to evaluate the biliary system in five healthy volunteers

and 13 patients of obstructive jaundice. The results were compared with other

imaging modalities (US, CT scan and conventional radiographs obtained during

PTC or ERCP). Authors concluded that MRCP has the capability for non

invasive imaging of the biliary tree in patients with obstructive jaundice but

improvement in technique is needed to overcome limited spatial resolution and

low signal to noise ratio.

3D MR cholangiography using contrast enhanced Fourier acquired

steady state technique (CE-FAST) was evaluated by Morimoto et al (1992) in

12 patients with malignancy related obstructive jaundice and the results were

correlated with percutaenous transhepatic biliary drainage performed 0-21 days

later. Authors found dilatation and obstruction of the bile ducts were clearly

demonstrated in all patients on MRCP and there was 100% correlation with

18
PTBD gram. Authors concluded that though spatial resolution of 3D MR

cholangiography is slightly inferior to the direct cholangiogrpahy the

information obtained is similar to PTC and the non invasive MR

Cholangiography procedure is less traumatic for the patient.26

The initial results with MR cholangiopancreatography studies were

achieved with gradient echo sequences by using a steady-state free precession

techniques.8,25 Subsequently, MR Cholangiopancreatography studies were

performed with fast or turbo spin echo pulse sequence (FSE). These sequences

were not only slow and required longer scan time for adequate spatial

resolution but were also prone to motion induced artifacts and signal loss. The

latest imaging techniques for MRCP are Rapid Acquisition with relaxation

Enhancement (RARE) and Half-Fourier Acquisition Single-Shot Turbo-Spin-

Echo (HASTE). 1,2 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.

Guidbaud et al (1994) 27 retrospectively evaluated the value of MR

cholangiography using T2 weighted fast spin echo sequences in 10 patients

with proven calculi in the common bile duct. The diagnosis of

choledocholithiasis was proven by stone extraction in all cases. Authors found

that the best results were obtained by using a combination of 3D MIP and

multiplanar reconstruction MR cholangiography and choledocholithiasis was

detected in all 10 patients. The authors concluded that MR cholangiography

based on T2-weighted fast spin echo sequences could be an important imaging

technique for patients with suspected bile duct obstruction and equivocal

19
sonography and/or CT results and suggested that large prospective clinical

trials are needed to confirm these results.

Barish et al (1995) 28 in their study of 30 patients with suspected

pancreaticobiliary diseases compared the efficacy of MRCP with ERCP. They

concluded that MRCP is a sensitive and specific as invasive techniques and

should be the technique of choice, when invasive techniques are incomplete,

unsuccessful or technically difficult.

Soto et al (1995) 29 in their study of patients with suspected

pancreaticobiliary diseases concluded that the projectional images rendered by

MRCP are as good as that of PTC or ERCP. They showed MRCP to be

extremely accurate in showing pancreatic dilatation, strictures, stones, cystic

dilatation with sensitivity approaching 100%.

Reinhold et al (1996) 30 in their study proved MRCP to provide

important diagnostic information in isolation and also MRCP can clearly

provide valuable information when ERCP is unsuccessful or inaccurate.

Miyazaki et al (1996) 31 in their study of 40 healthy volunteers and 56

patients with various pancreaticobiliary diseases compared the findings of

MRCP using HASTE sequence with ERCP or PTC. They showed that the

HASTE-MRCP technique is capable of depicting the biliary system and

pancreatic duct both in healthy volunteers and in patients with

pancreaticobiliary diseases. Specific findings of dilatation and duct narrowing

were easier to identify with HASTE-MRCP than with PTC or ERCP. They also

concluded that breath-hold HASTE-MRCP with phased array coil provides

20
quick and high quality imaging of both normal and abnormal pancreaticobiliary

system.

Regan et al (1996) 32 in their study of 23 patients with HASTE MRCP

proved that HASTE had high sensitivity for detecting stones in CBD and can

be performed rapidly and non invasively without the risks of radiation or

contrast and concluded that HASTE MRCP should be considered alternative to

ERCP in patients with clinical episodes of bile duct calculi and in whom ERCP

was contraindicated.

Keifer et al (1996)33 in their study of 200 patients with

pancreaticobiliary ductal disease proved that single shot MRCP was highly

sensitive (70 to 80%) and specific in detecting lesions in bile duct and

pancreatic duct.

Soto et al (1996)34 evaluated prospectively 46 patients suspected to have

biliary tract abnormalities with 3D fast spin echo MR cholangiography and

compared the findings with direct cholangiography. Authors reported that MR

Cholangiography correctly identified normal caliber common bile duct,

common hepatic and intrahepatic bile ducts in 17/18 patients (specificity

94.1%). MRCP correctly showed the presence of bile duct dilatation and site of

obstruction in 27 of 28 patients (96.3%) shown to have dilated common bile

duct and intrahepatic ducts on direct cholangiography. Authors concluded that

MRCP provides a comprehensive non-invasive examination for suspected

biliary diseases. It can decrease the total cost of diagnostic work up by

eliminating the need for multiple consecutive invasive and non-invasive

studies. The only limitation of MRCP is its inability to offer any therapeutic

21
maneuver. Thus, it may significantly decrease the need for diagnostic ERCP.

MRCP may be used as method to obtain cholangiographic images in patients in

which ERCP is incomplete or has failed due to technical reasons. Further

demonstration of normal bile ducts allows avoidance of unnecessary invasive

diagnostic tests. Authors also pointed out that there is an additional value of

MRCP over ERCP and PTC as it shows an excellent quality cross sectional

images of liver and pancreas which are obtained in the same sitting, allowing

direct visualization of both intraductal and extraductal lesions.

Liberpoulos et al (1997) 35 in their study of 166 patients with various

proved biliary diseases compared the efficacy of MRCP findings with ERCP

findings. They concluded that MRCP shows a comparable sensitivity and

specificity to ERCP in assessing diseases of the biliary system.

Robinson et al (1997) 36 in their study of 24 patients with obstructive

jaundice using MRCP concluded that there is a role for MRCP as a second line

investigation following ultrasound scanning in patients with obstructive

jaundice.

Tomoaki I chikawa et al (1997) 37 in their study of pancreatic ductal

adenocarcinoma preoperative assessment with helical CT versus dynamic MR

imaging, concluded that dynamic MR imaging more diagnostic than helical CT

in the preoperative detection and evaluation of local tumour extension.

Guibaud et al (1998)38 in their study of 7 neonate and infant patients

with suspected bile duct disorders have proved that MRCP is highly accurate in

diagnosing the presence, level and cause of bile duct obstruction. They also

proved that MRCP is the investigation of choice for early diagnosis of biliary

22
atresia and it is non-invasive alternative in selected patients, in whom ERCP or

hepatic biopsy is contraindicated.

Miyazaki et al (1998)39 in their study of 45 children compared the

efficacy of HASTE sequence. They concluded that the level of dilatation

determined on the MRCP images corresponded with the results of surgery. He

also proved that in comparison with surgical or ERCP findings, MRCP showed

high accuracy for detecting anomalies of pancreaticobiliary tree. In overall

comparison between MRCP and surgical or ERCP results, MRCP had

diagnostic accuracy of 100% in diagnosing choledochal cyst and congenital

biliary atresia and of 69% in the anomalous connections between the bile and

pancreatic ducts.

Hoa et al (1998) 40 in their study of 60 persons compared the efficacy of

MRCP in evaluating the morphology and contractility of the normal vaterian

sphincter complex. They concluded that by obtaining serial breath-hold images

using single shot techniques, the most distal portion of the bile duct and

pancreatic duct can be visualized in most healthy patients.

Schwartz et al (1998) 41 in their study of 32 patients with pathologically

confirmed neoplastic obstruction of the biliary tract or pancreatic duct

compared the efficacy of breath hold single shot fast spin echo (SSFSE)

sequence. They concluded that MRCP using breath-hold SSFSE sequence is

accurate in identifying the level of obstruction and presence of underlying

tumor.

Hiroyki irie et al (1998)42 compared the efficacy of MRCP and ERCP

in 16 patients with choledochal cysts. They proved that MRCP offered

23
diagnostic information which was equivalent to that of ERCP. They also

showed that MRCP better defined the proximal biliary tree than ERCP,

however ERCP was superior in paediatric patients. They concluded that MRCP

should be considered as first choice imaging technique for choledochal cyst.

Fulcher Tuner, Capps et al (1998) 43 Breath-hold, heavily T2.

