Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography

Hindawi Surgery Research and Practice Volume 2018, Article ID 5216089, 5 pages https://doi.org/10.1155/2018/5216089 Research Article Detection of Common Bile Duct Stones in Mild Acute Biliary Pancreatitis Using Magnetic Resonance Cholangiopancreatography David Aranovich ,1,2 Veacheslav Zilbermints,1,2 Natalia Goldberg,2,3 and Oleg Kaminsky1,2 1 Department of General Surgery, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel Affiliated with Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel 3 Department of Diagnostic Radiology, Beilinson Hospital, Rabin Medical Center, Petach-Tikva, Israel 2 Correspondence should be addressed to David Aranovich; Received 9 June 2018; Revised 19 September 2018; Accepted 4 October 2018; Published 22 October 2018 Academic Editor: Cosimo Sperti Copyright © 2018 David Aranovich et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. All patients with mild acute biliary pancreatitis should undergo early cholecystectomy. Whether routine common bile duct (CBD) imaging should be employed before the surgical procedure in these patients is a matter of current controversy. The aim of this study was to investigate the rate of detection of CBD stones using magnetic resonance cholangiopancreatography (MRCP) at different time intervals from admission. Methods. From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis underwent MRCP. Fifty-six (n � 56) of them with mild biliary pancreatitis met the study criteria. The patients were divided into two groups. Group A did not have stones in the CBD (n � 45), and Group B had stones in the CBD (n � 11). The time from admission to MRCP was divided into several periods (day 1 through day 180), and the presence of the CBD stones on MRCP was weighted against remoteness from admission. Liver chemistry profiles were compared between the groups on admission and before the MRCP. Results. The cumulative rate of choledocholithiasis was 19.7% (Group B, n � 11). Forty-five patients (Group A, n � 45, 80.3%) did not have gallstones in the CBD. Eight patients with choledocholithiasis (8/56, 14.2%) were detected during the first 10 days from admission out of 27 patients. In patients who underwent MRCP between days 11 and 20, choledocholithiasis was found in two patients (2/56, 3.5%) and in one patient between days 21 and 30 (1/56, 1.8%). No stones were found in patients who underwent MRCP beyond 30 days from admission. Liver chemistry profiles did not show a significant difference in both groups. CBD dilatation was observed at presentation in 11 patients (n � 11/56), 6 in Group A (6/45, 13.3%) and 5 in Group B (5/11, 45.5%) (p � 0.016). Conclusions. Routine CBD evaluation should be encouraged after mild acute biliary pancreatitis. Early performance of MRCP gives high yield in selecting the patients for endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy. A liver chemistry profile either on admission or before MRCP cannot predict the presence of CBD stones. 1. Introduction The passage of gallstones from the gallbladder through the common bile duct (CBD) into the duodenum has been implicated in the pathophysiology of acute biliary pancreatitis [1]. Most patients with acute biliary pancreatitis experience a rather mild course of the disease, with typical abdominal pain and transient elevation in liver function test (LFT) results and pancreatic enzyme levels [2]. Knowledge on the common bile duct (CBD) clearance in any symptomatic gallstone-related condition is anticipated before removal of the gallbladder. However, the event of stone passage and spontaneous CBD clearance is uncertain, even following complete clinical recovery and biochemical resolution of acute biliary pancreatitis. Our policy is to perform CBD evaluation with magnetic resonance cholangiopancreatography (MRCP) or intraoperative cholangiography (IOC) before elective cholecystectomy for acute 2 biliary pancreatitis. MRCP is commonly performed either during index hospitalization or on an outpatient basis, depending on the availability of the MRCP. The same admission cholecystectomy is recommended in patients with mild biliary pancreatitis, which shows satisfactory recovery with conservative treatment. Nevertheless, the same admission surgery is not always implemented because of operating room availability or patients’ preferences. Thus, many patients are discharged home upon recovery and scheduled for elective procedures later on. This less favorable situation creates a subset of patients recovered from an initial episode of mild biliary pancreatitis on the one hand, but with an uncertain risk of choledocholithiasis on the other hand. We prefer to screen these patients with MRCP for occult choledocholithiasis prior to cholecystectomy at any time interval and irrespective of the liver chemistry profile. The purpose of this study was to evaluate the rate of choledocholithiasis detection using MRCP, after mild biliary pancreatitis, across different time intervals after index admission and to compare liver chemistry profiles on admission and before MRCP in patients with and without choledocholithiasis. 2. Methods The study was approved by the Institutional Review Board of the Rabin Medical Center, protocol number 0731-16-RMC. Medical records were extracted from the hospital’s electronic database system. Patients with acute biliary pancreatitis were identified using the ICD-9 code. The procedure code for MRCP was combined with the ICD code for acute pancreatitis in the computer search algorithm to select those patients who underwent MRCP prior to cholecystectomy. From January 1, 2011, through December 31, 2016, 72 patients with acute biliary pancreatitis who underwent preoperative CBD evaluation using MRCP were identified. The diagnosis of acute biliary pancreatitis was based on clinical grounds, namely, upper abdominal pain, abdominal tenderness, and elevated levels of bilirubin, transaminases (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)), alkaline phosphatase (ALKP), amylase, lipase, and the visualization of gallstones using abdominal ultrasonography [3]. Patients with mild acute biliary pancreatitis were selected from the records by the absence of organ failure and local or systemic complications and a Ranson’s score of less than three [4]. Patients with severe pancreatitis, one or more organ failures, or documented pancreatic necrosis were excluded from the study (n � 16). Based on these criteria, we selected for retrospective analysis 56 patients with mild acute biliary pancreatitis, who underwent MRCP before planned cholecystectomy. All patients made an uneventful recovery and were scheduled for cholecystectomy. The patients selected for the study were asymptomatic between the episode of (...truncated)