Familial occurrence of congenital bile duct cysts

Congenital bile duct cysts are now a well-documented anomaly of the biliary tree, and have become more common in Japan. Familial occurrence of congenital bile duct cysts, however, is extremely rare, with only six reported cases in the literature. We report a familial pattern of congenital bile duct cysts in a mother and her daughter. A 33-year-old female was admitted for evaluation of right upper quadrant abdominal pain and fever 6 days after an uneventful delivery of her second child. A computed tomography (CT) and ultrasound scan (US) revealed an obstructed biliary tract. Percutaneous transhepatic biliary drainage was then performed, and a cholangiogram revealed a Scholtz type B choledochocele without an anomalous connection of the pancreaticobiliary ducts. Endoscopic US demonstrated that the choledochocele was associated with a stone in the cyst. A pylorus-preserving pancreatoduodenal resection was performed, and a histological study revealed that the choledochocele was lined by biliary mucosa without evidence of malignancy. The newborn infant had an abdominal tumour. An US and CT revealed a congenital bile duct cyst. An operation was performed and the intraoperative cholangiogram showed an Alonso-Lej type I congenital bile duct cyst with an anomalous connection of the pancreaticobiliary ducts. Whether congenital bile duct cysts are hereditary remains to be elucidated.     

Evaluation of MRCP compared to ERCP in the diagnosis of biliary and pancreatic duct

Recently, Magnetic Resonance Cholangiopancreatography (MRCP) is developed as a noninvasive diagnostic modality in the diagnosis of biliary and pancreatic tract. Using Endoscopic Retrograde Cholangiopancreatography (ERCP) as the gold standard, we evaluated the diagnostic quality of MRCP and direct cholangiography. Fifty-six patients (9 cases of cholangiocarcinoma, 5 of gallbladder carcinoma, 1 of gallbladder carcinoma and anomalous arrangement of pancreaticobiliary ductal system, 4 of cholecystlithiasis, 3 of papillary carcinoma, 1 of adenomyomatosis of the gallbladder, 1 of primary sclerosing cholangitis, 1 of hepatolithiasis and postoperative bile duct stricture, 4 of mucin producing pancreatic tumor, 13 of pancreatic carcinoma, 1 of chronic pancreatitis and pancreas divisum, 9 of chronic pancreatitis, and 1 of chronic pancreatitis and biliary stricture) are studied prospectively with MRCP and direct cholangiography (included ERCP and percutaneous transhepatic cholangiography). The image of MRCP accorded with direct cholangiography in twenty-two of 27 patients with biliary tract disease, and in sixteen of 29 patients with pancreatic disease. The different diagnosis is observed in ten of 56 patients. In cases of not visualized gallbladder, pancreatic cyst without communicated to the pancreatic duct, and pre-stenotic dilatation of biliary and pancreatic duct, the image of MRCP was better than that of ERCP. However, the image of MRCP for the diagnosis of either benign or malignant strictures, mucin producing pancreatic tumor, and a branch of pancreatic duct in patients with pancreatic carcinoma were not suitable for evaluation than that of ERCP. In our study, ERCP is superior to MRCP due to the important information for diagnosis such as mentioned above. Therefore we advocate using ERCP as the first diagnostic tool in the diagnosis of biliary and pancreatic duct.     

Choledochal cyst and neoplasm: a comprehensive review of 106 cases and presentation of two original cases

Choledochal cysts are prone to complications: cholangitis, biliary cirrhosis, portal hypertension, lithiasis, rupture, pancreatitis, and carcinoma. The coincidence of choledochal cysts and neoplasia ranges from 2.5 to 26 per cent. One hundred six cases of choledochal cysts with neoplasms have been collected from the literature. We have tabulated the results of 68 cases found to have a neoplasm at the initial laparotomy and of 38 patients with pristine choledochal cysts treated electively who subsequently developed a neoplasm. Two original cases are presented. The primary site of neoplasia was not confined only to choledochal cysts. There appears to be a propensity for malignancy to develop anywhere in the biliary tract or gallbladder or pancreas in conjunction with the choledochal cyst. Accompanying choledochal cysts is a high incidence of an anomalous relation at the pancreaticobiliary junction with subsequent malignancy formation. A pathogenetic basis is postulated.     

