Published online before print May 17, 2002, 10.1148/radiol.2241011223
(Radiology 2002;224:410-416.)
© RSNA, 2002
MR Cholangiography in Symptomatic Gallstones: Diagnostic Accuracy according to Clinical Risk Group1
Joo Hee Kim, MD,
Myeong-Jin Kim, MD,
Sung Il Park, MD,
Jae-Joon Chung, MD,
Si Young Song, MD,
Kyung Sik Kim, MD,
Hyung Sik Yoo, MD,
Jong Tae Lee, MD and
Ki Whang Kim, MD
1 From the Department of Diagnostic Radiology (J.H.K., M.J.K., S.I.P., J.J.C., H.S.Y., J.T.L., K.W.K.), BK21 Project for Medical Science (M.J.K.), Division of Gastroenterology, Department of Internal Medicine (S.Y.S.), and Department of Surgery (K.S.K.), Yonsei University College of Medicine, Seodaemun-ku Shinchon-dong 134, Seoul 120-752, Korea. Received July 19, 2001; revision requested September 11; revision received October 25; accepted December 10. Supported by Yonsei University Research Fund of 2001. Address correspondence to M.J.K. (e-mail: kimnex@yumc.yonsei.ac.kr).
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ABSTRACT
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PURPOSE: To determine the diagnostic accuracy of magnetic resonance (MR) cholangiography in the detection of common bile duct (CBD) stones in patients with symptomatic gallstones.
MATERIALS AND METHODS: Single-shot half-Fourier MR cholangiographic images were obtained in 121 consecutive patients who were referred for MR cholangiography prior to cholecystectomy for symptomatic gallstones. One radiologist interpreted the MR cholangiographic images without prior knowledge of laboratory test results or findings from examinations with other imaging modalities. Patients were retrospectively divided into three groups with high, moderate, and low risk (n = 70, 22, and 29, respectively) for CBD stones. The sensitivity, specificity, and accuracy of MR cholangiography in the detection of CBD stones in each group were calculated. The accuracy of laboratory and sonographic findings in the identification of CBD stones was also calculated.
RESULTS: CBD stones were diagnosed in 49 (70%) of 70 patients in the high-risk group. One false-positive diagnosis was made, and two false-negative diagnoses were made. Of the 22 patients in the moderate-risk group, seven (32%) had CBD stones, and there was one false-positive and one false-negative diagnosis. In the low-risk group, CBD stones were correctly identified with MR cholangiography in one patient, and there was one false-positive diagnosis. A combination of positive laboratory and sonographic findings yielded a sensitivity of 98% but a specificity of only 34% if any unusual finding in any one of the tests was regarded as a positive finding.
CONCLUSION: MR cholangiography is highly accurate in the detection of CBD stones in all patients, regardless of the grade of risk, and should be considered in patients with a moderate to high risk of CBD stones before cholecystectomy.
© RSNA, 2002
Index terms: Bile ducts, calculi, 766.2891 • Bile ducts, MR, 766.121411, 766.121412 • Gallbladder, calculi, 766.2891 • Magnetic resonance (MR), cholangiopancreatography, 78.121411, 78.121412
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INTRODUCTION
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The prevalence of common bile duct (CBD) stones in patients who undergo cholecystectomy has been reported to be in the range of 10%–20%, and the frequency of undetected CBD stones is approximately 0%–4.2% (1–5). Accurate identification of CBD stones is important to avoid the surgical morbidity associated with residual stones. Endoscopic retrograde cholangiography (ERC) has been widely used for the preoperative detection of CBD stones and serves not only as an accurate diagnostic modality but also as a therapeutic maneuver. It is invasive, however, and has been associated with a complication rate of 3.0%–5.5% and a mortality rate of 0.2%–1.0% (6,7). To select candidates for preoperative ERC, the following criteria were used: clinical evidence of jaundice, cholangitis, or biliary pancreatitis; an elevation in hepatic enzyme levels (ie, bilirubin, alkaline phosphatase, and transaminase); or sonographically determined CBD dilatation (4,5,8). Selection on the basis of these noninvasive tests leads to high sensitivity but low specificity for detecting CBD stones. For this reason, the detection rate of CBD stones with ERC has been reported to be only 35%–64%, despite the fact that ERC was applied in selected patients (9).
Although MR cholangiography has been shown to provide an accurate diagnosis of CBD stones (10–17), only a few investigators have evaluated the utility of MR cholangiography in the preoperative evaluation of symptomatic gallstones, and, accordingly, the precise role of MR cholangiography in this regard has yet to be determined (18–20). Some authors have recommended MR cholangiography for patients with a moderate risk of CBD stones and have recommended ERC before any other imaging examination for patients with a high risk (18,19), while others have recommended MR cholangiography for patients with high or moderate risk for CBD stones and have recommended ERC for patients in whom stones had been depicted with other imaging modalities (17).
