1

ABSTRACT DIAGNOSTIC DISEASE ACCURACY OF COMPUTED EVALUATION TOMOGRAPHY WITH (CT) IN

DETECTING THE CAUSE OF OBSTRUCTION IN BILIARY OBSTRUCTIVE COMPARATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

Statement of the Problem The study aims to assess the accuracy of CT in detecting the cause of obstruction in biliary obstructive disease in comparison with ERCP. Specifically the study sought the answers to the following questions: 1. What is Computed tomography ? 2. What is endoscopic retrograde cholangiopancreatography? 3 .What is diagnostic accuracy of CT in detecting causes of biliary obstructive disease compared with ERCP in terms of : a. Sensitivity b. Specificity c. Detection accuracy

Methodology The study employed semi-systematic literature review was employed in the study. An electronic search was performed using a wide range of data base in order to obtain the information for the progress of the study. Each study was carefully reviewed for their content and relevance to present investigation.

Summary of Findings 1.What is Computed Tomography (CT) CT or computed tomography is a diagnostic imaging procedure that uses x-rays to obtain cross-sectional images. It is a non-invasive procedure that aid in the correct diagnosis of biliary obstructions among others. Among the risks in CT procedure to patients are possible allergy from contrast agent used in some cases and lifetime exposure to radiation adverse health effects like hair loss, skin injury among others. 2. What is Endoscopic retrograde cholangio pancreatography (ERCP). Endoscopic retrograde cholanagiopacreatography is both a diagnostic and therapeutic tool. Endoscopic refers to a thin, flexible tube with a tiny video camera and light at the end, while retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. ERCP is an invasive diagnostic modality indicated in detecting biliary obstructions.

3 .What is accuracy rate of CT in detecting causes of biliary obstructive disease compared with ERCP ? a. Sensitivity

Except with two studies the sensitivity rate of ERCP is consistently higher compared with that of CT rate in detecting obstructive jaundice, biliary strictures, common bile duct stones, choledochal stones and pancreatitis.

b. Specificity Studies have shown that ERCP is superior to CT specificity-wise in detecting causes of obstruction biliary strictures, jaundice and common bile duct stones, but is out-performed in one case that involves detection of pancreaticobiliary.

c. Detection Accuracy

In all biliary obstructions examined by four studies indicate that only choledochal cysts, bile duct injury had CT in equal footing with ERCP. But detecting gallbladder stones, intrahepatic bile duct stones except with 1 study; choledocholithaiasis, pancreatobiliary tumor, gallbladder carcinoma; pancreatic head carcinoma, bile papilla carcinoma and chronic pancreatic, CT remains inferior to ERCP.

Conclusions 1. Computed tomography is a non-invasive diagnostic imaging procedure that aided diagnosis and detection of some biliary obstructions. 2. Endoscopic retrograde cholangiography is an invasive diagnostic imaging tool and therapeutic instrument for diagnosing and detecting biliary obstruction.

3. In comparison between CT and ERCP, CT has

lower sensitivity rate

compared to ERCP in detecting biliary obstructions like choledochal stones, obstructive jaundice, biliary strictures; common bile duct stones and biliary pancreatitis. 5. In terms of specificity ERCP is found superior among diagnostic imaging modalities including CT. Only 1 studies had found out that CT has 100% specificity in detecting pancreatico biliary as against 91.7% of ERCP . The rest the studies showed that ERCP remains superior with CT in terms of specificity rate in detecting obstructive jaundice, biliary strictures and common bile duct stones. 6. In terms of detection accuracy, studies reviewed indicated the consistently high accuracy rates of ERCP over CT.

Recommendations The researcher recommends local studies on the clinical values of different diagnostic imaging tools in view of rising cases of obstructive biliary disease in the country.