Scanning electron microscopy studies of the human lens capsule after capsulorhexis

Choledochal cysts are malformations of the biliary ductal system, which rarely occur in infancy. In neonates and infants, choledochal cysts are congenital, may be associated with distal biliary atresia and typically presents with cholestatic jaundice and acholic stools characteristic of biliary obstruction. In older children and adults, it may be acquired in association with an anomalous pancreaticobiliary union and presents with any combination of intermittent jaundice, abdominal pain, and a palpable abdominal mass. Early detection of choledochal cysts is important in the prevention of the fatal complications of biliary obstruction. Here, we present two cases of congenital choledochal cyst in which the patients were 9 weeks old and 7 weeks old respectively. Both of them presented with jaundice, acholic stools, and hepatomegaly. Combined use of sonography, computed tomography and hepatobiliary scintigraphy demonstrated the presence of choledochal cysts. Thereafter, they underwent surgical excision of the cysts with Roux-en-Y reconstruction of the biliary tree; the results were successful.     

Pancreatic trauma in patients with pancreatobiliary anomaly

One patient with a choledochal cyst and anomalous pancreaticobiliary junction had pancreatic transection causing bile peritonitis. Intraoperative cholangiopancreatography revealed this anomaly. In another patient with pancreas divisum, cannulation of the minor papilla (ERCP) demonstrated focal stenosis of the dorsal pancreatic duct, corresponding to the site of the minor laceration. The possibility of a coexisting pancreatobiliary anomaly should be considered in the diagnosis of pancreatic trauma, particularly in terms of the interpretation of pancreatograms.     

Magnetic resonance cholangiopancreatography: a novel approach to the evaluation of suspected pancreaticobiliary neoplasms

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is a new noninvasive diagnostic method for pancreaticobiliary (PB) imaging without endoscopy, sedation, or iodinated contrast. The purpose of this study was to evaluate the ability of MRCP to depict pancreatic and biliary ductal anatomy compared to that of endoscopic retrograde cholangiopancreatography (ERCP) and to evaluate the ability of MRCP to accurately diagnose PB neoplasms. METHODS: Twenty patients had MRCP, and 17 also had ERCP. All studies were read prospectively by experienced reviewers blinded to other imaging data. Pathologic diagnosis was made in all patients. RESULTS: Bile duct dilatation seen by ERCP in 14 of 17 patients was correctly identified by MRCP in all 14 patients, and normal ducts were correctly identified by MRCP in the other 3 patients. The pancreatic duct was visible on MRCP in the pancreatic head in 17 of 20 patients, the body in 17 of 20 patients, and the tail in 15 of 20 patients. At ERCP, pancreatic duct dilatation was present in 11 cases and was identified by MRCP in 10 of them. Eighteen of 20 patients had malignant PB neoplasms. MRCP indicated PB neoplasm in 19 patients. Seventeen of these 19 patients had histologically confirmed malignant neoplasms pathologically, whereas 2 had benign pathology (both chronic pancreatitis). Among the 17 patients who also had ERCP, MRCP and ERCP correctly agreed on a final diagnosis of malignant neoplasm in 14 cases. In the three cases in which MRCP and ERCP disagreed on a final diagnosis, MRCP was correct in one and incorrect in two. CONCLUSIONS: MRCP can accurately and noninvasively delineate PB ductal anatomy and diagnose PB neoplasms comparably to ERCP. MRCP is an interesting new noninvasive method for evaluating patients with suspected PB neoplasms.     