Weighted half-Fourier RARE MRCP was performed in 265 patients with

suspected pancreaticobiliary disease and in 35 control patients. MRCP yielded

an accuracy of 100% in determining the presence of pancreaticobiliary disease,

the presence and level of biliary obstruction, and obstruction due to bile duct

calculi. MRCP findings were correlated with those at direct cholangiography,

pathologic examination cross sectional imaging, clinical follow-up. They

concluded that half-Fourier RARE MRCP enables accurate evaluation of

pancreaticobiliary diseae and obviates ERCP in some patients.

Larena et al (1998) 44 in their study showed that MRCP was a promising

alternative to ERCP in evaluation of pancreatic duct especially in ill patients,

patients with complete occlusion of the pancreatic duct, overweight debilitated

and noncooperative patients.

Lam et al (1999) 45 in study of 14 patients proved that MRCP was more

sensitive than CT cholangiography for detection of choledochal cysts and

related pathologies.

J.C. Varghese et al (1999) 46 in their study of 191 patients compared

MRCP and sonogrpahy with ERCP. They proved MRCP was highly accurate

(87%) similar to that of ERCP in diagnosis of choledocholithiasis and it is far

24
superior to sonography. They concluded that MRCP has a potential to replace

ERCP.

Norton et al (1999) 47 conducted MRCP technique in 22 young patients

with suspected biliary disease. They concluded that unlike ERCP and PTC,

which can not be performed in children without general anesthesia, MRCP

rarely required anesthesia. MRCP enables visualization of the entire liver and

biliary system, whereas ERCP cannot image proximal to a biliary obstruction

and PTC cannot opacity ducts distal to an obstruction. ERCP cannot be

performed in postoperative setting of biliary enteric anastomosis.

Dokhe et al (1999)48 in their study of anomalies and anatomic variants

of the biliary tree using MRCP HASTE and RARE sequences concluded that

anatomical variants of cystic duct and hepatic ducts, which are usually difficult

to diagnose on CT and Sonography, are easily detected by MRCP. They found

that MRCP can easily show anomalies and choledochocele on HASTE coronal

source images.

Varghese et al (1999) 49 conducted comparison between MRCP and

ERCP in 100 patients with biliary tract disease. They concluded that MRCP has

a high diagnostic accuracy when compared with direct cholangiography in the

detection of bile duct diseases. They also proved that MRCP accurately

diagnosed the presence and level of strictures in all patients. The overall

sensitivity, specificity and accuracy of MRCP in detection of bile duct lesions

were 97%, 98% and 97% respectively. They showed that MRCP diagnosed

choledocholithiasis in sensitivity and specificity of 93% and 97% respectively

with accuracy of 97%. They also noted that MRCP showed bile duct lesion in

25
all postoperative patients, whereas ERCP could not show either due to altered

gastrointestinal anatomy or technical factors. The authors concluded that

MRCP has been found to be a simple, safe and highly accurate alternative to

diagnostic ERCP, and MRCP has a potential to replace diagnostic ERCP.

Kelly Van Epps et al (1999) 50 conducted a study of 350 patients over a

period of 4 years using HASTE MRCP sequences. They concluded that HASTE

offers a non-invasive rapid imaging modality to evaluate Gall Bladder, biliary

tree and pancreatic duct. Its multiplanar, fluid sensitive capability have

particular value in detection of CBD stones, acute cholecystitis and diagnosing

Gall Bladder stone and pancreatitis. HASTE MRCP also useful in identifying

complication following laproscopic cholecystectomy.

D.R. Brine, R.L. Soulen (1999) 51 the role of MR imaging and MRCP is

demonstrated in a case of pancreaticobiliary carnicoma associated with a large

choldedochal cyst. The size of cyst presented considerable difficulty in

evaluation with both ERCP & CT. They concluded that MRI with MRCP is a

safe and cost effective next step in the evaluation of patients with significant

biliary duct dilatation or congenital abnormalities of the biliary tree.

HO JT et al (1999) 52 in their study of 35 patients using Haste MRCP

concluded that MRCP using HASTE sequence was fast and accurate for

depiction of the biliary and pancreatic system, with a diagnostic value

comparable to that of direct cholangiography.

Kyo et al (1999) 53 in their study of 162 patients evaluated diagnostic

efficacy of non-breath-hold MRCP and concluded that non-breath-hold MRCP

26
can reliably depict normal and diseased pancreaticobiliary ducts except for

cystic duct and non dilated pancreatic ducts.

Jose C. Varghese et al (1999) 49 in their study of 58 patients with failed

or inadequate ERCP concluded that MRCP was found to have a unique and

valuable role in the investigation of patients in whom ERCP failed or was

inadequate, as it showed pathology with high accuracy and thus avoided

invasive procedures such as Percutaneous Transhepatic Cholangiography in the

diagnosis of Bile Duct Disease after failed ERCP.

Takyushi Masui et al (1999) 54 in their study of 89 patients using

SSFSE MRCP concluded that while single thick-slice MRCP only provided

information about the biliary tree pathologies. Multiprojection Volume

Reconsturction MRCP provided additional information about solid tissue

components in and around the pancreas and showed their precise location.

Hiroshi Kondo et al (2001) 55 in their retrospective study of 43 patients

with biliary calculi to compared observer performance for the diagnosis of

choledocholithiasis using the cholangiography with volume rendered maximum

intensity projection and thick section half Fourier Rapid Acquisition with

Relaxation Enhancement sequences. They concluded that observer performance

with volume rendered MR cholangiography was better than that with MIP and

thick section MR cholangiography for diagnosis of choledocholithiasis.

Volume rendering may be an efficient technique for the reconstruction of MR

cholangiography.

Jorge E. Lopera (2001) 56 determined the usefulness of MR

cholangiogrpahy in defining the extent of biliary ductal involvement in 29

27
patients with malignant hilar and perihilar biliary obstruction and also

evaluated the accuracy of MRCP to plan percutaneous interventions in these

patients. All patients underwent PTC and 27 out of 29 patients also underwent

biliary drainage and/or stent placement within 7 days after MRCP. They

concluded that high accuracy of MRCP for defining extent of ductal

involvement in patients with malignant hilar and perihilar obstruction allows

adequate planning or percutaneous intervention in a majority of patients.

Ballantyne S.A. et al (2003) 57 in their descriptive study of imaging the

pancreatico-biliary system with MRCP determined that MRCP is an

increasingly valuable and rapidly developing technique in the non-invasive

assessment of the pancreatico-biliary tree and it is replacing ERCP as a

diagnostic procedure in the investigation of the same.

Mi Suk Park et al (2004) 58 in their retrospective study of

differentiation of extrahepatic bile duct cholangiocarcinoma from benign

stricture.Findings at MRCP versus ERCP, in 50 patients showed that accuracy

of MRCP is comparable with that of ERCP. Regardless of modality a long

segment of extrahepatic bile duct stricture with irregular margin and

asymmetric narrowing suggests cholangiocarcinoma, and shot segment with

regular margin and symmetric narrowing suggest benign stricture.

Anderson M et al (2005) 59 in their study of MRI with MRCP with 51

patients of obstructive jaundice found that MR imaging is more accurate than

CT in differentiating between malignant and benign lesions in patients with

suspected periampullary tumors mainly due to the information obtained on the

MRCP images of biliary and pancreatic duct anatomy.

28
 Bhatt C et al (2005)60 in their study of 50 patients with biliary and

pancreatic pathology determined that USG is the cheap and easily available

modality in patients suspected to have biliary and pancreatic pathology and

MRCP has high diagnostic value.

Seung Hong Choi et al (2005) 61 in their study of differentiating

malignant from benign common bile duct stricture with multiphasic helical CT

with 50 patients showed that hyperenhancement of involved CBD during the

portal phase is the main factor distinguishing malignant from benign CBD

strictures.

Shanmugam V. et al (2005) 62 in their study of IS MRCP the new gold

standard in biliary imaging proved that MRCP is highly sensitive and specific

for choledocholithiasis and avoids the need for invasive imaging in most

patients with suspected choledocholithiasis.

Anderson N. Stephan et al (2006) 63 in their study of accuracy of

MDCT in the diagnosis of choledocholithiasis concluded that MDCT are

moderately sensitive and specific for showing choledocholithiasis.