CHAPTER I THE PROBLEM AND ITS BACKGROUND

Introduction In any type of disease exact diagnosis is essential for proper medical management and treatment. This is very important especially when the presenting symptoms need immediate attention and could endanger the life of the patient. There are diseases that could not be detected or diagnosed by auscultation alone. Different diagnostic imaging modalities are used for accurate diagnosis of diseases. These tools are used in examining diseases in the internal organs. Diagnostic imageological tools are either invasive or non-invasive types. Sometimes both types are used when initial diagnosis is doubtful. These tools greatly aid in the diagnosis of internal organs like the bile duct. Bile duct is any of a number of long tube-like structures that carry bile. Bile is required for the digestion of foods is excreted by the liver into passages carrying it toward the hepatic duct which joins with the cystic duct to form the common bile duct that opens into the intestine. The biliary tree is the whole network of various sized ducts branching through the liver (www.wikipedia.com). Several problems and abnormalities can arise from the bile

ducts. There are many causes of biliary obstruction. In recent years saw a rapid and continuous evolution in the diagnosis of biliary obstructive disease (Ferrari, 2005). These tools include invasive and non-invasive types. These include traditional

methodologies such as ultrasonography (US); computed tomography (CT), endoscopic

retrograde

cholangiopancreatography

(ERCP),

percutaneous

transhepatic

cholangiography) magnetic resonance cholangiopancreatogaphy (MRCP) and other modalities which are improvement of the existing ones. In this study, the focus of interest lies between computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP). The main objective of the study is to assess the diagnostic accuracy of CT in detecting causes of biliary obstructive disease compared with ERCP. Conceptual Framework Diagnostic tests and examinations are used to confirm, exclude or classify the location, severity, size, shape or other clinically meaningful subgroups of disease in order to guide treatment, indicate prognosis or monitor progress. These tests are also indicated in cases when clinical history and examination provide insufficient information to distinguish a disease/s from a set of candidate diseases (differential diagnoses) or to plan management. The results of these tests may lead to a decision threshold for a given diagnosis or it may lead to further testing. In the case of biliary obstruction, clinical decision-making is particularly complex, due to the wide range of differential diagnoses including pancreaticobiliary disease that may need to be considered and the potentially high penalty of delayed treatment if the cause is not detected in a timely fashion (MSAC,2005). In making diagnosis concerning biliary obstructive disease, there are a number of diagnostic modalities available that includes CT and ERCP. Determining the However,

outcomes of the results of these test predetermined the health outcomes.

the outcomes depends on the accuracy of the test results with reference to sensitivity,

specificity, and accuracy of detection. In the study, rate of sensitivity, specificity, level of detection are predictors of accuracy of diagnosis of causes of biliary obstruction.

Statement of the Problem The study deals with an evaluation of diagnostic accuracy CT in detecting causes of biliary obstructive disease in comparison with ERCP. Specifically, the study aims to answer the following questions: 1. What is Computed tomography ? 2. What is endoscopic retrograde cholangiopancreatography? 3 .What is diagnostic accuracy of CT in detecting causes of biliary obstructive disease compared with ERCP in terms of : a. Sensitivity b. Specificity c. Detection accuracy

Significance of the Study Accurate diagnosis is essential in making informed decisions about the therapy and treatment of diseases. The cost of wrong diagnosis is very high and at extreme fatal for the patients and devastating for the doctors and the institutions. In the case of diagnosing biliary obstruction, several imaging tools or modalities are available to aid the doctors to come up with the correct and accurate diagnosis. The results of the tests predetermined the outcome of the treatment. Computed tomography and endoscopic

retrograde cholangiopancreatography are but two of the diagnostic tools in detecting biliary obstruction and causes. Understanding the clinical value of each type will

increase the readers knowledge and help doctors decide which of the two type will be effective in making informed clinical decisions regarding the patients conditions which ultimately benefit the patients. Hence, the significance of the study.

Definition of Terms These terms are used in the study. For clarity and appreciation of the present study, these terms are defined: Computed Tomography (CT). In the study refers to both plain and improved typed OF diagnostic imaging tool in detecting biliary obstruction. It is a cross-sectional representation of anatomy that is constructed by a computer from the signals generated by x-ray beams passing through the body from different directions (MASC,2005). Diagnostic accuracy. As used in the study refers to the correctness of the results of the tests using CT and ERCP. Endoscopic retrograde cholangiopancreatography (ERCP). It is another

diagnostic tool for detecting biliary obstruction. It is an invasive tool that can also be used for therapeutic intervention (MASC,2005). Negative predictive value. It refers to the proportion of patients with negative test results who are correctly diagnosed (www.wikipedia.com). Positive predictive value. Defined as proportion of patients with positive test results who are correctly diagnosed (www.wikipedia.com).

