Comparison of Endoscopic Retrograde Cholangiopancreatography (ERCP) and Magnetic Resonance Cholangiopancreatography (MRCP) in Bile Duct Imaging

doi:10.4236/ss.2012.310097

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Surgical Science, 2012, 3, 489-493

http://dx.doi.org/10.4236/ss.2012.310097 Published Online October 2012 (http://www.SciRP.org/journal/ss)

Comparison of Endoscopic Retrograde

Cholangiopancreatography (ERCP) and Magnetic

Resonance Cholangiopancreatography

(MRCP) in Bile Duct Imaging

Mehmet Ali Eryılmaz1, Ömer Karahan1, İsmet Tolu2, Ahmet Okuş1, Serden Ay2*, Barış Sevinç1,

Ahmet Hakan Halıcı1

1Konya Training and Research Hospital General Surgery Clinic, Konya, Turkey

2Konya Training and Research Hospital Radiology Clinic, Konya, Turkey

Email: *[email protected]

Received August 10, 2012; revised September 11, 2012; accepted September 22, 2012

ABSTRACT

Purpose: The aim of this study was to compare magnetic resonance cholangiopancreatography (MRCP) with endo-

scopic retrograde cholangiopancreatography (ERCP) in diagnosing bile duct pathologies. Materials and Methods: We

documented the data of 171 patients with both ERCP and MRCP between January 2009 and December 2010 at the

Konya Education and Research Hospital. Results: Of the 171 patients, 100 (58.5%) were female and 71 (41.5%) were

male. The median age was 63 (55 to 89). ERCP was used to diagnose bile duct stones in 102 (59%) patients, bile duct

tumour in 14 (8%) patients, hydatic cysts opening up to the bile duct in 4 (2%) patients and bile duct stenosis in 3 (1.8%)

patients. For the detection of bile duct stones, MRCP had a sensitivity of 92%, a specificity of 74% and a diagnostic

accuracy of 83%. For bile duct tumours, MRCP had a sensitivity of 85%, a specificity of 98% and a diagnostic accuracy

rate of 92%. Conclusion: In our centre, the results of MRCP and ERCP were similar for the last two years. However,

MRCP was superior with respect to diagnosis as it was cheaper and non-invasive. Thus, ERCP should be preferred for

therapeutic processes.

Keywords: ERCP; MRCP; Bile Duct Disease; Diagnosis; Treatment

1. Introduction

In the diagnosis of bile duct pathologies, clinical labora-

tory findings and imaging studies play important roles.

Frequently used imaging techniques are ultrasonography

(USG), magnetic resonance cholangiopancreatography

(MRCP) and endoscopic retrograde cholangiopancrea-

tography (ERCP). Abdominal USG is useful in detecting

bile duct morphology; however, its sensitivity in detect-

ing the ethiology of bile duct obstruction is low. In the

diagnosis of bile duct stones, USG must be combined

with other imaging methods [1]. The advantages of

MRCP are it is not invasive or radionuclear and provides

3D images [2]. ERCP is another way of detecting those

pathologies. Although it is an invasive method, some

therapeutic investigations like sphincterotomy, stone

extraction and stent placement can be performed while

performing a diagnostic study [3]. According to some

authors, 10% of MRCP and 5% of ERCP performed in

our country are optimal [4]. Therefore, we aimed to de-

tect the differences and the advantages of the two tech-

niques by comparing their diagnostic accuracy, cost, time

and morbidity in our hospital.

2. Materials and Methods

2.1. Patients

At the Konya Training and Research Hospital between

January, 2009 and December 2010, 655 patients under-

went MRCP, and 283 patients, ERCP, for bile duct pa-

thologies. 171 patients who had both MRCP and ERCP

were included in the study. MRCP was used on patients

who had clinical jaundice symptoms with or without pain

in the upper right quadrant of the abdomen, and labora-

tory results showing higher values than GGT = 40 IU/L,

ALP = 120 IU/L, direct bilirubin = 0.2 mg/dl, and

USG-detected choledoch duct wider than 7 mm, who had

pre-diagnoses of bile duct disorders. Those who received

diagnoses such as bile duct stones or stenosis, bile leak-

age, parasitosis, pancreatic tumors, papilla water tumors,

*Corresponding author.

M. A. ERYILMAZ ET AL.

490

underwent ERCP in order to perform treatment or biopsy.

Age, gender, and details of MRCP and ERCP reports of

the patients included in the study were obtained retro-

spectively from the hospital automation system.

2.2. MRCP Technique

MRCP was performed before ERCP. In order to have an

empty stomach and a maximally full gall bladder, the

patients didn’t have any food for 6 hours before the pro-

cedure. The MRCP device was 1.5 Tesla and had 4 phase

channels (Avanto, Simens Medical Systems, Germany).

The patients were not sedated for the MRCP procedure.

Total procedure duration was approximately 4-5 minutes.

MRCP images were evaluated by an experienced radi-

ologist (Figures 1 and 2). No contrast material was used

to obtain the MRCP images. The Social Security Institu-

tion paid TL 65 for the MRCP procedure in 2010.

