Download PDF
Endoscopy 2001; 33(8): 668-675
DOI: 10.1055/s-2001-16218
Original Article

© Georg Thieme Verlag Stuttgart · New York

Potential Impact of Magnetic Resonance Cholangiopancreatography on Endoscopic Retrograde Cholangiopancreatography Workload and Complication Rate in Patients Referred Because of Abdominal Pain

R. J. Farrell 1 , N. Noonan 1 , N. Mahmud 1 , M. M. Morrin 2 , D. Kelleher 1 , P. W. N. Keeling 1
  • 1 Depts. of Clinical Medicine and Gastroenterology, St James' Hospital, Trinity College, Dublin, Ireland
  • 2 Dept. of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
Further Information

Publication History

Publication Date:
31 December 2001 (online)

Also available at
    Permissions and Reprints

Background and Study Aims: Endoscopic retrograde cholangiopancreatography (ERCP) has a significant mortality, morbidity, and failed cannulation rate. Magnetic resonance cholangiopancreatography (MRCP) is a safer, noninvasive method of imaging the pancreaticobiliary tree. A substantial number of patients are referred for ERCP because of abdominal pain, a high proportion of whom have normal ducts or pathology not requiring interventional ERCP. The aim was to assess the potential impact of MRCP on overall ERCP workload and patient outcome if MRCP were the primary investigation in patients referred for ERCP because of abdominal pain.

Patients and Methods: 1758 consecutive ERCPs performed in 1148 patients over a 3-year period in a single tertiary referral center in the pre-MRCP era were reviewed. Cannulation failure, ERCP findings, need for follow-up ERCP and all 30-day major complication rates were analyzed with regard to clinical indications.

Results: The overall workload comprised 1108 (63 %) successful initial ERCPs, 188 (11 %) failed cannulation attempts and 462 (26 %) follow-up ERCPs. Of the patients, 299 (27 %) had normal ERCP findings, 331 (30 %) had choledocholithiasis and 246 (22 %) had strictures. lf MRCP had been used as the primary imaging investigation in the 451 patients (39 %) referred for ERCP because of abdominal pain, we estimate that 197 patients (44 %) would have avoided ERCP, and the overall ERCP workload would have been reduced by 13 %. Initial MRCP in suspected gallstone pancreatitis and certain miscellaneous groups, it was estimated, would have further decreased ERCP workload by 9 %. Four of 40 major ERCP-related complications (3.5 %) and one of four ERCP-related deaths (0.35 %) would potentially have been avoided.

Conclusions: Initial MRCP in patients referred with abdominal pain would potentially have avoided ERCP in 44 % of cases, reduced ERCP workload by 13 % and significantly reduced patient morbidity and mortality. The relatively small reduction in ERCP workload among these patients reflects the fact that over half of them had probable sphincter dysfunction, a significant proportion of whom might have benefited from biliary manometry and/or endoscopic intervention despite a normal MRCP. Furthermore, a small number of patients with calculi and subtle biliary and pancreatic strictures would be missed by this approach.