Evaluation of axis alignment system for correction of myopic astigmatism with the excimer laser

BACKGROUND: Anomalous pancreaticobiliary junction (APBJ) without congenital choledochal cyst (CCC) carries a high risk of gallbladder carcinoma development. The aim of this study was to obtain information allowing early diagnosis and appropriate management. METHODS: The clinical features, imaging findings and surgical outcome of 18 patients with APBJ without CCC were analysed retrospectively. RESULTS: Fourteen patients had symptoms, including those of acute pancreatitis (five patients). In 16 patients the gallbladder showed abnormalities, including carcinoma (eight) and mucosal hyperplasia (11). Ultrasonography detected gallbladder carcinoma with 100 per cent sensitivity and mucosal hyperplasia with 91 per cent sensitivity. A long common channel was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) in all patients, endoscopic ultrasonography in nine of ten, and magnetic resonance cholangiopancreatography (MRCP) in five of five. Five of eight patients with gallbladder carcinoma underwent extended cholecystectomy with bile duct excision. Three patients with cancer and eight with no cancer had cholecystectomy alone. None developed bile duct carcinoma or acute pancreatitis after operation. All patients without malignancy remained asymptomatic for a mean follow-up period of 4.7 years. CONCLUSION: Prophylactic cholecystectomy is recommended for patients with APBJ without CCC. For early diagnosis of APBJ, gallbladder abnormalities on ultrasonography or acute pancreatitis of unknown aetiology should prompt further investigation with ERCP or less invasive imaging modalities such as endoscopic ultrasonography and MRCP.     

Bile duct cysts in adults

INTRODUCTION: Bile duct cysts are rare, congenital dilations of the intrahepatic and/or extrahepatic biliary tract. Most of them present during childhood. The classical triad right upper quadrant pain, jaundice and abdominal mass is present only in a few instances. We report here the bile duct cysts which were diagnosed at our institution from 1989 to 1996. METHODS: 3245 consecutive endoscopic retrograde cholangiopancreatograms (ERCP) were evaluated retrospectively. Diagnosis was made when localized cystic dilations of the intrahepatic and/or extrahepatic biliary tract were present. Diffuse dilations of the intrahepatic and extrahepatic biliary tract were excluded. RESULTS: Bile duct cysts were found in 20 patients (17 females, 3 males) among 3245 ERCPs. Their mean age was 56 +/- 20 (median 64, range 10 to 83) years. The cyst types (according to the Alonso-Lej classification with the Todani modification) were type I in 11 (55%), type II, III and IV in two instances each (10%), and type V (or Caroli's disease) in 3 patients (15%). Leading symptoms were cholestasis in 14 patients, 10 of whom had abdominal pain, jaundice in 4 patients, and single cases of pancreatitis, cholangitis, and abdominal mass. In 2 patients the diagnosis was made incidentally. 10 patients had bile duct stones. We performed endoscopic sphincterotomy in 15 patients with concretions or persistent symptoms, 3 patients had cyst resection. One of these, with a type I cyst, already had a disseminated cholangiocarcinoma. 10 of 17 patients without cyst resection are currently symptom-free after complete removal of all gallstones. One male patient with cholecystolithiasis, who is not operable due to advanced liver disease, has recurrent cholangitis, 4 patients have died from causes unrelated to the bile duct cysts, and 2 patients are lost to follow up. CONCLUSION: Bile duct cysts in adults are rare. There is a preponderance in the female gender, and the most common type is the extrahepatic (choledochal) cyst. The leading symptoms are cholestasis and right upper quadrant pain. There is an increased risk of cholangiocarcinoma. In young patients the cysts should be entirely removed to prevent malignancy. Older persons are usually symptomless after complete removal of gallstones.     