Young Kon Kim et al (2006) 64 in their study of value of adding T1

weighted image to MR cholangiopancreatography for diagnosing intrahepatic

biliary stones, with 148 patients suspected of having biliary stones,who

underwent MRI including MRCP, a fat suppressed T1 weighted fast low angle

shot sequence (FLASH) and an axial HASTE sequence who were enrolled in

the study, concluded that combining the axial T1 weighted image with MRCP

is valuable for detecting intrahepatic stones.

29
 METHODOLOGY

This study on “ROLE OF MRCP IN SUSPECTED CASE OF

OBSTRUCTIVE JAUNDICE VS COMPUTED TOMOGRAPHY /

ULTRASONOGRAPHY.” has been carried out in the Department of

Radiodiagnosis, J.J.M.C. Medical College, Davangere. A total no of thirty six

patients suffering from various diseases of biliary tract and pancreas of all age

groups and either sex were included in this study.

Most of the patients were diagnosed clinically as obstructive jaundice.

All the patients had undergone USG and most them have diagnosed on

USG prior to Helical CT and MR examination.

The study protocol was approved by the ethical committee. All the

patients gave informed consent to participate. Patients were excluded if

considered unsuitable for MRI-MRCP and Helical CT examination, due to

claustrophobia or renal insufficiency preventing the use of contrast enhanced

CT.

For study purpose we trend to refrain patients from ERCP or biliary

drainage prior to MR and CT procedures to avoid artifacts in this examinations.

Median time between CT and MR examination was 4 days (0-10 days).

Patient preparation for USG :

• All the patients were instructed to come with empty stomach on the day

of procedure.

30
Patient preparation for Helical CT:

• All the patients were instructed to come with empty stomach on the day

of procedure.

• All patients renal functional status were noted before undergoing

contrast CT.

• All patients clinical history were elicited to rule out previous contrast

reactions/allergies.

Patient preparation for MRI with MRCP.

• All the patients were instructed to fast for 6 hours prior to examination.

• All the metallic belongings removed prior to the examination.

• In few uncooperative and critically ill patients, respiratory triggering

was used.

METHODS:

USG was performed using a Philips IU 22 pro machine. Both curvilinear

and linear probes were used in the study. Images of the biliary tree were

recorded for later review.

Helical CT was performed on a Toshiba Activion 16 Multislice CT

Scanner. Patients were asked to drink 800 ml of diluted oral contrast 1 hour

before procedure and 200 ml of diluted oral contrast immediately before

procedure. Unenhanced CT with 1mm collimation of the upper abdomen was

performed to locate the pancreas. Contrast (80 ml, 300mg I/ml) was then

injected intravenously The scans were taken from diaphragm to iliac crest on

5mm collimation,5mm reconstruction interval, pitch of 1.0, and FOV of 30-40

cms. The images were reformatted upto smaller intervals.

31
 MRI-MRCP was performed on Philips ACHIVA 1.5 Tesla MRI

Scanner. Patient was given concentrated pineapple juice prior to scan. All

images were obtained with breath holding and parameters were individualized

to optimize each for a suspended breathhold of about 15s.All conventional

sequences were acquired in axial plane. Detailed parameters of each sequence

are summarized below.

No of Slice
TR TE Gap FOV
Sequence Slices Thickness Matrix
(ms) (ms) (mm) (mm)
(mm) (mm)
Ssh SPAIR COR 465 80 25 5 0.5 486 330
Ssh SPAIR TRA 425 80 40/35 5 0.5 420 330
Ssh SPAIR SAG 462 80 40 5 0.5 384 270
T2TSE HR TRA 2504 100 36 5 0.5 512 360
T1W 3D TSE 10 4.6 80 1.0 0.1 256 375
MRCP 3D HR 1204 650 110 1.0 0.8 512 266
Ssh MRCP RAD 8000 800 12 40 0.4 512 300
RT- Respiratory Triggering: bh- breath hold:

The following Parameters were studied for Ultrasound, Helical CT and

MRI with MRCP;

1. Level of obstruction(four Anatomical Segments)

• Hepatic

• Suprapancreatic

• Pancreatic

• Ampullary

2. Presence of bile duct calculi

• Non visualized

• Definitely visualized.

32
 3. Status of CBD

• Smooth tapering

• Abrupt end

• Rounded

• Irregular

4. Degree of dilatation of intra hepatic biliary radicals

• Minimal

• Moderate

• Marked

5. Gall bladder pathology including size, wall, stones.

6. Dilatation of pancreatic duct.

7. Pancreatic atrophy, calcifications, and pseudocysts.

8. Presence of masses(with or without enhancement-for Helical CT

only)

9. Invasion of viscera, fascial planes.

10. Presence of metastasis.

Then classification of imaging findings as benign or malignant cause of

obstructive jaundice is based on following scale of confidence.

DEFINITELY BENIGN:

Biliary duct dilatation with a visible stone in the duct.

PROBABLY BENIGN:

Cystic dilatation of bile duct. Pancreatico-biliary duct dilatation

considered benign(i.e. Sign of chronic pancreatitis).

33
INCONCLUSIVE:

Not confidently diagnosed as benign or malignant.

PROBABLY MALIGNANT:

Iso-Hypo enhancing mass(for CT only) with indirect signs of

tumor such as duct dilatation with ductal cut-off adjacent to the mass or

atrophic distal parenchyma or pancreato biliary dilatation considered malignant

without sign of a mass or lesion in pancreatic head without duct dilatation.

DEFINITELY MALIGNANT:

Mass in the pancreatic head with consistent duct dilatation. Isolated

CBD dilatation with an abrupt narrowing located cranial to the level of mass

lesion.

Ultrasonography, MRI and CT scans were analysed separately. All

examinations were analysed by eminent radiologist experienced in body CT

and MRI. Final diagnosis was established with per operative or

histopathological correlation .Among these twenty six patients underwent

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.

34
 ILLUSTRATION 1:
CASE OF CHOLELITHIASIS WITH CHOLEDOCHOLITHIASIS 

USG CT

MRCP CECT

35
 ILLUSTRATION 2
CASE OF CHOLEDOCHOCELE 

USG CT

MRCP CECT

36
 ILLUSTRATION 3
CASE OF MIRIZZI’S SYNDROME 

CT CECT

MRCP

37
 ILLUSTRATION 4
CASE OF CA HEAD OF PANCREAS 

USG CECT

MRCP T2W MR

38
 ILLUSTRATION 5
CASE OF KLATSKIN’S TUMOUR 

USG T2W MRI

MRCP

39
 ILLUSTRATION 6
CASE OF CAROLI’S DISEASE

T2W COR

T2W AXIAL

MRCP

40
 ILLUSTRATION 7
CASE OF LYMPHOMA

NECT

T2W (COR)

MRCP

41
 ILLUSTRATION 8
CASE OF Gb MASS

CECT T2W (AXIAL)

T1W (AXIAL) MRCP

42
 ILLUSTRATION 9
CASE OF PERIAMPULLARY CARCINOMA

CECT T2W (COR)

3D MRCP MRCP

43
 ILLUSTRATION 10
CASE OF HYDATID CYST

T2W AXIAL T2W CORONAL

MRCP MRCP

44
 ILLUSTRATION 11
TYPE 1 CHOLEDOCAL CYST

ILLUSTRATION 12
TYPE 4A — CHOLEDOCAL CYST

ILLUSTRATION 13
SCLEROSING CHOLANGITIS

45
 RESULTS

Our study was conducted to determine the MR -MRCP in the evaluation

of patients with obstructive jaundice Vs Helical CT /USG. This study included

36 patients. The youngest patient of our study was 3 months old and the oldest

was 85 years. The mean age of patients with benign lesions was 37.4 years and

that with malignant lesions was 46.5 years. All the lesions were detected by

both CT and MRI with MRCP. CT characterized 15 patients had benign cause

of obstructive jaundice, out of which, 1 case (6.6%) turned out to be malignant.

Out of 21 cases characterized as malignant by CT, 2 cases (9.5%) turned out to

be benign.

Out of 16 cases characterized benign by MRI with MRCP imaging,

only 1 case (6.2%) turned out malignant, which was characterized benign by

CT too. Out of 20 cases characterized as malignant by MR with MRCP, 1 case

(5%) turned out to be benign.

For calculation of statistics “Statistical Package for the Social Sciences

17 (SPSS 17)”, software was used to analysed the datas and open epi software

was used to calculate sensitivity, specificity, NPV, PPV and diagnostic

accuracy. p-value was calculated by chi-square test, p-value less than 0.05 was

considered as statistically significant.