Sensitivity. One of the predictors of diagnostic accuracy refers to how many cases of a disease a particular test can find (Boring 1990). Specificity. Another diagnostic accuracy predictors in the study, refers to how accurately it diagnoses a particular disease without giving false positive results.

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CHAPTER II REVIEW OF RELATED LITERATURE AND STUDIES

Related Literature The following is extracted from an assessment report prepared by the Medical Service Advisory Committee of Australia that is found relevant to the present study on accuracy of detection of diagnostic imaging modalities such as computed tomography (CT) and endoscopic retrograde cholangeopancreatography (ERCP).

Normal function of the bile ducts and pancreas

Bile is a liquid produced by the liver that contains bile salts, cholesterol, lipids and waste products, such as the pigment bilirubin. It is needed for the digestion and absorption of fats and fat-soluble vitamins. The normal function of the bile ducts is to transport bile from the liver to the gallbladder, where it is stored and concentrated, and then it is released into the duodenum where it aids digestion. The bile is transported from the gallbladder to the duodenum via the common bile duct through the valvular opening of the sphincter of Oddi at the ampulla of Vater. After eating, the entrance of fat or protein into the small intestine triggers the secretion of a hormone called cholecystokinin, which stimulates contraction of the gallbladder and the opening of the sphincter of Oddi so that bile may pass into the duodenum. The pancreas is a small gland that lies behind the stomach and is surrounded by the intestines and liver. Normal function of the pancreas is essential for the production

11

of hormones such as glucagon and insulin that are released into the blood stream to regulate blood glucose levels as well as enzymes that are released into the duodenum for digestion. The pancreas also produces digestive enzymes and these enter the duodenum from the pancreatic duct via the Ampulla of Vater to aid digestion.

Diseases associated with obstruction of the bile or pancreatic ducts Pancreaticobiliary diseases (not including patients with associated gallbladder disease) accounted for 19,552 hospital separations in Australia over the 12-month period from 2002-2003. As described on page 10, common clinical presentations where MRCP may be indicated include patients with symptoms or signs due to biliary obstruction as a result of bile duct stones or strictures due to cancer, inflammation or other benign causes. Surgical treatment for bile duct stones and localised benign strictures is often curative. If untreated, biliary obstruction can lead to fulminant infection (cholangitis) and death. Long-term obstruction can also lead to chronic liver disease.

Stones in the common bile duct Common presenting symptoms of bile duct stones are acute pain, jaundice and sometimes fever due to cholangitis (infection of the duct) with or without sepsis (Ko & Lee 2002). Bile duct stones may also be a cause of symptoms in patients who have had their gallbladder removed as described below.

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Post-cholecystectomy syndrome Post-cholecystectomy syndrome is a term used to describe the presence of symptoms following cholecystectomy, that can be attributed to the gallbladder or its removal. These symptoms include pain, nausea, vomiting and jaundice. In some cases, these patients require further investigation to exclude biliary causes including common bile duct stones.

Strictures of the bile duct Strictures of the bile duct may be due to malignancy or benign causes. Further imaging of the bile duct is indicated if ultrasound and CT scans are equivocal and may also be used to determine the extent of the stricture for disease staging and planning management .

Cancer of the pancreas Ductal adenocarcinoma is the most common type of pancreatic cancer. Common symptoms include jaundice, abdominal pain and weight loss. Primary cystic tumours are rarer and more likely to be identified in asymptomatic patients incidentally. Although rare, the detection and accurate differentiation between benign and malignant cystic tumours and the extent of disease are critical to plan appropriate treatment.

Cholangiocarcinoma Cholangiocarcinoma may arise in the bile ducts within the liver (intrahepatic, 10% of cases) or outside the liver (extrahepatic), including at the hepatic hilus. Incidence of

13

this uncommon cancer increases with age and the diagnosis is usually made in patients over 60 years of age presenting with jaundice and in some cases, abdominal pain, pruritus and weight loss. Early onset may occur in patients aged between 40 and 60 years with risk factors such as primary sclerosing cholangitis and choledochal cysts.

Cancer of the ampulla of Vater Ampullary cancer was the primary diagnosis at discharge for 278 patients hospitalised in Australia in 2002-2003 (Table 3). It presents with biliary obstruction but also may present with cholangitis or pancreatitis. The early detection of this disease and distinction from cancer of the pancreas or second part of the duodenum are important because management is different and early surgery can be curative..