Three-dimensional magnetic resonance cholangiopancreatography for evaluation of obstructive jaundice

The purpose of this study was to assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in studying the anatomy, sites, and causes of obstructive jaundice. From September 1994 to May 1996 three-dimensional MRCP was performed on 31 patients with abdominal pain and obstructive jaundice with a fast spin-echo T2-weighted pulse sequence. The images were reconstructed using maximal intensity projection, AVERAGE and SURFACE algorithm processing techniques at a graphics workstation. All the reconstructed images were compared with those obtained using conventional cholangiographic techniques, such as endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and drainage, and intraoperative cholangiography. The patients' diagnoses included choledochal cyst (13), cholangiocarcinoma (five), choledocholithiasis (four), pancreatic head carcinoma (three), rhabdomyosarcoma (one), papillary Vater carcinoma (one), recurrent gastric carcinoma (one), ascaris (one), and biliary atresia (two). Extrahepatic biliary dilatation was present in all 13 patients with choledochal cyst; the pancreatic ducts and their entrance level to the common bile duct were observed in eight of these patients. The level of obstruction in patients with cholangiocarcinoma was well documented but the biliary tract of one patient with biliary atresia was not identified by MRCP. In one patient with biliary rhabdomyosarcoma, MRCP clearly delineated the extrabiliary extension of the tumor. In a patient with ascaris in the common bile duct an increase in signal intensity inside the digestive tract of the worm denoted fluid in its gut. Lithiasis was shown in all of the four patients with choledocholithiasis. Thus, MRCP is a useful tool in the assessment of biliary tract obstruction and its causes, and is a valuable addition to ultrasonography.     

Malignant change in the biliary tract after excision of choledochal cyst

BACKGROUND: Choledochal cyst is a rare congenital condition with a high risk of malignant change if untreated. The risk of malignancy after surgical excision of choledochal cyst is not known. METHODS: Forty-eight patients with choledochal cysts managed over a 21-year period were reviewed, to determine the risk of malignant change after cyst excision. Thirty-nine of 48 patients had no carcinoma at first admission; their mean(s.d.) age was 20(18) years. Thirty-seven of 39 patients underwent cyst excision and cholecystectomy followed by hepaticoenterostomy. RESULTS: Cyst excision was incomplete in 28 of the 37 patients because dilated portions of the biliary ducts remained proximally and/or distally. In these 37 patients, no carcinoma has developed in the remnant proximal hepatic duct or the terminal bile duct after mean(s.d.) follow-up of 9.1(6.4) years. In the remaining nine patients, biliary carcinoma was diagnosed at the first visit. Six patients died from recurrence with a mean(s.d.) survival time of 13(11) months, while three patients were alive and free from recurrence 2 months, 1 year and 7 years after operation. CONCLUSION: Malignant change has not been observed after total or subtotal excision of choledochal cysts in this series.     

Lithiasic, congenital, choledochal dilatation: problems of diagnosis and therapy

We report a case of a 30-year old female with congenital lithiasic choledochal dilatation which was not diagnosed at the ultrasonographic examination. Congenital biliary dilatation abnormalities are rare and may clinically present with episodic biliary colics or more rarely with recurrent pancreatis. Ultrasound, CT-scanning and ERCP usually make these anatomic alterations evident but in some cases there may be some doubt despite the vast range of radiological techniques available (PTC, Tc99m-Isida scinti-scan). The best results from a diagnostic point of view are obtained from the ERCP that may in fact visualize an anomalous pancreatico-biliary junction, rule out carcinoma, accurately define the cyst dimensions or show the intrahepatic ductal radicals. Furthermore, the extraction of intracystic stones or the treatment of choledochocele through a papillostomy may be performed. However the ERCP may cause traumatic pancreatitis, above all in youngster as was verified in our patient. During surgical exploration, the definitive diagnosis can be achieved via intraoperative cholangiography. We emphasize that in patients with congenital choledochal dilatation, the dilated choledochus should be excised even in young children to avoid the risk of malignancy which may occur also following cyso-duodeno- or cystojejunostomy treatment. In our patient an hepatiocojejunostomy on a Roux-en-Y limb was performed. This single case has been oresented along with a review of the literature to recall such anomalies in differential diagnosis of biliary colics and to stress that the choice treatment is surgical resection.     