It is inferred that for diagnosing the causes of obstructive jaundice the

Sensitivity, Specificity, PPV, NPV, Accuracy was 18.75%, 40%, 20%, 38.1%,

30.56% for US, 87.5%, 95%, 93.33%, 90.48%, 91.67% for CT and 93.75%,

95%. 93.75%, 95%, 94.44% MRI respectively.

46
 T able-1 : T able showiing Age diistribution
n of Study Subjects

Agee Group No. of Pa

atients Percent

<1 2 years 2 5.5

13-330 years 6 16.6

31-660 years 17 47.3

600 Years 11 30.6

In the
t study itt was obserrved that majority
m i.ee. 47.3% off the patien
nts with

obstructivee jaundice were betw

ween 31 to 60 years of
o age. Thee youngest patient

was 3 monnths old wiith choledoochal cyst and

a the olddest was 855 years old
d female

with GB c arcinoma

Perccent

5.5
30.6 166.6
<122 years
13-330 years
31-660 years
47.3 60 Years
Y

ure 1: Pie Diagram showing

Figu s Age
A distrib
bution of th
he subjects

47
 Taable 2: Tab
ble showin
ng sex distrribution o f the studyy subjects

Sex No. of Pa
atients Percent

M
Male 19 53

F emale 17 47

T
Total 36 100

In the
t study it
i was obseerved that majority i..e. 53% off the patien
nts with

obstructivee jaundice were malees. It is eviident that there

t is maale prepond
derance

in hepatobbiliary diso rders.

0%

4
47%
53% M
Male
F
Female

Figgure 2: Piee Diagram showing sex

s distribution of th
he patientss

48
Table 3: Table sho wing type of lesion causing
c ob
bstructive jaundice among
a

t study subjects
the s

Type of Lesion No. of Pa

atients Percent

B
Benign 16 44

Maalignant 20 56

T
Total 36 100

In the
t study itt was obserrved that th
he most coommon cauuse for obsttructive

j
jaundice iss malignancy i.e. in 56%
5 of casees.

Perccent

0%

44%
56% Benign
Malignant
M

Figure 3:: Pie diagrram showin

ng type off lesion cau
using obstrructive jau
undice

49
Table 4: Table show
wing beniggn causes for Obstru
uctive jaun
ndice amo
ong the

subjects

Beniggn Causes No of cases

c Percent

CBD
D calculi 4 25

CBD witth GB calcculi 4 25

Beniggn stricturee 4 25

Anatom
mic variannt 3 19

Choolangitis 1 6

T
Total 16 100

In the
t study it was obsserved thatt the mostt common benign caause for

obstructivee jaundice was CBD

D with calcculi and GB
G calculi and strictture i.e.

75%. Leasst common cause for obstruction

o n was cholaangitis.

25 25 25 25

20 19

15

10
6

0
D CALCULI
CBD CBD WITH
H GB ENIGN
BE ANATOMIIC CHOLA
ANGITIS
CALCU
ULI STR
RICTURE VARIANT
T

Figure 4:: Bar diagrram showiing the ben

nign causees of Obstrructive Jau
undice

50
 Table 5: Table sho wing maliignant cau
uses for Ob
bstructive jaundice among
a
the subjects

Malign
nant Causees No of cases
c Percent

Periam
mpullary C a 8 40

Cholanggiocarcinom
ma 4 20

C GB
Ca 4 20

Klatskkins tumorr 2 10

Ca headd of Pancreeas 1 5

Metastatiic compres sion 1 5

Total 20
0 100

In the
t study i t was obseerved that the
t most c ommon maalignant caause for

obstructivee jaundicee was peri ampullary carcinoma i.e. 40%

%. Least common
c

cause for obstructioon was Metastatic

M compressio
c on and caarcinoma head
h of

pancreas i..e. 5%.

40 40

35
30
25
20 20
20
15 10
10 5 5
5
0

Figuree 5: Bar diiagram sh owing the malignan t causes off Obstructtive

Jaunddice

51
Table 6: Table
T show
wing distr ibution off Benign an
nd Malign ant Lesion
ns with

respect to
t age

Age Groupp B
Benign Cas es Malignnant Cases Totaal cases

0-12 1 50 1 50 2

13-30 5 83.3 1 16.77 6

31-60 8 47 9 53 17

>60 2 18.1 9 81.99 11

Total 16 20 36
X2=6.8, dff = 3, p=0. 078

In the
t study it
i was obseerved that malignant lesions w ere commo
on after

60yrs i.e. in
i 81.9%. Benign
B lesions were more
m comm
mon in the age group 1 to 30

years i.e. 83.3%.

8

90
833.3 81.9
80

70

60
53
50 50
50 47

40

30
16.7 18.1
20

10

0
0-12 13-30 31-660 >60

Benign Malignant

Figure 6: Bar diaagram shoowing distrribution o f Benign aand Malign

nant

Lesio ns with reespect to a ge.

52
 Table 7:: Table shoowing His topatholog
gical diagn
nosis amon
ng benign cases

Histop
pathologicaal Diagnossis No of ca ses Percen
nt

CB
BD benign stricture 4 25

CBD stoones 4 25

C
CBD & GB
B stones 4 25

C
Choledoch al cyst 2 12.5

Extra hepatic bi liary atresiia 1 6.25

Cholanggitis 1 6.25

Total 16 100

In the
t study it was obsserved thatt the mostt common benign caause for

obstructivee jaundice based on histopathol

h logy was l arge bile dduct calculi/stones

in 75% of cases.

25 25 25 25

20

15
12.5

10
6.25 6.25

0
CBD D BENIGN  C
CBD STONES CBD & GB  CHOLEDOCHAL  EXTRA
A  CHOLAN
NGITIS
STTRICTURE STONES CYST HEPATIC 
BILIARYY 
ATRESIAA

Figure 7: Bar diagrram showiing Histop

pathologicaal diagnos is among benign
b

casees

53
Table 8: Table
T show
wing Histoopathologiccal diagnoosis amongg malignan
nt cases

Histtopathologgical Diagn
nosis No of cases Percen
nt

Ad enocarcinooma duodennum 8 40

CB
BD Cholanngiocarcinooma 4 20

Adenocarccinoma GB
B 4 20

Hiilar Cholanngiocarcinooma 2 10

Addenocarcinnoma pancrreas 1 5

Metastatiic Adenoc arcinoma infiltrating

i
1 5
CBBD

Tootal 200 100

In the
t study i t was obseerved that the
t most c ommon maalignant caause for

obstructivee jaundice based on histopathol

h ogy was Duodenal
D A
Adenocarcin
noma in

40% of caases follow

wed by Choolangiocarccinoma andd Gall bladdder carcin
noma in

40% of casses.

40 40

35

30

25
20 20
20

15
10
10 5 5
5

Figur e 8: Bar diagram

d sh
howing Hi stopatholoogical diaggnosis amo
ong
malignan
nt cases

54
Table 9: Table
T show
wing diagn
nosis by Heelical CT scan
s and H
Histopatho
ological

diagno
osis.

Histopaathologicall diagnosiss Significcance

Benign
n Ma
alignant

Helical Benign 14 (TP

P) 1 (FP) 15
X2 = 24
4.89,
CT
M
Malignant
t 2 (FN)) 1 9 (TN) 21 df =1
1,
p <0.0000
000607
16 20 36

995% Confiidence
Limitt

Seensitivity 87.5%
8 63.98 - 96.5
9

Sp
pecificity 95% 76.39 - 99
9.11

Positive Predictive
P e Value 93.33%
9 70.18 - 98.81

Negative Predictivee Value 90.48%

9 71.09 - 97
7.35

Diagnoostic Accuracy 91.67%

9 78.17 - 97
7.13

96.00%
95%
94.00% 93.33%

92.00% 91.67%
90.48%
90.00%

87.50%
88.00%

86.00%

84.00%

82.00%
SENSITIVITYY SPECIFFICITY POSITIVE 
P NEGATIVE  DIAGNO
OSTIC 
PR
REDICTIVE  PREDICTIVE  ACCURA
ACY
VALUE VALUE

Figure 9: Bar Diagrram showi ng Validitty of Helic al CT as a Diagnostic Test

55
 Tablle 10: Tab le showingg diagnosi s by MRI with MRC
CP scan an
nd

Histop
pathologiccal diagnossis.

