Ekstrahepatik Kolestazlı Hastalarda Manyetik Rezonans Kolanjiyopankreatografinin Tanısal Doğruluğu: Retrospektif Bir Kohort Çalışması

Year 2023, , 32 - 40, 16.04.2023

Beyza Yüksel , Nihat Okçu

https://doi.org/10.46332/aemj.1017662

Abstract

Amaç: Ekstrahepatik kolestazın ayırıcı tanısı, görüntüleme tekniklerinin değişken duyarlılık ve özgüllük oranları nedeniyle zor olabilir. Manyetik rezonans kolanjiyopankreatografi (MRCP), safra yollarının değerlendirilmesinde kullanılan non-invaziv bir yöntemdir. Biliyer obstrüksiyonda MRCP'nin tanısal doğruluğunu araştırmayı amaçladık.

Araçlar ve Yöntem: Ocak 2012 ile Aralık 2016 arasında ekstrahepatik kolestaz ile Atatürk Üniversitesi Gastroenteroloji Bölümü’ne başvuran hastaların tıbbi kayıtları geriye dönük olarak incelendi. MRCP sonrası endoskopik retrograd kolanjiyopankreatografi (ERCP) yapılan hastalar çalışmaya dahil edildi. Hastaların demografik ve klinik özellikleri not edildi. ERCP altın standart tanı yöntemi olarak kabul edildi. MRCP'nin tanısal etkinliği, ERCP ile karşılaştırıldığında duyarlılık, özgüllük, doğruluk, negatif ve pozitif prediktif değerler hesaplanarak değerlendirildi.

Bulgular: Yaş ortalaması 60.1±17.5 yıl olan 615 hasta çalışmaya dahil edildi. MRCP kullanılarak sırasıyla 337(%54.8), 101(%16.4) ve 39(%6.3) hastada koledokolitiazis, malign ve benign darlıklar teşhis edildi. 65 hastada (%10.6) normal MRCP bulguları mevcuttu. ERCP ile kesin tanılar koledokolitiazis (n=390, %63.4), malign darlık (n=152, %24.7), benign darlık (n=62, %10.1) ve normal bulgular (n=11, %1.8) olarak belirlendi. MRCP'nin sensitivite ve spesifitesi koledokolitiyazis için %70.8 ve %72.9, malign darlık için %55.9 ve %96.5, benign darlık için ise %16.1 ve %94.8 idi. Koledokolitiazis, malign ve benign darlıklar için genel doğruluk oranları sırasıyla %71.5, %86.5 ve %86.8 idi.

Sonuç: MRCP'nin tanısal doğruluğu, farklı biliyer/kolestatik etiyolojiler için değişkendir. Koledokolitiaziste duyarlılığının daha düşük olması nedeniyle, özellikle biliyer obstrüksiyon için klinik bir şüphe olduğunda normal MRCP bulguları dikkatle ele alınmalıdır.

Keywords

sensitivite, spesifite, ERCP, kolestaz, MRCP

Diagnostic Accuracy of Magnetic Resonance Cholangiopancreatography in Patients with Extrahepatic Cholestasis: A Retrospective Cohort Study

Abstract

Purpose: Differential diagnosis of extrahepatic cholestasis can be challenging due to the variable sensitivity and specificity rates of imaging techniques. Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive method used for the evaluation of biliary tree. We aimed to investigate the diagnostic accuracy of MRCP in biliary obstruction.

Materials and Methods: Medical records of patients admitted with extrahepatic cholestasis between January 2012 and December 2016 were retrospectively reviewed. Patients who had endoscopic retrograde cholangiopancreatography (ERCP) following MRCP were included. The final diagnosis of ERCP was accepted as gold standard. The diagnostic efficiency of MRCP was evaluated by calculating sensitivity, specificity, accuracy, negative and positive predictive values as compared with ERCP.

Results: There were 615 patients with a mean age of 60.1±17.5 years. Using MRCP, choledocholithiasis, malignant and benign strictures were diagnosed in 337(54.8%), 101(16.4%), and 39 patients (6.3%), respectively. Normal MRCP findings were present in 65 patients (10.6%). Final diagnoses via ERCP were: choledocholithiasis (n=390, 63.4%), malignant stricture (n=152, 24.7%), benign stricture (n=62, 10.1%), and normal findings (n=11, 1.8%). The sensitivity and specificity of MRCP were 70.8% and 72.9% for choledocholithiasis, 55.9% and 96.5% for malign stricture, 16.1% and 94.8% for benign stricture, respectively. Overall accuracy rates were 71.5%, 86.5%, and 86.8% for choledocholithiasis, malign and benign strictures, respectively.

Conclusion: Diagnostic accuracy of MRCP is variable for different biliary/cholestatic etiologies. Due to a lower sensitivity for chole docholithiasis, normal MRCP findings should be handled with caution, especially when there is a clinical suspicion of biliary obstruction.