Pancreatitis Pancreatitis refers to acute, chronic or relapsing inflammation of the gland. Typical symptoms are abdominal pain, jaundice, malaise and vomiting. Blood tests show raised pancreatic enzymes. The commonest causes of acute pancreatitis are gallstone obstruction of the pancreatic duct and alcohol abuse. It also occurs as a complication of ERCP. Recovery with supportive treatment is usually uneventful; however, in 10-15% of patients it can be complicated by a systemic inflammatory response and lead to pancreatic necrosis, which has a high mortality rate. Chronic pancreatitis is characterised by permanent damage to the gland. Treatment of chronic pancreatitis involves the management of pain and malabsorption due to insufficient pancreatic enzymes. In the long term, up to 50% of patients require

14

treatment of diabetes. Complications include inflammatory cysts (pseudocysts), pancreatic stones, pancreatic or biliary duct strictures, duodenal stenosis, portal hypertension and an increased risk of pancreatic cancer .

Related Studies Jang, Chong, and Kim (2010) studied the safety of performing ERCP in young children from Korea. The researchers concluded that ... diagnostic and therapeutic ERCPs were performed safely and effectively in Korean children for the management of various biliary and pancreatic diseases. Pediatricians and pediatric surgeons, especially those working in Asian countries, should become more familiar with ERCP as a diagnostic and therapeutic modality, as Asia has a high incidence of CCs and anomalous union of the pancreaticobiliary duct. According to Chong, Yin and Lim (2005) ERCP is a potentially life-saving intervention in the elderly population. Our study showed that ERCP is safe in the elderly Asian populations. In conclusion, our study showed that ERCP is safe in the elderly Asian population. Minor complications are usually transient and related to sedation, and mortality is usually related to severity of illness and underlying malignancies. ERCP should be considered when indicated in the elderly population as this may be life saving.

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CHAPTER III METHODOLOGY

Research Design The study is a qualitative literature review. It utilized relevant research that has been done on the same field. The results of these studies were extracted to obtain the relevant data necessary to answer the questions raised in the study.

Selection of the Studies Studies selected in the study are those that involved comparison of imaging modalities for detecting biliary obstruction that includes CT and ERCP. The studies selected includes all or any of the predictors used by the present study in making comparative evaluation of CT with ERCP. The present study employed a deliberate sampling of studies was based on the criteria that studies involves an assessment of different diagnostic imaging modalities for biliary obstructions that include CT and ERCP and that the assessment includes all or any of the predictors set for comparing and evaluation of both imaging modalities. Eleven studies qualified on the criteria set for inclusion in this research.

Data Gathering Procedure An electronic search was performed using a wide range of data base in order to obtain the information for the progress of the study. Each study was carefully reviewed for their content and relevance to present investigation. Twenty-five potential studies

16

were screened and initially assessed. Out of these 4 studies were rejected for the title; the abstract of the remaining 21 were screened and out of these 5 were rejected. The full content of the 16 studies were read and screened. Two studies were rejected. Fourteen selected were found potentially relevant and but 3 were rejected for quality. Finally eleven studies were selected and employed as primary source of data in the present research.

Data Analysis The data gathered from the studies selected in the study were assessed according to the criteria set in the present study. As previously mentioned studies must include an evaluation of diagnostic modalities for biliary obstruction that includes CT and ERCP. These studies must include all or any of the data on the rate of sensitivity, specificity, rate of positive and negative predictive values and rate of detection.

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CHAPTER IV PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

This chapter presents the results of the literature review on the diagnostic accuracy of CT in detecting causes of biliary obstruction in comparison with ERCP.

What is Computed Tomography (CT) CT is a diagnostic imaging procedure that uses x rays to obtain cross-sectional images of the body. Since its introduction and rapid adoption into medicine in the mid-1970s, CT has become recognized as a valuable medical tool for the diagnosis of disease, trauma, or abnormality and for planning, guiding, and monitoring therapy

(www.wiki.medpedia,com). 1. A motorized table moves the patient through a circular opening in the CT imaging system. 2. While the patient is inside the opening of the CT imaging system, an x-ray source and detector within the housing rotate around the patient. A single rotation takes about 1 second. The x-ray source produces a narrow, fan-shaped beam of x-rays that passes through a section of the patient's body. 3. A detector opposite from the x-ray source records the x-rays passing through the patient's body as a "snapshot" image. Many different "snapshots" (at many angles through the patient) are collected during one complete rotation.