Histopatho
H ological
Significcance
diagno
osis

Beniign Malignant
M

MRI with
h Benign
n 15 (T
TP) 1 (FP) 16 X2 = 28.36
2
MRCP df = 1
Malignaant 1 (F N) 19 (TN) 20
p<
166 20 36 0.00000
00101

995% Confiidence
Limitt
Seensitivity 93.75%
9 71.67 - 98.89
Sp
pecificity 95% 76.39 - 99
9.11
Positive Predictive
P e Value 93.75%
9 71.67 - 98.89
Negative Predictivee Value 95% 76.39 - 99
9.11
Diagnoostic Accuracy 94.44%
9 81.86 - 98.46

95.20%
95.00% 95% 95%

94.80%
94.60%
94.44%
94.40%
94.20%
94.00%
93.75%
% 93.75%
93.80%
93.60%
93.40%
93.20%
93.00%
SENSITIVIT
TY SPECIF
FICITY PO
OSITIVE NEGATIVE DIAGNO
OSTIC
PRE
EDICTIVE E
PREDICTIVE ACCURAACY
VALUE
V VALUE

Figurre 10: Bar Diagram showing Validity

V of MRI with
h MRCP as a
Diagnostiic Test

56
 Tabl e 11: Tablle showingg diagnosiss by USG and
a Histop
pathologiccal

diagno
osis.

Histopath
hological
Signifi cance
diagn
nosis

Be nign Malignant
M t

Beniggn 13 8 21
USG X2 = 7.106
7
Inconclu
usive 3 8 11 df = 2
p < 0 .028
Malign
nant 0 4 4

16 20 36

995% Confiidence
Limitt
Seensitivity 18.75%
1 6.591 - 43
3.01
Sp
pecificity 40% 21.88 - 61.34
Positive Predictive
P e Value 20% 7.047 - 45.19
Negative Predictivee Value 38.1%
3 20.75 - 59
9.12
Diagnoostic Accuracy 30.56%
3 18 - 46 .86

40.00% 4
40%
38.10%
35.00%
30.56%
30.00%

25.00%
20%
18.75
5%
20.00%

15.00%

10.00%

5.00%

0.00%
SENSITIVITYY SPECIFFICITY POSITIVE 
P NEGATIVE  OSTIC 
DIAGNO
PR
REDICTIVE  PREDICTIVE   ACCUR
RACY
VALUE VALUE

Figure 111: Bar diaagram show

wing diagn
nosis by U SG and H istopathollogical
diagnoosis.

57
 Table 122: Table s howing Coomparison
n of diagnoostic valuees of Helical CT
and MRI with MRC CP in causses of obsttructive ja undice

MRI with
h MRCP Helical C
CT USG
U

Seensitivity 93.75
5% 87.5% 18..75%

Sp
pecificity 95%
% 95% 4 0%

Positive Predictive
P Value 93.75
5% 93.33%
% 2 0%

Negative Predictivee Value 95%

% 90.48%
% 38
8.1%

Diagnoostic Accurracy 94.44

4% 91.67%
% 30..56%

100.00% 93.75% 95% 95%

9 93..75%93.33% 95% 94.44%91
90.48% 1.67%
90.00% 87.50%

80.00%
70.00%
60.00%
50.00%
40.00%
40%
30.00% 8.10%
38

20.00% 30.56%
18.75% 20%
10.00%
0.00%
SENSITIVITTY SPECIFICITY POSITIVE  NEGATIV
VE  DIAG
GNOSTIC 
PREDICTIVE  PREDICTIV
VE  ACC
CURACY
VALUE VALUE

MR
RI with MRCP Helical CT USG

Figure 12:
1 Compaarison of diagnostic
d values
v of Helical
H CT
T and MRII with
M
MRCP in caauses of ob
bstructive jaundice

Fro m the abovve table it can be infferred that for diagnoosing the cause
c of

obstructivee jaundice , MRI witth MRCP has a gre ater diagn ostic accu
uracy of

94.4% thaan Helical CT with accuracy is 91.6% and USG

G with diaagnostic

accuracy of
o 30.56%.

Thee sensitivitty of MRI with MRC

CP is greaater than thhat of Heliical CT

and USG in
i diagnosiing the cauuse of obstrructive jaunndice.
58
 DISCUSSION

Diagnosing patients with suspected biliary or pancreatic pathologies in

their early stage is most important in patient care and management. Knowledge

of the advantages and disadvantages of each technique are needed to determine

the appropriate work up of patients with these pathologies.

With the introduction of MR Cholangiopancreatography in addition with

conventional MRI, diagnosing biliary and pancreatic ductal pathologies

invasive procedure like ERCP can be avoided solely for the purpose of

diagnosis.

In our study we have studied 36 patients suffering from various causes

of obstructive jaundice.

The youngest patient was 2 months old presented with choledocal cyst

and oldest patient was 85 yrs old with GB carcinoma. Maximum number of

patients (47.3%) were adults in the age group of 31-60yrs with 53% sufferers

were males. All of our cases presented with jaundice and abdominal pain. Most

common sign encountered in our study was icterus.

USG was done in all the patients prior to Helical CT and MRI with

MRCP.USG was able to detect gall bladder calculi in all of the cases with

100% accuracy .USG showed difficulty in picking up distal CBD calculus in

two patients, diagnosed clearly with CT and MR with 100% accuracy. This

shows that MR with MRCP is superior to USG in detecting CBD calculi and

other distal CBD pathologies. Our study is in concordance with Guibad et al

1994; In their study they found an accuracy of 100% in detecting CBD calculi

on MRCP in cases with equivocal sonographic and CT results.(38)

59
 In imaging of benign lesions( n=16) MR with MRCP diagnosed CBD

with GB calculi in all 8 patients with such a final diagnosis and CT also

showed the same in all and both the modalities showing 100% accuracy in

detecting CBD and GB calculi. MR with MRCP showed calculus region as an

area of signal void, and CT showed it as hyperdense lesion. Our study is in

concordance with Soto et al 2000;In their study they found sensitivity of 94%

and specificity of 100% for detecting bilary calculi in MRCP27 . Stephan et al

2006: In their study they found the sensitivity of diagnosing CBD calculus was

87% and our study showed that CT is more superior than their study 64 .

Stricture disease was diagnosed in 4 patients MR with MRCP clearly

showed benign nature of stricture in all four cases approaching 100% accuracy.

MRCP showed clearly the length of the stricture segment very well and

differentiated stricture as malignant and benign. Among these in Helical CT

two patients were diagnosed to have malignant nature of obstruction ,based on

characters of distal CBD, such as rounded ending of CBD abruptly.

Histopathology examination of the resected specimen revealed benign nature of

obstruction in those two cases which CT reported as malignant. Our study is in

concordance with Bhatt et al; In their study they found 100% accuracy for

MRCP in diagnosing benign CBD strictures. 60 One case of cholangitis has been

diagnosed wrongly as CBD growth in MR with MRCP, which histology proved

it as a benign lesion.

Anatomic variants of 3 cases have been diagnosed on Helical CT and

MR with MRCP. One case of biliary atresia and two cases of choledochal cysts.

Both showed diagnostic accuracy of 100%.Our study is in concordance with

60
Bhatt et al; In their study they found 100% accuracy for MRCP in diagnosing

anatomical variants 60 .

In imaging of malignant lesions (n=20), 8 cases of periampullary growth

was diagnosed with histopathological correlation. Among these 7 patients were

diagnosed to have periampullary growth in MR with MRCP, and Helical CT.

Conventional MRI sections aided a lot in arriving final conclusion. In two of

these cases MRCP demonstrated “double duct” sign which helped more in

arriving final diagnosis. One patient was diagnosed to have stricture disease

among the periampullary growth patients, due to technical fault and due to

patient non-cooperation in both the modalities. Hence the diagnostic accuracies

of both the modalities approaching 88%.Our study is in concordance with

Anderrson et al 2005; In their study they found 90%accuracy for MR and

80%accuracy for CT in diagnosing periampullary growth59 .

In 4 patients with extrahepatic cholangiocarcinoma MR with MRCP

diagnosed all four cases with a 100% accuracy with the help of conventional

MRI, while CT clearly showed growth in 2 cases and with suspicion in

remaining 2 cases, thus approaching 100% accuracy for MR with MRCP

compared to 88-90%accuracy in CT. When studying correlation between

imaging findings and final diagnosis we found a stricture with malignant

characteristics at MRCP to be the most predictive sign of malignancy. Our

study is in accordance with Andersson et al 2005; found that among MR with

MRCP strictures with malignant characteristics at MRCP were the only

independent predictor of malignancy 59 . In these respects MRCP was more

accurate than CT imaging.

