ACR Appropriateness Criteria®
Clinical Condition: Jaundice
Variant 1: Acute abdominal pain; at least one of the following: fever, history of biliary surgery, known cholelithiasis.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| CT, abdomen |
7 |
|
| MRI, abdomen, MRCP |
5 |
|
| NUC, Cholescintigraphy |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Painless; one or more of the following: weight loss, fatigue, anorexia, duration of symptoms greater than 3 months. Patient otherwise healthy.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| CT, abdomen, dynamic multiplanar or helical |
8 |
|
| US, abdomen |
8 |
|
| MRI, abdomen, with MRCP |
7 |
|
| INV, ERCP and EUS |
6 |
|
| INV, PTC |
4 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Painless; one or more of the following: weight loss, fatigue, anorexia, duration of symptoms greater than 3 months. Patient will not tolerate radical surgical procedure.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| INV, ERCP and EUS |
8 |
|
| US, abdomen |
8 |
|
| CT, abdomen, dynamic multiplanar or helical |
8 |
|
| MRI, abdomen, with MRCP |
7 |
|
| INV, PTC |
5 |
|
| NUC, Cholescintigraphy |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 4: Clinical condition and laboratory examination makes mechanical obstruction unlikely.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| US, abdomen |
8 |
|
| CT, abdomen |
5 |
|
| MRI, abdomen, with MRCP |
5 |
|
| NUC, Nuclear medicine |
4 |
|
| INV, ERCP and EUS |
4 |
|
| INV, PTC |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 5: Confusing clinical picture; patient not described in previous scenarios.
| Radiologic Exam Procedure |
Appropriateness Rating |
Comments |
| US, abdomen |
8 |
|
| CT, abdomen |
8 |
|
| INV, ERCP |
6 |
|
| MRI, abdomen |
6 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Appropriateness Criteria
To determine the appropriateness of any imaging test, it is necessary to consider the general clinical category to which the patient belongs. The major categories are (1) high likelihood of mechanical obstruction; (2) low likelihood of mechanical obstruction; and (3) indeterminate. For situations in which the pre-imaging probability for obstruction is high, it is also appropriate to consider a secondary question: whether the obstruction is likely to be benign or malignant.
Situation 1A: High Likelihood of Benign Biliary Obstruction
Patients in this category present with jaundice and acute abdominal pain. There may be a prior history of gallstones documented by sonography or of prior biliary surgery. Sonography is an accurate and the least expensive method for detecting dilated intrahepatic bile ducts and the common hepatic duct at the hepatic hilum. Biliary ductal calculi are not detected with the same sensitivity as gallbladder calculi. The subhepatic common duct is not visible in a high proportion of patients due to overlaying bowel gas. In addition, intrahepatic bile ducts may not be dilated in the early phase of acute obstruction or in patients with partial obstruction.
ERCP though invasive and expensive, is the most sensitive technique for detecting biliary calculi and endoscopic sphincterotomy, and associated therapeutic interventions may be curative. Appropriate patient selection, based on established clinical criteria, significantly improves the diagnostic yield of ERCP. IF ERCP cannot be performed (for example, in patients with previous gastroenteric anastomoses) or if attempted ERCP is unsuccessful or inadequate, MRCP is the most sensitive noninvasive method to document the presence of biliary calculi.
In patients with a history of prior surgery or suspected sclerosing cholangitis, in whom biliary stricture is a diagnostic consideration, MRCP is the preferred imaging test, avoiding the possibility of suppurative cholangitis that may be induced by endoscopic catheter manipulation into an obstructed biliary system. MRCP findings may guide directed approaches such as ERCP with brushing, percutaneous transhepatic biliary stenting or reconstructive surgery.