The aim of this study was to determine the diagnostic accuracy of MR cholangiography in the detection of CBD stones in patients with symptomatic gallstones who were classified into risk groups according to clinical, laboratory, and sonographic findings.
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MATERIALS AND METHODS
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This study included 121 consecutive patients who had undergone MR cholangiography prior to cholecystectomy for symptomatic gallstones. There were 67 male and 54 female patients, ranging in age from 14 to 87 years (mean, 63 years). Clinicians referred patients for MR cholangiography if they were suspected of having CBD stones on the basis of clinical or biochemical findings. All patients gave informed consent. The study was conducted in accordance with the approval and recommendations of our institutional review board.
MR cholangiography was performed in all patients with a 1.5-T system (Horizon; GE Medical Systems, Milwaukee, Wis) by using a phased-array multicoil. Initially, localizer images were obtained in the coronal and transverse planes by using a spoiled gradient-recalled sequence with 130/1.7 (repetition time msec/echo time msec), flip angle of 90°, field of view of 36 x 24–36 cm, section thickness of 10 mm with no gap, matrix size of 256 x 128, and one acquisition. Subsequently, thin-section T2-weighted images were obtained by using a single-shot half-Fourier rapid-acquisition and relaxation sequence (single-shot fast spin-echo) with a 260–320-mm field of view. The imaging parameters were an effective echo time of 66–100 msec, field of view of 32 x 24 cm, section thickness of 5 mm with no gap, receiver bandwidth of 31.3 kHz, matrix size of 256 x 256, and half-Fourier acquisition. Fat suppression was not used for this sequence in order to maintain signals from the soft-tissue structure. In addition, multisection images were obtained with a long effective echo time of 645–869 msec by using a spatial fat saturation technique. All other parameters were the same as for T2-weighted images. Subsequently, single thick-section images were obtained with an echo time of 830–1,050 msec; a section thickness of 30–50 mm; and a field of view of 24 x 24 cm in the coronal, lateral, and left and right 15°, 30°, and 45° oblique planes (eight images were obtained). All of the above sequences are included among the routine sequences of MR cholangiographic examination at our institution.
One experienced radiologist (M.J.K.) interpreted all available MR images at a reading session also attended by two or three residents and fellows. The radiologist recorded the presence of CBD stones at this session without prior knowledge of laboratory test results or findings from examinations with other imaging modalities. A CBD stone was defined as a nodular area of low signal intensity within a high-signal-intensity lumen (21). Calculi were usually differentiated from a polypoid tumor of the bile duct by their angulated contours and dependent location in the bile duct and by being surrounded by high-signal-intensity bile. Less heavily T2-weighted MR images were also helpful for differentiating calculi and noncalculous filling defect in the bile duct. Case management was planned on the basis of a combination of clinical, laboratory, and MR cholangiographic findings at a preoperative conference attended by radiologists, physicians, and surgeons. The presence or absence of CBD stones was confirmed with either ERC (n = 38) or intraoperative cholangiography (IOC) (n = 62) in combination with an exploration of the CBD during surgery (n = 44). The presence of CBD stones (n = 57) was confirmed with either ERC or IOC in all patients. In 25 patients, the presence of CBD stones was excluded with the use of direct cholangiography (ie, ERC, transhepatic cholangiography, or intraoperative cholangiography). In the remaining 39 patients, the presence of CBD stones was excluded according to normal laboratory findings and the absence of stone-related symptoms after a clinical follow-up of at least 6 months.
Two radiologists (J.H.K., S.I.P.) reviewed patient medical records and retrospectively divided the patients into three risk groups—namely, high, moderate, and low risk (n = 70, 22, and 29, respectively), according to the criteria presented in Table 1. Many authors have suggested criteria for the assignment of risk groups (4–9,18–20). We included as many relevant criteria as possible to allow the prediction of CBD stones. Patients were assigned to the higher-risk group if they met any of the criteria that were sufficient to place them in that group.
Sonography was performed by a gastrointestinal radiologist (J.T.L. or H.S.Y.), a resident with supervision, or an experienced gastroenterologist (a) by using an HDI UltraMark 9 unit or an HDI 3000 unit (ATL, Bothell, Wash) with a 2.0–4.0-MHz multifrequency curved-array transducer and 128XP scanner (Acuson, Mountain View, Calif) or a 2.5- to 4.0-MHz curved-array transducer or (b) by using an SSD-1700 or SSD-5000 unit (Aloka, Tokyo, Japan) with a 3.5- or 5.0-MHz sector transducer. Original sonographic reports regarding the presence of dilatation of the CBD (>8 mm in diameter) were used to calculate the accuracy of the sonographic examination.