61
 2 patients were diagnosed to have Klatskins tumour , and the accuracy

of two modalities remain 100% .Our study is in concordance with Bhatt et al

2005;in their study they found accuracy of 100% for MRCP alone in

diagnosing Klatskins tumour 60 . But CT was not able to show exact extent of

two lesions as MRI did. Thus our study is in concordance with JK Han et al ;

they inferred that Spiral CT less accurate than cholangiography in evaluvation

of Klatskins tumor in relation to extent of tumour as CT has less z axis

resolution.

One case has been diagnosed to have extrinsic malignant nodal

compression in both the modalities approaching 100% accuracy in both.

Among four patients with GB Carcinoma MR with MRCP diagnosed all

four cases with 100% accuracy, while CT showed positive finding in 3 cases,

with accuracy of 75% and one case it diagnosed as malignant hilar obstruction.

Conventional MRI added a lot once again in arriving final diagnosis. Among

these, two patient had liver metastasis shown clearly by both the modalities.

Our study is in concordance with Bhatt et al 2005 ; in their study they found an

accuracy of 100% for MRCP alone in diagnosing GB Carcinoma 60 .

ERCP correlation was got with one patient and findings were correlated

with MRCP and found that , MRCP findings were comparable to that of ERCP.

Finding of our study is in concordance with Barish et al 1995; and Pavone et al

1988; in their study they found that MRCP images equivalent and better to

ERCP.28

ERCP is considered the standard of reference for imaging patients with

obstructive jaundice, as it provides high resolution images of biliary tree and

62
pancreatic duct. A great advantage of ERCP is its ability to perform therapeutic

interventional procedures, including stone removal, stricture dilatation, and

stent placement which will relieve obstruction. It requires a highly skilled and

experienced endoscopist. Technical limitations can lead to unsuccessful

examination. It may fail to show biliary tree proximal to severe obstruction. It

is associated with significant post procedure morbidity and mortality. It cannot

be performed in critically ill patients.35,36,49

Considering few limitations of Helical CT and USG and invasiveness

and complications of ERCP,MRCP alone can become the imaging modality of

choice in imaging patients with obstructive jaundice, and it becomes still more

superior on adding conventional MRI sections to it because, it is

• Non-Invasive imaging modality.

• No-Ionising radiation needed.

• No need of contrast media.

• Multiplanar imaging capability.

• Non-operator dependant.

• No post procedure complications.

• Can be performed in critically ill patients.

It can show biliary tract proximal as well as distal to obstruction.

Like any other imaging modality MR with MRCP also has few

limitations.

It cannot provide therapeutic option to the patient.

Claustrophobia.

63
 CONCLUSION

This study was conducted in the department of Radiodiagnosis, J.J.M.C.

Medical College, Davangere, over a period of 2 years and consisted of thirty

six patients of different ages and both sexes. Our study sought to define the

role and efficacy MR with MRCP in evaluation of patients with obstructive

jaundice.

In our study, age ranged from 2 months to 85 years with mean age of 42

years. Most of our case was in the age group of 31-60 years. Males accounted

for 53% of cases with male to female ratio 1:0.9.

Among the benign cause of obstructive jaundice CBD calculi were the

most common finding constituting about 50% of benign causes and it is

detected as an isolated or in association with other pathology. Both CT and

MR showed 100% accuracy in detecting calculus disorders and USG showed

52%.

Among the malignant causes periampullary carcinoma is the most

common cause and constitutes about 40% of malignant causes. USG showed

43% and both CT and MR showed with 95% with 95% sensitivity in detecting

malignant pathologies. Both CT and MR showed with 95% sensitivity in

detecting malignant pathologies. But it is still MRCP that has potential role in

delineating the malignant cause of obstructive jaundice, approaching almost

100% in accuracy.

During our study we observed that MRI with MRCP has 94% accuracy

in delineating the cause of obstructive jaundice. Compared with USG and

Helical CT, MRI with MRCP is equally sensitive and more specific in

64
differentiating the causes of obstructive jaundice as malignant. MRI with

MRCP is very accurate than CT/USG in identifying the various benign

pathologies , and this modality has shown a dramatic role in identifying

anatomic variants including choledochal cysts. With the help of conventional

MRI, MRCP has added its advantage of diagnosing malignant pathologies to a

extent that it was even possible to stage the malignant tumors.

This single modality(MRI with MRCP) apart from demonstrating the

causes of obstructive jaundice, can be used to demonstrate the involvement of

vascular structures with different sequences at a single setting with MR

angiography thus saving time and discomfort to the patient.

MR Cholangiopancreatography is very accurate in demonstrating calculi

at the distal end of CBD as an area of signal void, also in demonstrating

strictures as the cause of dilatation of biliary radicals. It showed the length of

stricture segment very well and differentiated stricture as malignant and

benign. The benign strictures were smooth tapered margins, where as in

malignant strictures there was an abrupt and irregular character of narrowed

segment with or without shouldering. MRCP is superior to CT in this regard.

With the help of source image , we can very well show the exact

location and extent of malignant tumours (like Ca GB, Klatskin tumour,

Cholangiocarcinoma, Ca pancreas), thereby providing a guide map for

segmental resection .MRCP is more superior than CT in this regard. Adding

conventional axial T1 and T2 weighted sequences it is easy to stage the tumor.

Based upon our study following conclusions can be drawn;

65
 MR with MRCP is an accurate, non invasive means of evaluating the

patients with obstructive jaundice.

It is useful in children, critically ill patients with ease.

It is useful in failed ERCP cases and it also shows biliary tree very well

proximal as well as distal to the level of obstruction.

It is better to Helical CT and USG in showing the distal CBD as well as

pancreatic duct.

The inherent multiplanar capability of MRI with MRCP makes MR

superior to other modalities in characterizing the lesion.

The diagnostic accuracy of MRI with MRCP suggests that it has the

potential to replace or limit the use of invasive procedures like diagnostic

ERCP, which should be used only in cases where intervention is being

contemplated.

In conclusion in this prospectively collected data of patients, MRI

combined with MRCP is equivalent to Helical CT in delineating the cause of

obstructive jaundice as malignant, but it is superior to Helical CT in diagnosing

benign causes of obstructive jaundice .This difference was mainly explained by

the MRCP in imaging malignant/benign biliary and/or pancreatic duct

strictures and to bile duct calculi. But still MRCP alone is more accurate than

Helical CT in delineating the cause of obstructive jaundice. Dynamic contrast

enhanced MRI did not add any better performance to cross sectional MRI

combined with MRCP without contrast. From the above table it can be inferred

that for diagnosing the cause of obstructive jaundice MRI with MRCP has a

66
greater diagnostic accuracy of 94.4% than helical CT with accuracy of 91.6%

and USG with diagnostic accuracy of 30.56%.

The sensitivity of MRI with MRCP is greater than that of helical CT and

USG in diagnosing the cause of obstructive jaundice.

67
 SUMMARY

Considering few limitations of Helical CT and USG and invasiveness

and complications of ERCP,MRCP alone can become the imaging modality of

choice in imaging patients with obstructive jaundice, and it becomes still more

superior on adding conventional MRI sections to it because, it is Non-Invasive,

No-Ionising radiation, Multiplanar imaging capability and no post procedure

complications.It can show biliary tract proximal as well as distal to obstruction.

Like any other imaging modality MR with MRCP also has few

limitations as It cannot provide therapeutic option to the

patient/Claustrophobia. MR with MRCP is an accurate, non invasive means of

evaluating the patients with obstructive jaundice.

The diagnostic accuracy of MRI with MRCP suggests that it has the

potential to replace or limit the use of invasive procedures like diagnostic

ERCP, which should be used only in cases where intervention is being

contemplated.

MRI with MRCP is extremely sensitive in detecting lesions in the biliary

and pancreatic duct. The only major hiccups in MRCP replacing all other

modalities in the evaluation of pancreatobiliary ductal pathologies presently are

expense, lesser availability, and the inability to take percutaneous biopsies.

FUTURE:

With interventional MRI, MRCP should play an important role in

diagnostic and therapeutic applications in biliary tract and pancreatic

pathology.