Situation 1B: High Likelihood of Malignant Biliary Obstruction
Patients in this category typically present with insidious development of jaundice and associated constitutional symptoms (weight loss, fatigue, etc.). Mechanical biliary obstruction can be confirmed by sonography. Malignant obstruction is most commonly due to pancreatic carcinoma but may be secondary to cholangiocarcinoma of either the proximal or distal duct or to periductal nodal compression. A contrast-enhanced multipass CT examination with multiplanar reformation has high sensitivity to lesion detection and 70% accuracy in discrimination of resectable and unresectable disease. Important information in tumor staging includes tumor contiguity or invasion of the superior mesenteric and portal vein, peripancreatic tumor extension, regional adenopathy, and hepatic metastases. Contrast-enhanced multipass CT has 70% accuracy in tumor staging.
MR and MRCP are also accurate in tumor detection and staging. There are no wide scale comparative studies of CT and MRI in the evaluation of malignant biliary obstruction. CT is generally more available and more frequently used, with MRI/MRCP reserved for patients with contraindications to CT.
ERCP is invasive and more expensive than CT or MRI, has equivalent sensitivity in tumor detection, but does not provide staging information for operability. Tissue diagnosis can be obtained by endoscopically directed brushing or guided ultrasound with fine needle aspiration (FNA). In patients with pancreaticobiliary cancer who are surgical candidates, there is no established role for preoperative biliary drainage by ERCP. However, endoscopic biliary drainage may be used for operative candidates in whom there is delay prior to surgery. Endoscopic or percutaneous transhepatic biliary drainage is appropriate for patients who are not candidates for surgery, the percutaneous transhepatic technique being preferred for patients with hilar biliary obstruction.
In patients with suspected malignant biliary obstruction and negative or equivocal CT or MRI studies, ERCP with EUS may provide an imaging and cytologic diagnosis (FNA).
Cytological tumor diagnosis in nonoperative candidates can be obtained either by EUS directed brushing or FNA, US directed or CT directed pancreatic or nodal biopsy of by fluoroscopically guided brushing or FNA (PTC).
Focal chronic pancreatitis may mimic pancreatic carcinoma on all imaging tests and only be conclusively diagnosed on operative exploration and biopsy.
Periductal nodal compression may result from metastatic disease or malignant lymphoma. Diagnosis is usually based on imaging appearances and clinical history. Tissue confirmation may be obtained by imaging directed percutaneous biopsy.
Situation 2: Low Likelihood of Mechanical Biliary Obstruction
In situations in which the pre-test probability of obstruction is low but concern about the possibility exists, either ultrasound or MRCP is the first-line test, because of patient convenience and low complication rates. MRCP findings are likely to be accepted without proceeding to ERCP or PTC. Of the two, UT is less expensive, though less definitive.
Situation 3: Indeterminate Likelihood of Obstruction
In this clinical situation, the patient's presentation is confusing, and the imaging work-up frequently is geared to the dominant clinical symptom. Ultrasound is an inexpensive, relatively accurate method, certainly appropriate if the sole question is whether or not obstruction exists. In cases in which most of the abdominal organs need to be assessed, either CT or MRI can be used, though CT more reliably displays all abdominal anatomy. When computed tomography evaluation is compromised (e.g., in patients unable to receive iodinated intravenous contrast material), the combination of MR and MRCP is a reliable alternative.
In summary, the diagnostic approach for adults presenting with jaundice depends to a large extent on (a) the pre-imaging probability that the jaundice is obstructive rather than nonobstructive; (b) the pre-test probability that the most likely cause is benign versus malignant; and (c) whether the patient is an operative candidate, once the diagnosis is made. Lastly, the availability of each possible modality and the expertise with which it is offered are important considerations in any clinical situation.
Abbreviations
- CT, computed tomography
- ERCP, endoscopic retrograde cholangiopancreatography
- EUS, endoscopic ultrasound
- INV, invasive
- MRCP, magnetic resonance cholangiopancreatography
- MRI, magnetic resonance imaging
- NUC, nuclear medicine
- PTC, percutaneous transhepatic cholangiography
- US, ultrasound
