Original article
Diagnostic Accuracy of Magnetic Resonance and Endoscopic Retrograde Cholangiography in Primary Sclerosing Cholangitis

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Background & Aims: To evaluate the accuracy and interobserver variability of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiography (ERC) in the diagnosis of primary sclerosing cholangitis (PSC). Methods: MRC at 1.5 T with thin- and thick-slice breath-hold technique was performed in 66 adult patients (median age, 44 y; 26 women) with an appropriate spectrum of hepatobiliary diseases. Maximum intensity projection images were reconstructed from the thin slices. ERC was performed within 48 hours of the MR examination. The reference standard of PSC diagnosis was based on a combination of clinical features and cholestatic biochemical profile with typical ERC and/or MRC abnormalities and supported by liver histology findings. Two independent reviewers who were unaware of final diagnoses analyzed all images retrospectively. Results: PSC was diagnosed in 39 (59%) of 66 patients. MRC provided comparable and poorer depiction than ERC of extrahepatic and intrahepatic ducts, respectively. However, the diagnostic accuracy of ERC and MRC were comparable. In the MRC detection of PSC, the average sensitivity of 2 independent readers was 80%, the specificity was 87%, and the accuracy was 83%. The corresponding values for ERC were a sensitivity of 89%, a specificity of 80%, and an accuracy of 85%. Interobserver agreement for the diagnosis of PSC was good (κ = .61) for MRC and excellent (κ = .81) for ERC. Conclusions: PSC can be diagnosed with high accuracy and good interobserver agreement. MRC and ERC performed equally well in the diagnosis of PSC when used blinded to clinical information.

Section snippets

Patients

From December 2001 through December 2003, there were 70 patients with liver and/or biliary diseases who underwent MRC and ERC at our tertiary care center. All patients provided informed consent at the time of entry and the study was approved by the institutional review board. As a national transplantation center and with PSC being the most frequent indication for hepatic transplantation in Norway, the gastroenterology section of the medical department in our university hospital traditionally

Depiction

Breath-hold was adequate for MIP reconstruction in 49 (74%) of 66 patients. MRC provided comparable and poorer depiction than ERC of extrahepatic and intrahepatic ducts, respectively (Table 2, Table 3). MRC was superior to ERC in depicting the gallbladder. At MRC, there was a sharp decrease in the number of examinations with excellent or good depiction from first- to second-order ducts (from 62% to 35% of examinations, Table 3), which decreased further to 8% and 3% for third- and fourth-order

Discussion

Although accepted as the gold standard of diagnosing PSC, ERC may result in false-positive and false-negative diagnoses. PSC-like cholangiographic appearance of the intrahepatic bile ducts may be seen, for example, in some cases of cirrhosis.2 False-negative diagnosis at ERC may be related to inadequate opacification of the intrahepatic ducts and subtle changes therefore may be overlooked. This was the case in 2 patients with long-duration PSC in our study because of inadequate filling of

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