Figure 1. T2 axial MRCP image showing a bile duct stone.

Figure 2. 3D MRCP image showing a bile duct stone.

2.3. ERCP Technique

ERCP was performed in order to confirm bile duct pa-

thologies and to provide treatment, after informed con-

sent was received from the patients. The equipment used

during the ERCP procedures were C-Arm (Siemens, In-

dia), bipolar cautery (Olympus, Germany) and duodeno

video endoscopy (Olympus, Japan). Every patient was

admitted for treatment after fasting for eight hours. Par-

enteral Buscopan was administered to all patients. Endo-

scopic sphincterotomy (ES) and stone extraction were

performed in the cases of stone, debris or parasitosis. In

cases of tumoral lesions biopsy was performed for diag-

nostic confirmation, and stent placement was carried out

where needed. The ERCP procedure took approximately

30 minutes. The Social Security Institution paid TL 284

for ERCP in 2010.

2.4. Statistics

Sensitivity, specifity, positive and negative predictive

values and total accuracy rates were used. P value was

calculated by using SPSS (SPSS Inc., v16.0, 2009, Chi-

cago, IL, USA). A P value of <0.05 was accepted as sig-

nificant.

3. Results

One hundred (58.5%) of the hundred and seventy one

patients were female and 71 (41.5%) were male. The

median age was 63 years (55 to 89). In nine patients

(5.26%) the ERCP procedure could not be carried out. In

six of these patients, the choledoch could not be cannu-

lated, and 3 had pyloric stenosis. There was no failure

during the MRCP procedures. The results of MRCP and

ERCP in diagnosing bile duct disorders are given in Ta-

bles 1 and 2.

Of the patients who had both MRCP and ERCP,

MRCP detected bile duct stones in 103, and ERCP de-

tected 102. Endoscopic sphincterotomy and stone extrac-

tion with ERCP were performed on these patients. Of the

32 (19%) patients diagnosed by MRCP, ERCP found 26

(15.20%) to have dilated bile ducts. However, neither

method was able to distinguish pathology to explain the

dilatation. ERCP detected tumors in 14 out of the 15

(8.77%) patients diagnosed by MRCP with tumors, and

biopsies were taken by ES. ERCP could not be per-

formed on one patient due to inability to access the duo-

denum because of pyloric stenosis.

The diagnosis of 4 of the 5 (2.92%) patients diagnosed

by MRCP was confirmed by ERCP. ES was performed,

and cystic vesicles and membranes removed. Four pa-

tients (2.33%) were diagnosed with bile duct stenosis,

two were treated with ES, and one with ES + balloon

dilatation. Stent placement was performed on one.

M. A. ERYILMAZ ET AL.

491

Table 1. MRCP and ERCP results of patients with bile duct disease.

MRCP n (%) ERCP n (%) P

Unsuccessful investigation 0 9 (5) 0.002

Normal bile ducts 6 (4) 5 (3) 0.759

Bile duct stone 103 (60) 102 (59) 0.912

Bile duct dilatation (distal stenosis) 32 (19) 26 (15) 0.387

Bile duct tumor 15 (9) 14 (8) 0.846

Bile duct cystic disease 5 (3) 4 (2) 0.736

Bile duct stenosis 4 (2) 3 (1.7) 0.703

Bile duct inflammatory disease 2 (1.5) 4 (2) 0.410

Others 4 (2) 4 (2) 1

TOTAL 171 (100) 171 (100)

Table 2. Sensitivity test for MRCP.

Positive predictive

value

Negative predictive

value

Sensitivity

(%)

Specifity

(%)

Total accuracy

(%)

Bile duct stone 0.79 0.89 92 74 83

Bile duct tumor 0.80 0.98 85 98 92

Bile duct cystic disease 0.80 1 100 99 99

Bile duct stenosis 0.75 1 100 99 99

Complications developed in 5 (2.92%) of the cases

that underwent stone extraction with ERCP. Two patients

suffered duodenum perforation. Sphincteroplasty and

primary repairs of the perforation were carried out

through open surgery in one case. The other case recov-

ered through conservative treatment. One patient devel-

oped hemorrhage, another developed pancreatitis. Both

recovered through conservative treatment. The stone

basket compacted in one patient. Both the basket wire

and the stone were extracted with open surgery. Neither

technique gave rise to mortality.

It was observed that ERCP and MRCP led to similarly

accurate diagnoses, and there was no significant differ-

ence between the two techniques (P > 0.05) (Tables 1 and

2).

4. Discussion

MRCP is an important diagnostic tool for biliary pa-

thologies [4]. ERCP is an invasive procedure, and is used

for treatment rather than diagnosis [3,5]. The diagnosis

determined by MRCP can be confirmed by ERCP and/or

surgical methods. In our study, 171 of the 655 patients

that underwent MRCP underwent ERCP with the possi-

ble necessity of endoscopic treatment in mind. MRCP

defined stones in the bile ducts of 103 patients. ERCP

confirmed the presence of stones in 102 of those patients.