Biliary bile acids in the gall-bladder and the common bile duct of patients with anomalous pancreaticobiliary ductal junction

The high incidence of biliary tract carcinoma in patients with anomalous pancreaticobiliary ductal junction (APBDJ) with or without choledochal cyst (CC) has been well documented. Twenty-two patients with APBDJ were divided into three groups: Group A, four patients not associated with CC and biliary tract carcinoma; Group B, 13 patients with CC but without biliary tract carcinoma; and Group C, five patients with biliary tract carcinoma (four with and one without CC). Profiles of bile acids in the gall-bladder and/or common bile duct were analysed in these patients and compared with those in the control patients with cholecystlithiasis to examine the hypothesis that the levels of deoxycholic acid (DCA) and lithocholic acid (LCA) are elevated in patients with APBDJ because these secondary bile acids are mutagenic. Bile acids were quantified by gas-liquid chromatography. Total bile acid concentration in the gall-bladder bile was significantly lower in any group with APBDJ than that of controls. In the gall-bladder, increased proportion of chenodeoxycholic acid (CDCA) in Group A and B, decreased proportion of DCA in Group B and increased proportion of cholic acid (CA) in Group C were found in bile. In the bile duct, total bile acid concentration and proportion of DCA were significantly low in bile from Group C and decreased proportion of DCA and increased proportion of CDCA were found in bile from Group B. In both the gall-bladder and hepatic bile, proportion of LCA was not significantly different between any intergroups.(ABSTRACT TRUNCATED AT 250 WORDS)     

The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia

PURPOSE: 118 Patients with suspected obstruction of the biliary tract of pancreatic duct were examined to evaluate the accuracy of MR cholangiopancreatography (MRCP) in comparison with diagnostic findings in endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Using a 0.5-Tesla MR imaging system (FLEXART, Toshiba) and a QD body-coil, a recently developed heavily T2-weighted fast acquisition spin echo sequence (FASE) was applied. In this FASE sequence two significant features are implemented. A fast spin-echo (SE) sequence allows a large number of echos and conjugate K-space filling speeds up data acquisition. Thus, the acquisition time of single-shot breath-hold images takes only 3 seconds, which makes MRCP a feasible technique even in elderly or suffering patients. There is no need for time-consuming postprocessing procedures. RESULTS: In all MRCP examinations images of satisfactory quality were obtained. In cases of obstruction of the biliary or pancreatic duct, locations and lengths of stenoses were correctly demonstrated. Gallstones within the gallbladder or in the extrahepatic bile ducts were also properly visualised in MRCP. Stenoses caused by non-depicted pancreatic carcinoma, gallbladder carcinoma, or segmental pancreatitis were reliably shown. CONCLUSION: Even if MRCP will not replace ERCP, a number of clinical applications for non-invasive MRCP examination arise: primary diagnosis in patients with obstructive jaundice, obstruction of the biliary or pancreatic duct, if ERCP is not possible due to anatomic reason and in patients scheduled for laparoscopic cholecystectomy.     

Clinical significance of magnetic resonance cholangiopancreatography (MRCP) compared to endoscopic retrograde cholangiopancreatography (ERCP)