68
 MRCP to
Obstructive jaundice exclude other
pathologies
Cholecystecomised patients
(dilated or non-dilated duct)
Intact gall bladder
CBD calculus

Ultrasound scan

Positive Negative

GB calculus No GB calculus
Therapeutic
Ductal calculus CBD ERCP

Positive Negative Not dilated Dilated

CBD

Conservative
Mx
Dilated Not dilated

MRCP or EUS
(To avoid diagnostic
ERCP)

Ductal calculus

Conservative
Therapeutic Positive
Mx
ERCP Negative

follow
Cholecystectomy Clinic follow-up

Fig.2 Algorithm for the management of biliary

Calculus to reduce the number of diagnostic ERCP56.

69
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Resonance Cholangiopancreatography.J R Coll Physicians Edinb 2003;

33:21-27.

58. Mi-Suk Park, Tae kyoung kim, et al. Differentiation of Extrahepatic Bile

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77
 PROFORMA

MRI WITH MRCP VS HELICAL CT IN EVALUATION OF PATIENTS

WITH OBSTRUCTIVE JAUNDICE

PATIENT’S NAME :
AGE :
SEX :
HOSPITAL NO :
WARD :
UNIT :

USG FEATURES DATE : ( )

PARAMETERS:

HELICAL CT : DATE ( )

1. LEVEL OF OBSTRUCTION :

HEPATIC
SUPRA PANCREATIC
PANCREATIC
AMPULLARY

2. PRESENCE OF BILE DUCT CALCULI :

NON VISUALISED
POSSIBLE
DEFINITELY VISUALISED

78
3. STATUS OF DISTAL CBD :
SMOOTH TAPERING
ABRUPT END
ROUNDED
IRREGULAR

4. DEGREE OF DILATATION OF IHBR:

MINIMAL
MODERATE
MARKED

5. GALL BLADDER :

SIZE
WALL
STONES

6. PANCREATIC DUCT DILATATION :

PRESENT
ABSENT

7. PANCREAS :

ATROPHY
CALCIFICATIONS
PSEUDOCYSTS

8. MASS :
SOLID
CYSTIC
SOLID CYSTIC
ENHANCEMENT

79
9. VESSEL INVASION:

PRESENT
ABSENT

10. FASCIAL PLANE INVASION :

PRESENT
ABSENT

11. ORGAN INVASION :

PRESENT
ABSENT

12. PRESENCE OF LIVER METASTASIS :

PRESENT
ABSENT

MRI WITH MRCP: DATE ( )

1 .LEVEL OF OBSTRUCTION :
HEPATIC
SUPRA PANCREATIC
PANCREATIC
AMPULLARY

2. PRESENCE OF BILE DUCT CALCULI :

NON VISUALISED
POSSIBLE
DEFINITELY VISUALISED

80
3. STATUS OF DISTAL CBD :
SMOOTH TAPERING
ABRUPT END
ROUNDED
IRREGULAR

4. DEGREE OF DILATATION OF IHBR :

MINIMAL
MODERATE
MARKED

5. GALL BLADDER :

SIZE
WALL
STONES

6. PANCREATIC DUCT DILATATION :

PRESENT
ABSENT

7. PANCREAS:

ATROPHY
CALCIFICATIONS
PSEUDOCYSTS

8. MASS :

SOLID
CYSTIC
SOLID CYSTIC
ENHANCEMENT

81
9. VESSEL INVASION:

PRESENT
ABSENT

10. FASCIAL PLANE INVASION :

PRESENT
ABSENT

11. ORGAN INVASION :

PRESENT
ABSENT

12. PRESENCE OF LIVER METASTASIS :

PRESENT
ABSENT

CONCLUSION
DEFINITELY BENIGN
PROBABLY BENIGN
PROBABLY MALIGNANT
DEFINITELY MALIGNANT

FINAL DIAGNOSIS :
ULTRASOUND :
HELICAL CT :
MRI WITH MRCP :
SURGICAL DIAGNOSIS :
DATE OF SURGERY :
DIAGNOSIS :
PATHOLOGICAL DIAGNOSIS :
HPE NO AND DATE :
DIAGNOSIS :

82
 CONSENT FORM

Part 1 of 2

INFORMATION FOR THE PARTICIPANTS OF THE STUDY

1. Name of the Study: Role MR-MRCP in suspected case of obstructive

Jaundice Vs Helical CT /USG.

2. Institute: Department of Radio-Diagnosis, JJMMC DAVANGERE

3. Name of the Investigator: Dr Purnima Irom, PG Resident,

Department of Radio-Diagnosis, JJMMC

4. Name of Guide: Dr Pramod J Setty, HOD Professor,

Department of Radio-Diagnosis, JJMMC.

5. Name of Co Guide-

6. Background information & objectives:

Obstructive jaundice has been one of the leading causes of increased

morbidity. It has been mainly diagnosed by imaging modalities, among

these USG and CT are initial modalities of investigations,, recently MRI

with MRCP is emerging as an exciting tool for non invasive evaluation

of patients with obstructive jaundice.

1. To establish the role of MRI with MRCP and Helical CT in

diagnosing the cause of obstructive jaundice.

2. To compare the diagnostic accuracies of MRI with MRCP and

Helical CT in evaluating the cause of obstructive jaundice.

83
8. Procedure of the study:

All consecutive patients of obstructive jaundice according to inclusion

criteria will be taken for study after getting informed understandable

consent .Ultrasound and Helical CT Activion 16 Multislice CT Scanner

will be performed first and following that MRI with MRCP will be

performed within 3 days with help of Philips 1.5 Tesla MRI Scanner.

Diagnostic capabilities of Ultrasonography/Helical CT and MRI with

MRCP in delineating the cause of obstructive jaundice with reference to

surgical or pathological findings.

9. Expected risk for participants: Minimal adverse reactions due to

contrast use.

10. Expected benefits of research for participants: Patients with

obstructive jaundice can benefit directly or indirectly from imaging.

11. Confidentiality: Information obtained from subjects would be kept

confidential and used only for research purposes.

12. Compensation to the participants: Nil

13. Responsibilities of participants: Entirely voluntary; based on informed

consent.

14. Name of the contact person with official address and phone number:

Place:

Signature of investigator:

Date:

Witness:

84
 CONSENT FORM

Part 2 of 2

Title of the project .

The details of the study are provided to me in writing and have been

explained to me in my own language. I also received a copy of the “Consent

Form 1 of 2” giving the “Information for the patients of the study”. I fully

consent to participate in the study titled “ROLE OF MR I MRCP IN

SUSPECTED CASE OF OBSTRUCTIVE JAUNDICE VS HELICAL

CT/USG”. and undergo the imaging procedure.

Name: Address:

Signature of the participant: Date:

Signature of the witness : Date:

85
KEY TO MASTER CHART :

A Abrupt end

Am Ampulla

B Benign

CBD Common bile duct

CD Cystic duct

CHD Common hepatic duct

D Dilated

E Distal end of CBD

F Female

GB Gall Bladder

H Hepatic

IC Inconclusive

IHBD Intra Hepatic Bile Duct

L/MET Lymph node/Metastasis

M Malignant

N Normal

NV Non visualized

S Stricture

86
 MASTER CHART
LEVEL OF  DUCTAL STATUS IN  DUCTAL STATUS IN  DUCTAL STATUS IN 
BILIRUBIN CALCULI NIGN/MALIGNA
OBSTRUCTION USG CT MRCP
AGE   LOCAL EFFECT 
S.NO  NAME SEX IP NO FINAL DIAGNOSIS
(years) CD CBD GB /METASTASIS