Cholangitis was defined as the presence of fever (
37.3°C), chills, colicky right-upper-quadrant pain, and leukocytosis. The "status of postbiliary pancreatitis" was defined according to a history of biliary pancreatitis of no more than 2 months’ duration prior to admission, with subsided pancreatitis at the time of admission. Previous jaundice was considered to have returned if there was a history of jaundice in the absence of objective biochemical or sonographic data.
The sensitivity, specificity, and accuracy of MR cholangiography in the detection of CBD stones in each group were calculated. The sensitivity, specificity, and accuracy of the separate and combined results for each laboratory test and sonographic examination were also calculated.
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RESULTS
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Overall, CBD stones were present in 57 (47%) of the 121 patients. The prevalence of CBD stones and the sensitivity, specificity, and accuracy of MR cholangiography in the detection of CBD stones in each clinical risk group are presented in Table 2.
CBD stones were diagnosed in 49 (70%) of the 70 patients in the high-risk group (Fig 1). A false-positive diagnosis was rendered for one patient in the high-risk group. A clear nodular area of low signal intensity depicted at MR cholangiography was determined to be a CBD stone at prospective image interpretation and at retrospective review (Fig 2). Only dirty bile was found at ERC, however, which was performed 4 days after MR cholangiography. The patient’s total bilirubin concentration was 2.7 mg/dL (46.2 µmol/L) at MR cholangiography, but it normalized to 1.0 mg/dL (17.1 µmol/L) at ERC. The alkaline phosphatase level also decreased to 321 U/L at ERC from 665 U/L at MR cholangiography. Endoscopic sphincterotomy was performed in this patient. Two false-negative diagnoses were made (Fig 3). In both of these patients, CBD stones were not found at ERC, either. However, the CBD was explored during open cholecystectomy, and sandy stones smaller than 3 mm in diameter were found. Direct cholangiography was not performed in 10 patients in the high-risk group on the basis of MR cholangiographic findings, and these patients did not have any symptoms suggestive of CBD stones during at least 6 months of follow-up after cholecystectomy.
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Figure 1. Coronal thick-section ( /1,079 [effective]; 50-mm thickness) MR cholangiographic image obtained in a 57-year-old man with a high risk of CBD stones and an elevated bilirubin concentration (>1.5 mg/dL [>25.6 µmol/L]). Patient had a true-positive diagnosis of a CBD stone. Image shows a single stone (arrow) in the distal lumen of the CBD.
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Of the 22 patients in the moderate-risk group, seven (32%) had CBD stones. There was one false-positive and one false-negative diagnosis. At retrospective review, the false-positive diagnosis was likely to have resulted from signal voids caused by bile flow in the distal lumen of the CBD (Fig 4). In the patient with the false-negative diagnosis, ERC was performed 5 days after MR cholangiography, but CBD stones were still not found. CBD stones smaller than 3 mm were found at CBD exploration during open cholecystectomy.
In the low-risk group, a CBD stone was correctly identified at MR cholangiography in one patient (3%) (Fig 5). One false-positive diagnosis was made (Fig 6). This diagnosis was changed, however, during the preoperative conference.
The sensitivity, specificity, and accuracy of each laboratory test are presented in Table 3. A combination of laboratory test results showed a sensitivity of 91% and a specificity of 48% in the detection of CBD stones.
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DISCUSSION
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Many reports have been issued regarding the usefulness of MR cholangiography in the detection of CBD stones. Even with current imaging techniques, the accuracy of MR cholangiography in the diagnosis of CBD stones has varied widely, with reported sensitivities ranging from 57% to 100% and specificities ranging from 73% to 100% (1,10–18). The MR imaging sequences or receiver coils used and the proportion of patients with small (<5–6-mm) stones were likely to have affected study results (22). In the studies in which MR cholangiography was performed with a two-dimensional fast or turbo spin-echo sequence and a standard body coil, the sensitivity of MR cholangiography in the detection of CBD stones was reported to range from 57% to 92% (11–14). A previous study, in which patients with small stones comprised more than half of the study population, produced the lowest sensitivity (57%) in the detection of CBD stones (17). However, motion artifacts and blurring associated with the long acquisition times in the non–breath-hold technique used would make the detection of small stones difficult, and small stones may also move during MR cholangiography when long acquisition times are required. Improved MR cholangiographic performance was achieved by using the breath-hold single-shot half-Fourier sequence with a phased-array coil. With this technique, the reported sensitivity was 92%–100% (10,15). In our study, a single-shot half-Fourier sequence and a phased-array coil were used in all patients, and results were similar to those of other studies in which a similar technique was used. Recently, Soto et al (23) reported that the CBD stone detection rate was similar between a non–breath-hold three-dimensional fast spin-echo technique and a breath-hold single-shot half-Fourier technique. In their study, however, MR cholangiography with a two-dimensional fast spin-echo technique and a standard body coil was not included, and only two of the 24 patients had stones measuring 5 mm or smaller.