BACKGROUND AND STUDY AIMS: The clinical importance of magnetic resonance cholangiopancreatography (MRCP) as a noninvasive diagnostic modality for investigation of the biliary tree and pancreatic duct system is under debate. Using endoscopic retrograde cholangiopancreatography (ERCP) as the gold standard, this study determined in a prospective, blinded fashion the sensitivity and further statistic values of MRCP findings for evaluation of the biliary and pancreatic tract. PATIENTS AND METHODS: Seventy-eight patients referred for ERCP were studied prospectively with MRCP and ERCP during a 12-month period. All images were interpreted on a blinded basis by two radiologists. Any dilations, strictures, and intraductal abnormalities were recorded and correlated with the clinical diagnoses. RESULTS: MRCP images of diagnostic quality were obtained in 76 of the 78 patients (97%). Magnetic resonance cholangiography (MRC) showed sensitivities (and positive predictive values) of 71% (62%) for recognition of normal bile ducts, 83% (91%) for recognition of dilation, 85% (100%) for recognition of strictures, 77% (91%) for correct stricture location, and 80% (100%) for diagnosing bile duct calculi. In addition, the sensitivity of MRC in classifying benign and malignant strictures was 50% and 80%, respectively. The statistical values (sensitivity and positive predictive value) for magnetic resonance pancreatography findings were determined for the recognition of normal pancreatic ducts (33% and 50%), recognition of dilation (62% and 100%), recognition of strictures (76% and 87%) and correct location (66% and 100%), diagnosis of benign strictures (87% and 87%) and malignant strictures (60% and 75%), and for diagnosing pancreatic duct stones (60% and 100%). CONCLUSIONS: MRCP is capable of providing diagnostic information equivalent to ERCP in many patients, and should be applied whenever established techniques provide no results, or inadequate results.     

MR cholangiopancreatography (MRCP) for the mucin producing pancreatic tumor (MPT)

MRCP was performed for 17 patients with MPT (main duct type; 7 and branch duct type; 10) using HASTE and single shot RARE with a body phased array coil on a 1.5 T unit. The findings of MRCP were compared with those of endoscopic retrograde cholangiopancreatography (ERCP). In all cases, MRCP completely disclosed all dilated ducts and cysts, some of which were not seen by ERCP due to mucinous accumulation. In five of seven patients with main duct type, an excrescent nodle was more clearly visualized by ERCP than by MRCP. Mucinous accumulation was not confirmed by MRCP in all cases except one case, in which the dilated branch duct was revealed as lower intensity compared with the main duct using single shot RARE. Therefore MRCP and ERCP are complementary methods in diagnosis for the mucin producing pancreatic tumor.     

Spiral computed tomography for bilioenteric anastomotic stricture

Spiral computed tomography scanning after intravenous cholangiography (IVC-SCT) was used to assess the anatomy of the biliary tree and anastomosis in a 7-year-old girl with recurrent cholangitis 5 years after surgical excision of a choledochal cyst. The technique clearly visualized the stenosis of the hepaticojejunostomy and hepatic duct and the dilated intrahepatic ducts. IVC-SCT provides a precise, prompt, and accurate image with minimal invasiveness and is especially suitable for the preoperative evaluation of pediatric patients.     

MR cholangiopancreatography: technique, indications and clinical results

INTRODUCTION: MR cholangiopancreatography (MRCP) is a new noninvasive imaging technique for the study of biliopancreatic disorders, providing projectional images of the biliary tree and pancreatic duct without any contrast agent. MATERIAL AND METHODS: We used different sequences, with both breath-hold and nonbreath-hold techniques, to acquire MRCP images, first based on GE and then on FSE sequences. FSE images provide higher SNR and are less susceptible to artifacts (metal objects, motion and blood flow artifacts). At the Department of Radiology of the University of Rome La Sapienza, we acquired MRCP images with non breath-hold, 3D fat-suppressed TSE sequences (TR = 3000-2000, TE 700, turbo factor 128) optimized on a .5T magnet with 15 mT/m gradients. No patient preparation or sedation was required, although antiperistaltic drugs and oral administration of tap water were preferred. Four hundred and thirty patients were examined, all of them with an indication to conventional cholangiography. RESULTS: MRCP depicted the whole common bile duct and the first-order intrahepatic branches in all the normal cases. Its accuracy in identifying biliary obstruction level and site was 100%, versus 94.6% in characterizing its cause. MRCP had 96.3% diagnostic accuracy in choledocholithiasis, with some false positives and false negatives caused by: 1) small stones missed on MIP reconstructions; 2) signal loss due to complete CBD obstruction by stones; 3) pneumobilia; 4) differential diagnosis between small stones and air bubbles. The main role of MRCP in benign strictures is to provide a detailed map of the biliary tract for better treatment planning. In particular, MRCP is extremely useful in hepaticojejunostomy patients, where ERC is not indicated because of postoperative anatomical changes. Both conventional MRI and MRCP are important in malignant strictures to identify the lesion and to characterize and stage it. Finally, MR pancreatography is very useful to follow up chronic pancreatitis patients because it shows Wirsung duct strictures and dilatations, intraductal filling defects and, in some cases, the communication between the pseudocyst and the pancreatic duct. CONCLUSIONS: MRCP combined with conventional MRI can completely replace CT and ERCP in bilio-pancreatic disorders.     

