Paediatric MRCP: 10 year experience with 195 patients

Patient- and Examination-Related Predictors of 3D MRCP Image Quality in Children

BACKGROUND. MRCP provides noninvasive imaging of the biliary tree and pancreatic duct. In our experience, MRCP image quality is commonly suboptimal in children. OBJECTIVE. The purpose of this study was to characterize the frequency of nondi-agnostic 3D fast spin-echo (FSE) MRCP acquisitions and determine predictors of nondi-agnostic MRCP image quality in children. METHODS. This retrospective study included 200 randomly selected pediatric patients (101 female and 99 male patients; mean age, 11.7 years) who underwent MRCP between January 1, 2019, and December 31, 2020. Patient- and examination-related variables were recorded. Three fellowship-trained pediatric radiologists independently reviewed 3D FSE MRCP acquisitions for diagnostic quality (diagnostic vs nondiagnostic) and overall image quality score on a scale from 1 to 5 (1 = worst image quality imaginable, 5 = best image quality imaginable). After computing interreader agreement, analyses used readers' most common diagnostic quality assessment and mean image quality score. Multivariable logistic regression and linear regression analyses were used to identify predictor variables of a diagnostic examination and higher image quality score. RESULTS. Interreader agreement for an MRCP acquisition being diagnostic quality, expressed as a kappa coefficient, was 0.53-0.71; interreader agreement for image quality score, expressed as an intraclass correlation coefficient, was 0.68-0.74. A total of 36 of 200 (18%) MRCP acquisitions were nondiagnostic; the mean image quality score was 3.5 ± 1.1 (SD). Multivariable predictors of a diagnostic MRCP acquisition included greater body mass index (OR = 1.11 [95% CI, 1.02-1.21]; p = .02), scanner field strength of 1.5 T (odds ratio [OR] = 2.87 [95% CI, 1.23-6.68]; p = .01), and presence of acute pancreatitis (OR = 4.91 [95% CI, 1.53-15.77]; p = .008). Multivariable predictors of a higher image quality score (β = 0.05-0.94) included older age (p = .01), imaging performed with patient under sedation or general anesthesia (p < .001), presence of biliary dilatation (p = .004), and inpatient status (p = .02). A lower image quality score was predicted by a scanner field strength of 3 T (β = -0.61; p < .001). A greater amount of time between the start of the MRI examination and the MRCP acquisition exhibited a nonsignificant association with a decrease in the image quality score (p = .06). CONCLUSION. Pediatric MRCP acquisitions are commonly nondiagnostic. Patient-specific and technical factors systematically impact MRCP image quality in children. CLINICAL IMPACT. Recognition of image quality predictors that are potentially modifiable and amendable to proactive intervention can guide efforts to optimize MRCP image quality in children.

Cutting edge issues in juvenile sclerosing cholangitis

Sclerosing cholangitis (SC) is a rare chronic disorder characterised by inflammation and progressive obliterative fibrosis of the intrahepatic and/or extrahepatic bile ducts. Diagnosis is based on cholangiogram showing bile duct dilatation, narrowing and obliteration of the biliary tree, and histologically, on the presence of inflammatory bile duct damage leading to periductal fibrosis. In children the most common SC is associated with strong autoimmune features, overlapping with those of autoimmune hepatitis (AIH); this form is known as autoimmune sclerosing cholangitis, ASC. Conversely, primary SC (PSC), a condition in which the term "primary" indicates that aetiology and pathogenesis are unknown, is rare in paediatrics. Secondary SC (SSC) defines a cholangiopathy associated with an identifiable aetiology such as immunodeficiencies, infections or haematological disorders. ASC and PSC are strongly associated with inflammatory bowel disease (IBD). ASC responds biochemically well to immunosuppressive drugs and ursodeoxycholic acid (UDCA). Primary forms are exclusively managed with oral UDCA, while in the secondary forms the medical treatment depends on the underlying aetiology. Despite treatment, SC often progresses to biliary cirrhosis and end-stage liver disease requiring liver transplantation. The disease can recur after transplant. Better understanding of pathogenic mechanisms and better treatment modalities are needed to improve the prognosis of this invalidating hepatic disorder.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children

Gastrointestinal endoscopy is fundamental to diagnostic and therapeutic procedures in pediatric gastroenterology. In the decades since endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) for hepatobiliary and pancreatic disease were introduced into clinical practice, there has been increasing interest in these procedures, and practice guidelines and position papers that clearly define the role of ERCP and EUS in children have been published. Based on the distinction of endoscopy between children and adults, this review focuses on the current state of ERCP and EUS procedures in children, including the types of endoscopes used in children, general anesthesia and radiation exposure, biliary and pancreatic indications, considerations of education and training for ERCP and EUS procedures in children, and expectations for development of endoscopes for children.

Autoimmune sclerosing cholangitis: Evidence and open questions

Juvenile sclerosing cholangitis is a rare chronic hepatobiliary disorder characterized by inflammation of the intra- and/or extrahepatic bile ducts, bile duct dilatation, narrowing and obliteration, and, histologically, by inflammatory bile duct damage leading to periductular fibrosis. The diagnosis is based on endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. In children, it may be associated to a variety of systemic and hepatic conditions: thus, the term "primary" sclerosing cholangitis should be reserved for the rare cases without a known cause. Small duct disease is diagnosed in the presence of histological features diagnostic of sclerosing cholangitis and normal cholangiography. Autoimmune sclerosing cholangitis (ASC) is a form of sclerosing cholangitis with strong autoimmune features overlapping with those of autoimmune hepatitis (AIH). It is a well-recognized nosological entity in paediatrics, where it accounts for the majority of sclerosing cholangitis cases. It is as prevalent as AIH in children, is equally frequent in males and females, half of the patients have concomitant inflammatory bowel disease, virtually all patients have raised immunoglobulin G levels and positive anti-nuclear and/or anti-smooth muscle antibodies. Half of the ASC patients respond well to standard immunosuppressive treatment for AIH with the addition of ursodeoxycholic acid, but the transplant rate is higher than in AIH, and post-transplant recurrence is frequent. A number of open questions remain: are ASC and AIH distinct entities or different manifestations of the same condition? What is the role of histology? Is small duct disease a specific entity? What is the relationship between ASC and adult primary sclerosing cholangitis? What is the role of inflammatory bowel disease? In addition, validated diagnostic criteria for ASC are needed.

Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline

This guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and of the European Association for the Study of the Liver (EASL) on the role of endoscopy in primary sclerosing cholangitis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations.

Paediatric Gastrointestinal Endoscopy: European Society for Paediatric Gastroenterology Hepatology and Nutrition and European Society of Gastrointestinal Endoscopy Guidelines

This guideline refers to infants, children, and adolescents ages 0 to 18 years. The areas covered include indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileocolonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangiopancreatography; and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease has been dealt with in other guidelines and are therefore not mentioned in this guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this.

Pancreatic duct stenosis: Differential diagnosis between malignant and benign conditions at secretin-enhanced MRCP

PURPOSE

To define imaging criteria of benign and malignant nature in patients with main pancreatic duct (MPD) stenosis.

MATERIALS-METHODS

S-MRCPs of 35 patients with pancreatitis and 14 with adenocarcinoma were evaluated.

RESULTS

Adenocarcinoma caused higher prevalence of complete stenosis (14/14-100% vs 17/35-49%), dilated side-branches (14/14-100% vs 18/35-51%) and lower prevalence of duct-penetrating sign (0/14-0% vs 31/35-89%). The number of stenoses was higher in benign conditions (mean 1.4 Vs 1). Upstream MPD diameter was higher in cancer-induced stenoses (4.5 vs 2.9mm).

CONCLUSIONS

Single complete stenosis with dilated side branches, increased MPD caliber and absent duct-penetrating sign are suggestive of malignancy.

Acute Pancreatitis in Pediatric Patients: Demographics, Etiology, and Diagnostic Imaging

OBJECTIVE

The objective of this article is to provide updates on acute pancreatitis in children regarding the imaging findings, causes, and complications based on a review of the current studies in the pediatrics literature. We discuss the epidemiology of acute pancreatitis, the role of imaging and imaging findings in the diagnosis of acute pancreatitis, and the causes and complications of acute pancreatitis.

CONCLUSION

The incidence of acute pancreatitis is increasing in children. Imaging plays an important role in the diagnosis of acute pancreatitis because imaging findings can be used to establish the cause of acute pancreatitis, evaluate for complications of acute pancreatitis, and possibly predict the course of the disease.

Characteristics of Pediatric Pancreatitis on Magnetic Resonance Cholangiopancreatography

Pediatric pancreatitis is not uncommon and results in considerable morbidity and mortality in the affected children. Unlike adults, pediatric pancreatitis is more frequently associated with underlying structural abnormalities, trauma, and drugs rather than an idiopathic etiology. Magnetic resonance cholangiopancreatography (MRCP) is a good imaging modality for evaluating pancreatitis and determining etiology without exposure to radiation. This article focuses on MRCP findings associated with various causes of pancreatitis in children, particularly structural abnormalities of the pancreaticobiliary system, as well as describing the feasibility, limitations, and solutions associated with pediatric MRCP.

Increasing occurrence of choledochal malformations in children: a single-center 37-year experience from Finland

OBJECTIVE

Few reports on choledochal malformations (CMs) in European populations exist.

MATERIALS AND METHODS

The medical records of pediatric CM patients managed in our nationwide referral center for pediatric hepatobiliary surgery between 1976 and 2013 (n = 38; 71% females) were reviewed.

RESULTS

Over follow-up time, the relative proportion of fusiform CMs increased significantly (p = 0.007) and the estimated total incidence rose from 1:128,000 to 1:38,000 (p = 0.017). Cystic CMs (42%) presented at younger age than fusiform CMs (47%) (0.8 vs. 4.6 years, p = 0.001). Two-thirds had abdominal pain and half were cholestatic at presentation. Pancreatitis had occurred in 16%. In addition to ultrasound, 71% underwent magnetic resonance cholangiopancreatography and 39% underwent endoscopic retrograde cholangiopancreatography. Median CM dilatation was 15 (10-28) mm and a 12 (9-13) mm long common pancreaticobiliary channel was confirmed in 61%, increasingly during recent years. Intrahepatic biliary tree was dilated in 19%, whereas main ducts were dilated in 50%. Apart from two operated in the 1970s and one with choledochocele, patients underwent resection of extrahepatic bile ducts with Roux-en-Y hepaticojejunostomy at age of 4.2 (0.8-9.2) years. Postoperative bile leakage and hemorrhage required reoperations in two. At last follow-up 4.8 (1.3-13.2) years postoperatively, none had dilated intrahepatic biliary ducts or elevated plasma bilirubin (5 [3-7] µmol/l). Single cholangitis episodes had occurred in two, whereas others were asymptomatic.

CONCLUSION

CM incidence has increased significantly in Finland, being currently over threefold higher than previous estimates in the Western world would suggest. Removal of the extrahepatic biliary tree with hepaticojejunostomy for type I and IV CMs yielded excellent results.