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4. For each rotation of the x-ray source and detector, the image data are sent to a computer to reconstruct all of the individual "snapshots" into one or multiple cross-sectional images (slices) of the internal organs and tissues (like the biliary ducts). As in any diagnostic procedures, CT is not risk free. Among the main risks associated with CT ARE: 1. An increased lifetime risk of cancer due to x-ray radiation exposure. 2. Since the procedure in some cases involves use of contrast agent or dye, there is a possible allergic reactions or kidney failure. 3. The need for additional follow-up tests after receiving abnormal test results or to monitor the effect of a treatment on disease, such as to monitor a tumor after surgical removal. Some of these tests may be invasive and present additional risks. 4. Under some rare circumstances of prolonged, high-dose exposure, x-rays can cause other adverse health effects, such as skin reddening (erythema), skin tissue injury, hair loss, cataracts, and potentially, birth defects (if scanning is done during pregnancy). Radiation exposure is a concern in both adults and children. However, these concerns are greater for children because they are more sensitive to radiation and have a longer life expectancy than adults. As a result, accumulated exposures over a childs lifetime are more likely to result in an adverse health effect. A childs smaller size also has an impact on the radiation dose they receive. For example, if a CT scan is performed on a child using the same parameters as those used on an adult, an

19

unnecessarily large dose will be delivered to the child. CT equipment settings (exposure parameters such as, x-ray tube current, slice thickness, or pitch) can be adjusted to reduce dose significantly while maintaining diagnostic image .quality(www.hhs.gov.).

What is Endoscopic retrograde cholangio pancreatography (ERCP) The term endoscopic refers to the endoscope which is a thin, flexible tube with a tiny video camera and light on the end. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder. Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. The process of taking these X-rays is known as

cholangiopancreatography. Cholangio refers to the bile duct system, pancrea to the pancreas. ERCP is indicated for the following: Gallstones which are trapped in the main bile duct Blockage of the bile duct Yellow jaundice which turns the skin yellow and the urine dark Undiagnosed upper-abdominal pain Cancer of the bile ducts or pancreas Pancreatitis

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The main symptoms of pancreatitis are acute, severe pain in the upper abdomen, frequently accompanied by vomiting and fever. The abdomen is tender, and the patient feels and looks ill. The diagnosis is made by measuring the blood pancreas enzymes which are elevated. A sound wave test (ultrasound) or abdominal CT exam often shows an enlarged pancreas. The condition is treated by resting the pancreas while the tissues heal. This is accomplished through bowel rest, hospitalization, intravenous feeding and, pain medications. When pancreatitis is caused by gallstones, it is necessary to remove the gallbladder. This is usually done after the acute pancreatitis has resolved. At times, an ERCP (Endoscopic Retrograde CholangioPancreatography) test is recommended. This involves passing a flexible tube through the mouth and down to the small intestine. A small catheter is then inserted into the bile duct to see if any stones are present. If so, they are then removed with the scope (http://www. e-

radiography.net/technique/ercp/ercp.htm).

3 .What is accuracy rate of CT in detecting causes of biliary obstructive disease compared with ERCP ? a. Sensitivity In a study comparing CT and ERCP in pancreatibiliary disease, Tobin and his coauthors(2004) found CT to be superior than ERCP in terms of sensitivity having 100% sensitivity rate compared to 91.7 of the later. But in a study by Pasanen et al (1992) of diagnositic accuracy in diagnosis of choledochal stones, ERCP performed better with a sensitivity rate of of 80.6% compared to CTs 23.2%. Tobins et al. study involved only