INDIRECT
DIRECT
TOTAL

MRCP

MRCP
MRCP

MRCP

MRCP
IHBD
IHBR

IHBR
CHD

CHD

CHD
USG

USG
CBD

CBD

CBD

USG

USG

USG
PD

PD

PD
CD

CD

CD
CT

CT
CT

CT

CT
CHOLELITHIASIS WITH 
1 Gangamma 34 F 754186 6.7 3.4 3.3 D NV NV D N D D D D N D D D D N A A A P P P P P P NIL B B B
CHOLEDOCHOLITHIASIS
ACUTE PANCREATITIS SEQUELAE 
2 VEERAPPA 70 M 754997 6.5 3 3.5 N N N D N N N N D N N D D D N A A A A P P P P P NIL B B B WITH CHOLELITHIASIS & 
CHOLEDOCHOLITHIASIS
KLATSKIN'S TUMOUR WITH 
3 JANHBEE 63 F 755274 13.8 6.2 7.6 D NV NV N N D S NV S N D S NV S N A A A P P P P P P NIL IC B M CHOLELITHIASIS & 
CHOLEDOCHOLITHIASIS
CYSTIC DUCT CALCULUS  MIRIZZI'S SYNDROME WITH 
4 VEERESH 22 M 755240 19.5 10.2 9.3 D D D N N D D D N N D D D N N P P P A A A P P P B B B
COMPRESSING CHD CHOLELITHIASIS
MASS AT HEAD OF 
CA PANCREAS WITH  FOCAL 
5 KRISHNARMURTHY 51 M 755680 21 13.6 7.4 D NV NV D D D D NV D D D D A D D A A A A A A A A A PANCREAS CAUSING  M M M
PANCREATITIS
COMPRESSION
6 KALPANA 42 F 755102 6.5 4.1 2.4 N N N N N N N N N N N N N N N A A A A A A P P P NIL B B B CHOLELITHIASIS 
BENIGN STRICTURE ‐ DISTAL CBD 
7 SURESH 30 M 754929 5.1 1.6 3.5 N N NV D N N N NV D N D+B D N S N A A A A A A A A A NIL IC IC B
WITH CHOLANGITIS
CHOLEDOCHOCELE WITH 
8 HANIFAA BEE 65 F 755049 13.5 6.4 7.1 D D N D N D D N D N D D N D N A A A A A A A A A NIL IC B B
OBSTRUCTED CBD
CHOLANGIOCARCINOMA (DISTAL 
9 LAKSHMI BAI 78 F 755080 14.1 8 6.1 D D N D N D D N D N D D N D+M N A P P A A A A A A NIL IC B M
CBD) WITH CYSTIC DUCT CALCULI
10 RAMESH 40 M 755081 10.5 3.1 7.4
11 KALYAN NAIK 52 F 755058 14.4 8.7 5.5 D NV NV N N D NV N N N D S N N N A A A A A A A A A NIL IC IC M KLATSKIN'S TUMOUR
GB FOSSA MASS 
CAUSING EXTRANEOUS 
12 SHARDAMMA 65 F 625817 16..5 8.8 7.7 D N N N N D C N C N D C N C N A A A A A A P P P B M M ADENOCARCINOMA OF GB
COMPRESSION OF CHD 
& CBD
PERIAMPULLARY CA 
EXTENDING INTO HEAD 
PERIAMPULLARY CA WITH 
13 KUBERAPPA 65 M 655081 12.7 5.1 7.6 D D N N N D D N S N D D N S N A A A A A A A A A OF PANCREAS ,  IC M M
METASTASIS
METASTASIS TO LN AND 
VERTEBRA
14 BASHA JAMAL MOHAMMED 41 M 543287 10.2 6.5 3.7
CHOLELITHIASIS WITH 
15 KHOTRESH 37 M 678097 8.3 5.2 3.1 D D N D N D D N D N D D N D N A A A P P P P P P NIL B B B
CHOLEDOCHOLITHIASIS
LESION IN LT LOBE OF 
HILAR CHOLANGIOCARCINOMA 
16 DEVARAJ 65 M 67981 6.7 2.6 4.1 D D N N N D D D N N D D D N N A A A A A A A A A LIVER EXTENDING INTO  B M M
(KLATSKIN'S TUMOUR )
PORTA HEPATIS
POLYPOID LESION IN GB 
ADENOCARCINOMA OF GB WITH 
17 NAGARATHNAMMA 55 F 765059 8.9 5.8 3.1 N N N N N N N N D N N N N D N A A A A A A P P P WITH IMPACTED  B B B
CALCULUS CHOLECYSTITIS
CALCULUS
 LEVEL OF  DUCTAL STATUS IN  DUCTAL STATUS IN  DUCTAL STATUS IN 
BILIRUBIN CALCULI NIGN/MALIGNA
OBSTRUCTION USG CT MRCP
AGE   LOCAL EFFECT 
S.NO  NAME SEX IP NO FINAL DIAGNOSIS
(years) CD CBD GB /METASTASIS

INDIRECT
DIRECT
TOTAL

MRCP

MRCP
MRCP

MRCP

MRCP
IHBD
IHBR

IHBR
CHD

CHD

CHD
USG

USG
CBD

CBD

CBD

USG

USG

USG
PD

PD

PD
CD

CD

CD
CT

CT
CT

CT

CT
MASS HEAD OF 
PANCREAS CAUSING  CA HEAD OF PANCREAS WITH 
18 SANTHAMMA 38 F 7180291 15.9 8.6 7.3 D D N D N D D N D N D D N D+C N A A A A A A A A A IC M M
BILIARY PASSAGE  BILIARY OBSTRUCTION
OBSTRUCTION
ABRUPT TERMINATION 
OF CBD & MPD AT THE 
19 JAGATHAMBAL 50 F 712839 12.9 6.8 6.1 D D N D D D D N D D D D N D+C D A A A A A A A A A M M M CA PANCREAS
LEVEL OF HEAD OF 
PANCREAS
CHOLELITHIASIS WITH DISTAL CBD 
20 NAZREEN  21 F 712348 10.5 5 5.5 D D N D N D D N D N D D N D+S N A A A A A A P P P NIL B B B
STRICTURE
MASS INVOLVING 
POSTERIOR WALL AND 
NECK OF GB 
21 KAMMALAMMA 63 F 647891 6.7 2.6 4.1 D NV NV N N D D N S N D S S S+N N A A A A A A A A A B M M GB CARCINOMA
EXTENDING INTO 
PORTA HEPATIS WITH 
METASTASIS
22 ABDUL KATHER 56 M 657791 5.9 2.6 3.3 D NV NV N N D NV N N N D S N N N A A A A A A A A A NIL IC IC M CHOLANGIO CARCINOMA
BENIGN STRICTURE  OF DISTAL 
23 ANANTHI  36 F 678191 6.1 2.7 3.4 N N NV D N N N NV D N D+B D N S+N N A A A A A A A A A NIL IC IC B
CBD
24 DODAPPA 85 M 7819121 15.6 8.5 7.1 D N N N N D C N C N D C N C N A A A A A A P P P LIVER INVASION B M M GB CARCINOMA
25 MURGESHAPPA 34 M 678923 14.6 6.5 8.1 D NV NV D N D D D D N D D D D N A A A A A A P P P NIL B B B GB CALCULI WITH DISTAL CBD CAL
26 RADHAMMA 72 F 679345 6.8 3 3.8 D D N N N D D N S N D D N S  N A P P A A A A A A NIL IC B M PERIAMPULLARY CARCINOMA
27 VENKATESH KUMAR 39 M 774590 11.9 7.9 4 D D N D N D D N D N D D N D N A A A P P P P P P NIL B B B GB STONE WITH CHOLELITHIASIS
28 SHALDA BEGAM  29 F 773245 5.8 2.6 3.2 D D N D N D D N D N D D N D N A A A P P P P P P NIL B B B CHOLEDOCOLITHIASIS
29 RAMAPPA 75 M 774592 18.5 10.9 7.6 D D N N N D D D N N D D D N N A A A A A A P P P RIGHT LOBE LESON B M M CHOLANGIOCARCINOMA
DISTAL CBD 
30 SHAKUNTALA 28 F 715690 6.4 2.5 3.9 D D N N N D D N S N D D N S N A A A A A A A A A IC M M PERIAMPULLARY CARCINOMA
OBSTRUCTION
31 KUZHANDAIVEL 53 M 726903 7.3 3.5 3.8 N N NV D N N N NV D N D+B D N S N A A A A A A P P P NIL B B B BENIGN BILIARY STRICTURE
32 RAJENDRAN 51 M 756923 5.3 2.6 2.7 D NV NV D N D D D D N D D D D N A A A P P P P P P NIL B B B CHOLEDOCHOLITHIASIS
LESION IN THE LEFT 
33 RAJAKUMARI 57 F 726901 9.5 4.3 5.2 D D N D N D D N D N D D N D+M N A A A A A A A A A B M M CHOLANGIOCARCINOMA
LOBE
COMPRESSION OF 
34 RAJESH M 689023 11.9 7.9 4 D D N D N D D N D N D D N D+C N A A A A A A A A A B M M LYMPHOMA
DISTAL CBD
35 B/O SHANTHAMMA 3M M 689134 8.8 11 12 D D NV D N D D D D N D D D D N A A A A A A A A A NIL B B B CHOLEDOCHOCOELE
36 SUBHASH 7 M 729023 15 8.5 7.1 D D NV D N D D D D N D D D D N A A A A A A A A A NIL B B B CAROLI'S DISEASE