ES and stone extraction were performed. In one patient,

the choledoch could not be cannulated due to diverticula

in the duodenum. ES was performed on 14 patients that

ERCP showed to have bile duct stenosis due to tumors,

and biopsies were taken. In one case where a tumor in

the papilla was observed along with stones, ES + stone

extraction and biopsy were performed with ERCP. In one

case, stent placement was performed to ensure bile flow

(Table 1).

There are various studies investigating the sensitivities,

specifities and precision of MRCP and ERCP in deter-

mining the pathologies of the bile ducts. In a prospective

study by M. G. Scaffidi, et al., MRCP and ERCP results

in determining choledoch stones were compared, and

MRCP’s sensitivity was found as 88%, specifity as 72%,

and diagnostic accuracy as 83% [6]. In the study carried

out by Lopez Hanninen, et al., on 66 patients, the sensi-

tivity of MRCP in showing tumoral lesions of the bile

ducts was reported as 83%, its specifity as 96% and di-

agnostic accuracy as 90% [7]. In our study, in concor-

dance with literature, the sensitivity of MRCP in identi-

fying bile duct stones was determined as 92%, its speci-

fity as 74%, diagnostic accuracy as 83%, and in identi-

fying tumoral lesions, its sensitivity as 85%, specifity as

98% and diagnostic accuracy as 92% (Table 2).

Stenosis may develop in bile ducts due to prior surgery or

M. A. ERYILMAZ ET AL.

492

to primary sclerosing cholangitis. According to literature,

MRCP’s sensitivity in showing the localization and length

of the stenosis is 100% its specifity is 91%, and diagnos-

tic accuracy is 95% [8]. Our study results are similar. In

this field, we found MRCP’s sensitivity to be 100%,

specifity, 99% and diagnostic accuracy, 99%.

Bile duct obstruction due to hydatic cysts opening into

the bile duct can be seen in 5% - 25% of patients. ERCP

and ES are one of the treatment methods [9]. In our study,

hydatic cyst lesions opening into the bile duct were iden-

tified in 4 (2.33%) patients. ES was performed by ERCP,

and the vesicles and membranes of the cyst were re-

moved. In our study, the sensitivity of MRCP was deter-

mined as 100%, specifity as 99%, and diagnostic accu-

racy as 99%. There was no significant difference be-

tween MRCP and ERCP (P > 0.05).

Stones that are smaller than the section thickness of

the MR device may give false negative results, and in

patients where there is a gap of more than 72 hours be-

tween the MRCP and the ERCP, although MRCP has

indicated stones, ERCP may not find stones due to their

spontaneous passing [10]. In such cases, ES is a thera-

peutical procedure [11]. In our study, 32 patients by

MRCP and 26 patients by ERCP were detected to have

dilated bile ducts that could not be explained by any ob-

structive pathology such as stones or tumors, and ES was

performed.

MRCP and diagnostic ERCP were compared for cost

effectiveness through a literature scan over 28 articles by

Kaltenthaler et al., and it was decided that MRCP was

more economical [12]. In our study, it was determined

that the cost of one MRCP event cost TL 65, while one

ERCP event cost approximately TL 284.

Even in experienced hands, ERCP has a cannulation

failure rate of up to 3% - 9% [13]. In our study, it has

been observed that ERCP didn’t give satisfactory results

in 5.26% of the cases. ERCP, considered a reference

method presently, is accepted to have a morbidity rate of

0.8% - 10% [14]. Morbidity was 2.92% in our study. In

one case where a bile duct stone was detected, the mor-

bidity was due to basket compaction. Two cases had

perforations, one had a hemorrhage and one had pa-

creatitis. T. Obana et al., have observed no mortalities

connected to the ERCP procedure [15]. However, low

that it may be, ERCP has a mortality rate of 0.7% - 0.9%

[16]. There were no mortalities in our study.

Our study has shown the ERCP procedures which are

routinely carried out by gastroenterologists can be carried

out successfully by experienced General Surgeons. 10%

of the MRCPs and 5% of the ERCPs carried out in our

country in the beginning of the 2000s were optimally

successful [11]. In the 2010 plus years, MRCP can be

carried out on all cases where clinicians deem it neces-

sary without the need for sedation, and ERCP is carried

out with success rates of up to 95% (Table 1).

Our study has some shortcomings. While MRCP was

carried out on all patients with bile duct pathologies, se-

lected patients underwent ERCP. ERCP and MRCP were

not carried out on the same day. The diagnosis reached

with MRCP was confirmed with ERCP. Surgery was

performed in cases where ERCP was unsuccessful. In our

country, the cost of MRCP and ERCP are based upon the

unit price paid by the social security institution, and may

differ from other countries.

5. Conclusion

In the identification of bile duct pathologies, MRCP has

accuracy values near to that of ERCP. It is approximately

four times more economical, and takes far less time.

Therefore, MRCP should be used for diagnosis, and

ERCP should be performed for treatment, if necessary.

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