MR cholangiopancreatography of pancreas divism and anomalous arrangement of the pancreaticobiliary ducts

The purpose of this study was to evaluate the usefulness of MR cholangiopancreatography (MRCP) for pancreas divism and anomalous arrangement of pancreaticobiliary ducts (APBD). In 214 patients, MRCP was performed. In 204 patients (94%), pancreaticobiliary ductal junction could be recognized. Pancreas divism was observed in 13 of 204 patients (6%), and APBD was observed in 10 of 204 patients (5%). Dynamic MRCP after secretin stimulation was useful for diagnosing pancreas divism and APBD.     

Cholangiopancreatography with magnetic resonance. Clinical use of a new "inversion-recovery" sequence

This study was aimed at correlating the yield of a three-dimensional (3D) inversion-recovery (IR) turbo spin-echo MR cholangiopancreatography (MRCP) sequence with that of ERCP and PTC in the imaging of the normal and abnormal biliopancreatic tract. Thirty patients with suspected biliary and pancreatic diseases were examined with MRCP first and then with ERCP or PTC; they were also submitted to US, CT and conventional MR studies and in 5 of them CT cholangiography was also performed. Five patients were normal and 25 had various obstructive abnormalities: 5 patients had gallbladder stones, 8 common bile duct stones, 5 a cholangiocarcinoma and 7 an adenocarcinoma of the pancreatic head or papilla. MRCP was performed with a superconductive magnet at 0.5 T, with volumetric images on coronal planes acquired using an IR turbo SE sequence (TR 2500, TE 1000, TF 89, 4 NEX) with respiratory triggering and vascular presaturation. Segmental intrahepatic bile ducts were correctly depicted in all the patients with benign or malignant obstruction of the common bile duct, but with some respiratory artifacts. Common bile duct stones were correctly depicted in 7 of 8 patients, but studying also the single coronal slices. With this method, the stones were clearly demonstrated in 22 examined gallbladders. Neoplastic obstruction and the obstruction level were correctly identified in all patients. Pancreatic ducts were shown in normal patients and in 8 of 13 patients with neoplastic or lithiasic obstruction of the common bile duct mainly on the pancreatic head. ERCP was carried out successfully in 5 patients with common bile duct stones and in 7 patients with neoplastic obstruction; in the other cancer patients, PTC was necessary. To conclude, respiratory-triggered 3D IR turbo spin-echo MRCP is a noninvasive technique to study mostly biliary conditions which yields similar information to ERCP and PTC in a large number of patients. Moreover, this sequence can be used with midfield MR units to study the obstruction of the biliary and pancreatic ducts not only when invasive techniques fail, but also routinely.     

Successful management of ruptured choledochal cyst by primary cyst excision and biliary reconstruction

One to two percent of patients who have choledochal cysts present with cyst rupture and bile peritonitis. Reported cases have been managed with external drainage of the cyst followed by a second procedure to excise the cyst and reconstruct the biliary tract. The authors report two cases of ruptured choledochal cyst treated with primary cyst excision and biliary drainage. The satisfactory outcome of these patients suggests that this is the preferred management.