Overall, a false-negative diagnosis was rendered at MR cholangiography in three patients in our study. In these cases, the calculi were not depicted at ERC, either. However, CBD stones smaller than 3 mm were identified at exploration of the CBD. Although there might be a chance that those small calculi had passed from the gallbladder during the interval between ERC and surgery, both MR cholangiographic and ERC results were regarded as a false-negative diagnosis. In the present study, there was no patient with CBD stones in whom ERC depicted a stone and MR cholangiography did not. In one patient (not included in this study), however, ERC depicted CBD stones that were not visualized at MR cholangiography. In this case, the direct cholangiographic image did not depict a small calculus initially, but a small (<5-mm) calculus passing through the duodenal papilla was observed after sphincterotomy. Although, to our knowledge, there are no good prospective data, it has been suggested that small stones (<3 mm) may pass spontaneously through the duodenal papilla and not induce symptoms of bile duct obstruction (9). Liu et al (19) have also reported that small filling defects of approximately 2–3 mm identified at MR cholangiography were usually not identified during direct cholangiography. They assumed that the stones that were not detected at MR cholangiography and ERC in their study might be ignored because they may pass and not induce postoperative symptoms even if they were not removed at CBD exploration.
In one of the high-risk patients with a false-positive diagnosis, a nodular signal void was clearly depicted on MR cholangiographic images. However, only dirty bile was found at ERC performed 4 days later. A calculus was believed to have passed during the interval between MR cholangiography and ERC in this case. In the remaining two false-positive cases, correct diagnoses were achieved during retrospective review. One patient in the low-risk group showed an equivocal finding of CBD stones, and the diameter of the CBD was smaller than 4 mm. Although the patient presented with intermittent colicky pain, laboratory test results were normal, and sonographic images showed a normal CBD. The patient did not undergo ERC or IOC but underwent laparoscopic cholecystectomy; the patient did not present with stone-related symptoms after surgery. A flow-void signal from a small vessel adjacent to the distal CBD was regarded as the cause of the pseudocalculus. In the remaining case, the results of MR cholangiography suggested a distal CBD stone, but results of ERC performed 3 days after MR cholangiography did not. The bile flow–related signal void appeared to mimic stones in this case.
In most other studies in which investigators have addressed the accuracy of MR cholangiography in the diagnosis of CBD stones, the study populations have not been limited to candidates for cholecystectomy and have included patients suspected of having bile duct obstruction, regardless of the presence of gallstones, which explains the low prevalence of CBD stones in such studies (10–17). Several investigators have evaluated the role of MR cholangiography in the preoperative evaluation of symptomatic patients with gallstones (18–20). Dwerryhouse et al (18) used MR cholangiography in 40 candidates for cholecystectomy who had symptomatic cholecystitis with minor risk factors for CBD stones, such as abnormal hepatic function, previous gallstone pancreatitis, a dilated CBD of 7 mm or larger, and previous jaundice. They yielded a CBD stone detection sensitivity and specificity of 88% and 93%, respectively. If ERC was limited to patients with positive or failed MR cholangiography, the requirement for ERC would have decreased from 40 to 11 patients, but one case of CBD stones would have been misdiagnosed. Dwerryhouse et al (18) regarded the clinical findings of jaundice, cholangitis, and acute gallstone pancreatitis as high-risk factors, and patients with these symptoms underwent ERC without undergoing MR cholangiography. However, the prevalence of CBD stones in this high-risk group was not documented. Liu et al (19) performed MR cholangiography in patients who presented with symptoms of two or more abnormalities clinically, sonographically, or in terms of serum chemistry, and obtained a sensitivity and specificity of 85% and 94%, respectively. Four false-negative diagnoses of CBD stones occurred at MR cholangiography in that study. They recommended preoperative MR cholangiography for patients with biliary pancreatitis, a CBD diameter larger than 5 mm at sonography, or an elevated hepatic function test result. In patients with jaundice or cholangitis, dilatation of the CBD, and an elevation in hepatic function test result, ERC was recommended first. Demartines et al (20) also performed MR cholangiography in 70 candidates for cholecystectomy who had symptomatic gallstones. They achieved a sensitivity and specificity of 100% and 96%, respectively, by using both single- and multisection breath-hold single-shot half-Fourier sequences. In their study, the patients were divided into moderate- and high-risk groups according to bilirubin and alkaline phosphatase levels, CBD diameter, and history of biliary pancreatitis. CBD stones were found in 48% and 16% of the high- and moderate-risk groups, respectively. The authors proposed that ERC be performed first in patients in whom CBD stones are confirmed with different imaging modalities, but they recommended MR cholangiography in patients with a moderate to high risk of CBD stones.