Keywords

cholestasis, ERCP, MRCP, sensitivity, specificity

References

• 1. O’Neill AM, Anderson K, Baker LK, Schurr MJ. The Overall Poor Specificity of MRCP in the Preoperative Evaluation of the Jaundiced Patient Will Increase the Incidence of Nontherapeutic ERCP. Am Surg. 2020;86(8):1022-1025.
• 2. Makmun D, Fauzi A, Shatri H. Sensitivity and Specificity of Magnetic Resonance Cholangiopancreatography versus Endoscopic Ultrasonography against Endoscopic Retrograde Cholangiopancreatography in Diagnosing Choledocholithiasis: The Indonesian Experience. Clin Endosc. 2017;50(5):486-490.
• 3. Alsaigh S, Aldhubayb MA, Alobaid AS, et al. Diagnostic Reliability of Ultrasound Compared to Magnetic Resonance Cholangiopancreatography and Endoscopic Retrograde Cholangiopancreatography in the Detection of Obstructive Jaundice: A Retrospective Medical Records Review. Cureus. 2020;12:10.
• 4. Hacım NA, Akbas A, Meric S, et al. Predictive value of ultrasonography and magnetic resonance cholangiopancreatography in the diagnosis of biliary obstruction. Ann Ital Chir. 2020;91(3):277-282.
• 5. Warttig S, Ward S, Rogers G. Diagnosis and management of gallstone disease: summary of NICE guidance. BMJ. 2014;349:33-35.
• 6. Anwer M, Asghar MS, Rahman S, et al. Diagnostic Accuracy of Endoscopic Ultrasonography Versus the Gold Standard Endoscopic Retrograde Cholangiopancreatography in Detecting Common Bile Duct Stones. Cureus. 2020;12(12).
• 7. Hjartarson JH, Hannesson P, Sverrisson I, Blöndal S, Ívarsson B, Björnsson ES. The value of magnetic resonance cholangiopancreatography for the exclusion of choledocholithiasis. Scand J Gastroenterol. 2016;51 (10):1249-1256.
• 8. Aydelotte JD, Ali J, Huynh PT, Coopwood TB, Uecker JM, Brown CVR. Use of Magnetic Resonance Cholangiopancreatography in Clinical Practice: Not as Good as We Once Thought. J Am Coll Surg. 2015;221 (1):215-219.
• 9. Mesihović R, Mehmedović A. Better non-invasive endoscopic procedure: Endoscopic ultrasound or magnetic resonance cholangiopancreatography? Med Glas. 2019;16(1):40-44.
• 10. Epelboym I, Winner M, Allendorf JD. MRCP is Not a Cost-Effective Strategy in the Management of Silent Common Bile Duct Stones. J Gastrointest Surg. 2013;17(5):863-871.
• 11. Hanif H, Khan SA, Muneer S, Adil SO. Diagnostic accuracy of ultrasound in evaluation of obstructive jaundice with MRCP as gold standard. Pakistan J Med Sci. 2020;36(4):652-656.
• 12. Suthar M. Role of MRCP in Differentiation of Benign and Malignant Causes of Biliary Obstruction. J Clin Diagn Res. 2015;9(11):8-12.
• 13. Wee D, Izard S, Grimaldi G, Raphael K, Lee T-P, Trindade A. EUS assessment for intermediate risk of choledocholithiasis after a negative magnetic resonance cholangiopancreatography. Endosc Ultrasound. 2020;9(5):337.
• 14. Badger WR, Borgert AJ, Kallies KJ, Kothari SN. Utility of MRCP in clinical decision making of suspected choledocholithiasis: An institutional analysis and literature review. Am J Surg. 2017;214(2):251-255.
• 15. Zytoon AA, Mohammed HH, Hosny DM. The Role of Magnetic Resonance Cholangiopancreatography in Diagnosis of Hepatobiliary Lesions. J Med Imaging Radiat Sci. 2016;47(1):66-73.
• 16. Inan I, Sirik M. Diagnostic value of the choledochal sphericity index in the diagnosis of obstructive cholestasis using magnetic resonance cholangiopancreatography. Acta Gastroenterol Belg. 2020;83(4):571-575.
• 17. Tamir S, Braun M, Issachar A, Bachar GN, Benjaminov O. Yield of magnetic resonance cholangiopancreatography for the investigation of bile duct dilatation in asymptomatic patients. United Eur Gastroenterol J. 2017;5(3):408-414.
• 18. Abraham S, Rivero HG, Erlikh I V., Griffith LF, Kondamudi VK. Surgical and nonsurgical management of gallstones. Am Fam Physician. 2014;89(10):795-802.
• 19. Bose SM, Mazumdar A, Prakash S V, Kocher R, Katariya S, Pathak CM. Evaluation of the Predictors of Choledocholithiasis: Comparative Analysis of Clinical, Biochemical, Radiological, Radionuclear, and Intraoperative Parameters. Surg Today. 2001;31(2):117-122.
• 20. Yu CY, Roth N, Jani N, et al. Dynamic liver test patterns do not predict bile duct stones. Surg Endosc. 2019;33(10):3300-3313.