References

  • 1 Loperfido S, Angelini G, Benedetti G, et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.  Gastrointest Endosc. 1998;  48 1-10
    CrossrefPubMedGoogle Scholar
  • 2 Male R, Lehman G, Sherman S, et al. Severe and fatal complications from diagnostic and therapeutic ERCPs.  Gastrointest Endosc. 1994;  40 A29
    PubMedGoogle Scholar
  • 3 Tanner A R. ERCP: present practice in a single region. Suggested standards for monitoring performance.  Eur J Gastroenterol Hepatol. 1996;  8 145-148
    CrossrefPubMedGoogle Scholar
  • 4 Schlup M M, Williams S M, Barbezat G O. ERCP: a review of technical competency and workload in a small unit.  Gastrointest Endosc. 1997;  46 48-52
    CrossrefPubMedGoogle Scholar
  • 5 Ramirez F C, Dennert B, Sanowski R A. Success of repeat ERCP by the same endoscopist.  Gastrointest Endosc. 1999;  49 58-61
    PubMedGoogle Scholar
  • 6 Dowsett J F, Polydorou A A, Vaira D, et al. Needle knife papillotomy: how safe and how effective?.  Gut. 1990;  31 905-908
    PubMedGoogle Scholar
  • 7 Reinhold C, Bret P. Current status of MR colangiopancreatography.  AJR Am J Roentgenol. 1996;  166 1285-1295
    PubMedGoogle Scholar
  • 8 Guibaud L, Bret P M, Reinhold C, et al. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography.  Radiology. 1995;  197 109-115
    PubMedGoogle Scholar
  • 9 Soto J A, Barish M A, Yucel E K, et al. Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiopancreatography.  Gastroenterology. 1996;  110 589-597
    PubMedGoogle Scholar
  • 10 Sugiyama M, Atomi Y, Hachiya J. Magnetic resonance cholangiography using half-Fourier acquisition for diagnosing choledocholithiasis.  Am J Gastroenterol. 1998;  93 1886-1890
    CrossrefPubMedGoogle Scholar
  • 11 Adamek H E, Albert J, Weitz M, et al. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction.  Gut. 1998;  43 680-683
    PubMedGoogle Scholar
  • 12 Schwartz L H, Coakley F V, Sun Y, et al. Neoplastic pancreaticobiliary duct obstruction: evaluation with breath-hold MR cholangiopancreatography.  Am J Roentgenol. 1998;  170 1491-1495
    PubMedGoogle Scholar
  • 13 Sica G T, Braver J, Cooney M J, et al. Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis.  Radiology. 1999;  210 605-610
    PubMedGoogle Scholar
  • 14 Takehara Y, Ichijo K, Tooyama N, et al. Breath-hold MR cholangiopancreatography with a long-echo-train fast spin-echo sequence and a surface coil in chronic pancreatitis.  Radiology. 1994;  192 73-78
    PubMedGoogle Scholar
  • 15 Ernst O, Asselah T, Sergent G, et al. MR cholangiography in primary sclerosing cholangitis.  Am J Roentgenol. 1998;  171 1027-1030
    PubMedGoogle Scholar
  • 16 Soto J A, Yucel E K, Barish M A, et al. MR cholangiopancreatography after unsuccessful or incomplete ERCP.  Radiology. 1996;  199 91-98
    PubMedGoogle Scholar
  • 17 Mala T, Lunde O C, Nesbakken A, et al. Endoscopic retrograde cholangiopancreatography: a 4-year retrospective study.  Tidsskr Nor Laegeforen. 2000;  120 560-562
    PubMedGoogle Scholar
  • 18 Topazian M, Kozarek R, Stoler R, et al. Clinical utility of endoscopic retrograde cholangiopancreatography.  Gastrointest Endosc. 1997;  46 393-399
    PubMedGoogle Scholar
  • 19 Lombard M, Murray F, Connolly G, et al. A critical evaluation of the indications for ERCP.  Ir J Med Sci. 1986;  156 105-110
    PubMedGoogle Scholar
  • 20 Moreira V F, San Roman A L, Arocena C. Critical review of the indications of diagnostic endoscopic retrograde cholangiopancreatography in the 90s.  Med Clin (Barc). 1993;  101 389-396
    PubMedGoogle Scholar
  • 21 Ruddell W S, Lintott D J, Axon A T. The diagnostic yield of ERCP in the investigation of unexplained abdominal pain.  Br J Surg. 1983;  70 74-75
    PubMedGoogle Scholar