Some authors have recommended MR cholangiography only in patients with moderate risk for CBD stones (18,19), and others have recommended MR cholangiography for both high- and moderate-risk groups, except in proven cases (20). In the present study, 30% of the high-risk group did not have CBD stones, and 10 patients underwent cholecystectomy without undergoing MR cholangiography and experienced no stone-related symptoms thereafter. Although the application of MR cholangiography in the preoperative evaluation of gallstones depends not only on its diagnostic accuracy but also on its expense and availability, our results suggest that MR cholangiography can be used instead of diagnostic ERC in both moderate- and high-risk patients.
To our knowledge, in only one study have investigators evaluated the role of MR cholangiography in determining the presence of gallstones in consecutive candidates for cholecystectomy, regardless of risk factors for coexistent CBD stones (24). In a study by Reuther et al (24), 60 consecutive patients who were scheduled for cholecystectomy underwent MR cholangiography. CBD stones were correctly diagnosed in five (8%) patients without a false-positive finding. However, the clinical or laboratory findings in patients with CBD stones are not described. In the present study, only one patient in the low-risk group had CBD stones. This patient showed mild dilatation of the CBD at MR cholangiography, but it was not demonstrated at sonographic examination performed 1 month previously. The laboratory test results obtained within the week prior to MR cholangiography were normal. Therefore, the cause of the false-negative sonographic result appears to be the long interval between the two examinations. If this case is excluded, our combined laboratory and sonographic findings show a sensitivity of 100%, although specificity is low. Therefore, MR cholangiography is not recommended for all candidates for cholecystectomy for the purpose of screening for CBD stones. This is despite the fact that MR cholangiography may be useful in the detection of various anatomic variants that may increase the risk of surgical injury (25).
In the present study, MR cholangiographic data were based on the preoperative interpretation rendered by a staff radiologist in a joint reading session. Therefore, interobserver variability could not be assessed, and this is probably a limitation of this study. However, the accuracy of MR cholangiography in our study was similar to that in previous studies (10–16) and was also similar in each risk group. Another limitation is that the sonographic examinations were not standardized. Therefore, it may not be appropriate to directly compare sonographic and MR cholangiographic results. However, the accuracy of sonographic examination results in the present study was also in the range of that in previous studies (26–28). In addition, the criteria used to classify the risk groups are not completely standardized. The incidence of CBD stones in each risk group may differ according to which criteria are used and how they are used. We found that current clinical and laboratory criteria are sensitive but not sufficiently specific. Therefore, further study may be necessary to establish clinical or laboratory criteria that are more specific.
In conclusion, we found that screening patients with symptomatic gallstones for the presence of coexistent CBD stones by using criteria based on clinical, laboratory, and sonographic findings is highly sensitive. However, because of their low specificity, the incidence of purely diagnostic ERC may be high if it is performed on the basis of these criteria alone. MR cholangiography was found to be highly accurate in the detection of CBD stones in all risk groups. We recommend that MR cholangiography be performed before cholecystectomy in patients with a moderate to high risk of CBD stones to reduce the frequency of purely diagnostic ERC.
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FOOTNOTES
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Abbreviations: CBD = common bile duct,
ERC = endoscopic retrograde cholangiography,
IOC = intraoperative cholangiography
Author contributions: Guarantors of integrity of entire study, J.H.K., M.J.K.; study concepts and design, J.H.K., M.J.K.; literature research, J.H.K., M.J.K.; clinical studies, J.H.K., M.J.K., S.I.P., S.Y.S., K.S.K.; data acquisition, S.I.P., J.H.K., M.J.K.; data analysis/interpretation, all authors; statistical analysis, J.H.K., M.J.K.; manuscript preparation, J.H.K., M.J.K.; manuscript definition of intellectual content, J.H.K., M.J.K., J.J.C., S.Y.S., K.S.K.; manuscript editing and revision/review, J.H.K., M.J.K.; manuscript final version approval, all authors.
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ABSTRACT
INTRODUCTION