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57 patients; while that of Pasanen et all consisted of 220 patients. Meanwhile in the study of Pasanen et al in diagnosis of cholestasis among 220, CT fared better with 97% compared with ERCP 89%.. Meanwhile in a study comparing with CT among others, Vipul and Dy, found out that in more than 3000 patients, ERCP performed better in diagnosing common bile duct stones with 79-93% sensitivity rate compared to CTs 7175% rate. On the other hand a study comparing diagnostic accuracy among different modalities including CT and ERCP in diagnosing biliary strictures, Rosch, et al (2002), ERCP has 85% sensitivity rate compared to CTs 77%. The study involved 50 patients. Pasanen, et al (1991) compared the diagnostic accuracy in obstructive jaundice of CT and ERCP among others in 187 jaundiced patients. The results indicate that the

sensitivity rate of ERCP is greater at 87% than CTs 77%. In the study of Jong, et al (2002) ERCP pancreatitis. exhibited 90% sensitivity compared to only 40% of CT in biliary

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TABLE 1. STUDIES COMPARING CT AND ERCP IN TERMS OF SENSITIVITY Sensitivity Study No. of Patients Biliary Obstruction CT (%) ERCP (%)

Tobin,Vogetzang,Gore and Keigley

57 220

Pancreatico Biliary Choledochal Stones Cholectasis Obstructive Jaundice Biliary Strictures Common Bile duct Stones Biliary pancreatitis

100

91.7

Pasanen, P., et al Pasanen, P. et al Pasanen, P. et al. Rosch,T. Meining,A. et al. 220 187 50

23.3 97 77

80.6 87 87

77

85

Rathod, V and Dy, Frederick

3000

71-75 40

79-93 90

Moon, Cho et al.

32

b. Specificity In a study of Rathod and Dy, the specificity value of ERCP is 92-100% which is greater than the specificity value of CT which is 78-97% in detecting common bile duct stones. The same trend is noted in the study of Rosch et al (2002). as the specificity of ERCP is 75% strictures Tobin and his associates (2004) declared in their study that in terms of specificity, ERCP is 100% in diagnosing pancreaticobiliary disease compared to 91% of which is greater than the specificity of CT which is 63% in biliary

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CT.

Whereas in a study of 220 patients, Pasanen, et al (1992) claimed that in

diagnosing cholestasis ERCP specificity level is 94% while that of CT is 92%.

TABLE 2. STUDIES COMPARING CT AND ERCP IN TERMS OF SPECIFICITY

Specificity Study No. of Patients Biliary Obstruction CT (%) ERCP (%)

Tobin,Vogetzang,Gore and Keigley Pasanen, P. et al. Rosch,T. Meining,A. et al.

57 187 50

Pancreatico Biliary Obstructive Jaundice Biliary Strictures Common Bile duct Stones

100 92

91.7 94

63

75

Rathod, V and Dy, Frederick

3000

78-97

92-100

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c. Detection Accuracy TABLE 3. STUDIES COMPARING CT AND ERCP IN TERMS OF DETECTION ACCURACY No of Biliary Study Patients Obstruction CT (Causes) (%) Zhong,Yao,Li & Xu Upadhaya, et al Zhong,Yao, Li & Xu 82 100 82 Gallbladder stone Intrahepatic bile duct stone 75.0 85.71 100.0

ERCP (%) 80.0 95.83 100.0

Zhong,Yao,Li & Xu

82

Choledocholithiasis

88.2

94.1

Yang,Ping, et al;

58

Pancreato-biliary tumor Gallbladder carcinoma

80

92

Zhong,Yao,Li & Xu

75.0

60.0

Wei-Xing et al., Zhong,Yao,Li & Xu Zhong,Yao,Li & Xu Zhong,Yao,Li & Xu Zhong,Yao,Li & Xu

41 82 82 82 82 Ampullary carcinoma Pancreatic head carcinoma Bile papilla carcinoma Bile duct injury

84 50. 81.8 66.7 100.