  • 22 Chen Y K, McCarter T L, Santoro M J, et al. Utility of endoscopic retrograde cholangiopancreatography in the evaluation of idiopathic abdominal pain.  Am J Gastroenterol. 1993;  88 1355-1358
    PubMedGoogle Scholar
  • 23 Cotton P B, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus.  Gastrointest Endosc. 1991;  37 383-393
    CrossrefPubMedGoogle Scholar
  • 24 Hogan W J, Geenen J E. Biliary dyskinesia.  Endoscopy. 1988;  20 179-183
    PubMedGoogle Scholar
  • 25 Farrell R J, Khan M I, O'Byrne K, et al. Endoscopic papillectomy: a novel approach to difficult cannulation.  Gut. 1996;  39 36-38
    PubMedGoogle Scholar
  • 26 Varghese J C, Liddell R P, Farrell M A, et al. Diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.  Clin Radiol. 2000;  55 25-35
    CrossrefPubMedGoogle Scholar
  • 27 Outwater E K, Gordon S J. Imaging the pancreatic and biliary ducts with MR.  Radiology. 1994;  192 19-21
    PubMedGoogle Scholar
  • 28 McDermott V G, Nelson R C. MR cholangiopancreatography: efficacy of three-dimensional turbo spin-echo technique.  Am J Roentgenol. 1995;  165 301-302
    PubMedGoogle Scholar
  • 29 Hauer-Jensen M, Karesen R, Nygaard K, et al. Predictive ability of choledocholithiasis indicators. A prospective evaluation.  Ann Surg. 1985;  202 64-68
    PubMedGoogle Scholar
  • 30 Bar-Meir S, Halpern Z, Bardan E, et al. Frequency of papillary dysfunction among cholecystectomized patients.  Hepatology. 1984;  4 328-330
    PubMedGoogle Scholar
  • 31 Tanner A R, Dwarakanath A D, Tait N P. The potential impact of high-quality MRI of the biliary tree on ERCP workload.  Eur J Gastroenterol Hepatol. 2000;  12 773-776
    PubMedGoogle Scholar
  • 32 Trondsen E, Edwin B, Reiertsen O, et al. Prediction of common bile duct stones prior to cholecystectomy.  Arch Surg. 1998;  133 162-166
    CrossrefPubMedGoogle Scholar
  • 33 Rieger R, Wayand W. Yield of prospective, non-invasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients.  Gastrointest Endosc. 1995;  42 6-12
    PubMedGoogle Scholar
  • 34 Dwerryhouse S J, Brown E, Vipond M N. Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy.  Br J Surg. 1998;  85 1364-1366
    CrossrefPubMedGoogle Scholar
  • 35 Liu T H, Consorti E T, Kawashima A, et al. The efficacy of magnetic resonance cholangiography for the evaluation of patients with suspected choledocholithiasis before laparoscopic cholecystectomy.  Am J Surg. 1999;  178 480-484
    CrossrefPubMedGoogle Scholar
  • 36 Kumar S, Sherman S, Hawes R H, et al. Success and yield of second attempt ERCP.  Gastrointest Endosc. 1995;  41 445-447
    CrossrefPubMedGoogle Scholar
  • 37 Adamek H E, Albert J, Breer H, et al. Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study.  Lancet. 2000;  356 190-193
    CrossrefPubMedGoogle Scholar
  • 38 Zidi S H, Prat F, Le Guen O, et al. Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method.  Gut. 1999;  44 118-122
    PubMedGoogle Scholar
  • 39 Fan S T, Lai E C, Mok F P, et al. Early treatment of acute biliary pancreatitis by endoscopic papillotomy.  N Engl J Med. 1993;  328 228-232
    Google Scholar
  • 40 Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis.  Am J Gastroenterol. 1994;  89 1863-1866
    PubMedGoogle Scholar
  • 41 Folsch U R, Nitsche R, Ludtke R, et al. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis.  N Engl J Med. 1997;  336 237-242
    Google Scholar
  • 42 Trap R, Adamsen S, Hart-Hansen O, et al. Severe and fatal complications after diagnostic and therapeutic ERCP: a prospective series of claims to insurance covering public hospitals.  Endoscopy. 1999;  31 125-130
    Article in Thieme ConnectPubMedGoogle Scholar

R. J. Farrell,M.D. 

Beth Israel Deaconess Medical Center
Harvard Medical School

Dana 501, 330 Brookline Avenue
Boston, MA02215
USA


Fax: + 1-617-667-2767

Email: r.farrell@caregroup.harvard.edu

      >