100 100 100 100 100

Zhong,Yao,Li & Xu

82

Choledochal cyst Chronic pancreatitis

100

100

Zhong,Yao,Li & Xu

82

75.0

100

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In a study by Zhong, Yao, Li and XU (2003) they evaluate the clinical values of various imageological methods including CT and ERCP in diagnosing the pancreatobiliary diseases. The results of their study indicate that the accurate rate in detection of biliary obstructions such as gallbladder stones for CT 75% and for ERCP is 80%; intrahepatic bile duct stone is 100% for both methods, but the trend is different from the study of Upadhaya et al (2006) where ERCP remains superior with accuracy rate of 95.83 as against 85.7% for CT. Zhong, and his associated noted the accuracy of ERCP and CT in detecting Choledocholithiasis where ERCP remains superior with 94.1% rate as compared to 88.2% rate for CT.where Zhong et al is 88.2 % for CT and 94.1%; The same trend is noted by the authors in detecting pancreatic carcinoma(CT-81.8; ERCP100%); bile papilla carcinoma (CT-66.7% and ERCP -100%); and chronic pancreatitis with accuracy rate of 75% for CT and 100% for ERCP. However, the authors show that both modalities have the same accuracy rate in detecting choledochal cyst and bile duct stones with 100%. Meanwhile the accuracy rate of detecting pancreato-biliary tumour, Yang-Ping et al (2007), find ERCP superior with 92% as against 80% rate of CT. In the study of Wei-Xing, et al found the accuracy rate of ERCP in detecting ampullary carcinoma to be 100% as against 84% of CT. The same trend is noted in the study of Zhong, Yao, Li and Xu (2003) where CT accuracy rate is documented as 50% and that of ERCP as 100%.

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CHAPTER V SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

This chapter is the culminating part of the study. It presents the summary of findings, conclusions and recommendations.

Summary of Findings 1.What is Computed Tomography (CT) CT or computed tomography is a diagnostic imaging procedure that uses x-rays to obtain cross-sectional images. It is a non-invasive procedure that aid in the correct diagnosis of biliary obstructions among others. Among the risks in CT procedure to patients are possible allergy from contrast agent used in some cases and lifetime exposure to radiation adverse health effects like hair loss, skin injury among others. 2. What is Endoscopic retrograde cholangio pancreatography (ERCP). Endoscopic retrograde cholanagiopacreatography is both a diagnostic and therapeutic tool. Endoscopic refers to a thin, flexible tube with a tiny video camera and light at the end, while retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. ERCP is an invasive diagnostic modality indicated in detecting biliary obstructions.

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3 .What is accuracy rate of CT in detecting causes of biliary obstructive disease compared with ERCP ? a. Sensitivity Two studies that of Tobin, and Pasanen had indicated that CT has higher level of sensitivity rate in detecting pancreatico biliary; and cholectasis; compared with ERCP; however the rests of the 7 studies reviewed indicated that the accuracy rate of ERCP is consistently higher than CT in detecting obstructive jaundice, biliary strictures; common bile duct stones, Choledochal stones and biliary pancreatitis.

b. Specificity According to three studies reviewed the level of specificity of CT is lower in diagnosing obstructive jaundice; detecting biliary strictures and common bile duct stones compared with the rate of ERCP; but is found higher than the later in detecting pancreaticobiliary.

c. Detection Accuracy

In all biliary obstructions examined by four studies indicate that only choledochal cysts, bile duct injury had CT in equal footing with ERCP. But detecting gallbladder stones, intrahepatic bile duct stones except with 1 study; choledocholithaiasis, pancreatobiliary tumor, gallbladder carcinoma; pancreatic head carcinoma, bile papilla carcinoma and chronic pancreatic, CT remains inferior to ERCP.

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Conclusions 1. Computed tomography is a non-invasive diagnostic imaging procedure that aided diagnosis and detection of some biliary obstructions. 2. Endoscopic retrograde cholangiography is an invasive diagnostic imaging tool and therapeutic instrument for diagnosing and detecting biliary obstruction. 3. In comparison between CT and ERCP, CT has lower sensitivity rate compared to ERCP in detecting biliary obstructions like choledochal stones, obstructive jaundice, biliary strictures; common bile duct stones and biliary pancreatitis. 5. In terms of specificity ERCP is found superior among diagnostic imaging modalities including CT. Only 1 studies had found out that CT has 100% specificity in detecting pancreatico biliary as against 91.7% of ERCP . The rest the studies showed that ERCP remains superior with CT in terms of specificity rate in detecting obstructive jaundice, biliary strictures and common bile duct stones. 6. As to detection accuracy, ERCP had been proven by studies reviewed to remain the gold standard for diagnosis of biliary obstruction.

Recommendations The researcher has noted in the course of researching for studies, there has been no local studies on the subject. It is believed that cases obstructive biliary disease is increasing in the country. And the need for accurate diagnosis for biliary obstructions demands the need for adequate knowledge among our doctors of clinical values of different diagnostic imaging tools. For this reason, the researcher recommends studies on the subject beyond systematic literature reviews.

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BIBLIOGRAPHY Boring, Simon. Sensitivity, specificity, and predictive values. In Clinical Methods: The History, Physical and Laboratory Examination. Walker HK. Hall WD, Hurst. eds. Butterworths. 3rd. ed., 1990. Chen,WX, Xie,QG, Zhang,X. Hu, TT, Xu P and Gu ZY. Multiple imaging techniques in the diagnosis of ampullary carcinoma. Hepatobiliary Pancreat.Dis.Int.,2008. www.hbpdint.com. Retrieved Oct. 19,2010. Chong,VH, Yin, HB, Lim,CC. Endoscopic retrograde cholangiopancreatography in elderly:outcomes, safely and complications. Singapore Medical Journal,2005. Jang,Joo Young, Chong, HY, and Kim, KM. Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children. World Journal of Gastroenterology.2010. Medical Service Advisory Committee. A magnetic resonance cholangiopancreatography Assessment Report. 2005. Moon JH, Cho YD, Cha SW, Cheon YK, Ahn HC, Kim YS, Kim YS, Lee JS, Lee MS, Lee HK, Shim CS, Kim BS. The detection of bile duct stones in suspected biliary pancreatitis: comparison of MRCP, ERCP, and intraductal US. American Journal of Gastroenterology. 2005. Pasanen P., Partanen K., Pikkarainen P. Alhava E. Pirinen A. & Janatuinen E. Diagnostic accuracy of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the detection of pancreatic cancer in patients with jaundice or cholestasis. PubMed, 1992. _____________________ Diagnostic accuracy of ultrasound, computed tomography and Endoscopic Retrograde cholangiopancreatography in the detection of obstructive jaundice. PubMed. 1991. _____________________. Ultrasonography , CT and ERCP in the diagnosis of choledochal stones. Acta Radiologica, Stockholm, Sweden. 1992. Rathod, Vipul and Dy, Frederick. Role of EUS in common bile duct stones prior to laparoscopic cholecystectomy: how does it compare with other imaging modalities.

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.Rosch

T, Meining A, Fruhmorgen S, Zillinger C, Schusdziarra V, Hellerhoff K, Classen M, Helmberger H. A prospective comparison of the diagnostic accuracy of ERCP, MRCP, CT, and EUS in biliary strictures. Gastrointest Endosc 2002; 55: 870-876 PubMed DOI

Tobin,Richard, Vogelzang, R., Gore, R. and Kiegley, B. A comparative study of computed tomography and ERCP in pancreaticobiliary disease. Journal of Computed tomography. 2004. WANG Zhi, WANG Kang, MA Fenghua,et al. Department of Radiology, Putuo Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 200062, P. R. China;A Comparative Study in the Diagnosis of Biliary Obstruction with SSFSE MRCP and ERCP[J];Journal of Clinical Radiology;2006-07 Yang,Ping-sheng, Dong,Qi-long, Chen, Yu-Hui, Chen, Kai, Zheng, Xiangdong. Evaluation of CT, MRCP, and ERCP in the diagnosis of pancreastiboliary tumour. Journal of Southeast China National Defense Medical Science. 2007. Upadhyaya V, Upadhyaya DN, Ansari MA, Shukla VK. Comparative assessment of imaging modalities in biliary obstruction. Indian J Radiol Imaging [serial online] 2006 [cited 2010 Oct 24];16:577-82. Available from: http://www.ijri.org/text.asp?2006/16/4/577/32273 Zhong L, Yao QY, Li L, Xu JR. Imaging diagnosis of pancreato-biliary diseases: A control study. World J Gastroenterol 2003; 9(12): 2824-2827 http://www.wjgnet.com/1007-9327/9/2824.asp . Retrieved Oct. 18,2010.

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Figure 1. Pathway flow of diagnosing causes of cholestatic jaundice

source:www.imagingpathways.health.wa.gov. au

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APPENDIX B SUMMARY OF SELECTION PROCESS

Potentially relevant studies identified and screened n = 25

Studies rejected for title n=4

Total abstract screened n=21

Studies Rejected for abstract n=5

Total full paper screened n=16

Rejected full papers n=2

Studies potentially relevant n=14

Studies excluded for quality n=3

Included Studies n=11