MRCP is more sensitive and specific than CECT (helical) for detecting ductal stones, however EUS achieves higher or comparable sensitivities to MRCP.
It is our protocol in cases of ductal dilatation on USG to order an ALP, if that is raised we perform MRCP, if ALP is normal, we go ahead with Lap chole without probing further.
ALP elevation should raise the suspicion of CBD stones. Just dilatation is no indication for further evaluation especially in the 50 plus population.
MRCP is the more sensitive of the tests and as such the gold standard in the investigation of CBD stones. ALP elevation is not always present in particular if the stones only cause intermittent obstruction. Microlithiasis might not even show up on MRCP and if this is suspected then EUS ( endoscopic ultrasound) would be the test of choice.
Parameters helps in predicting or rule our CBD stone in gall stone pancreatitis were billirubin > 3, ALP > 250, GGTP- >350 and CBD size in USG >9 mm .using this criteria unnecessary MRCP can be avoided.Patient can directly go ahead with cholecystectomy if all factors are absent and ERCP if all are present..
There are different scores to predict CBD stones and MRCP is the best way to check it in the preoperatory setting, but if the patient is fit for Surgery we perform a laparoscopic cholecystectomy and IOC and if stones are present, we go on by a choledocotomy or a transcystic approach. ONe step diagnosis and treatment. So, we avoid many MRCP. For us, ERCP is only a therapeutic procedure
We wouldn’t use CT to rule out CBD stones. The use of MRCP has increased significantly in recent years and what clinical benefits these scans have remains unclear. A uk based RCT (Sunflower) is due to look at the use of MRCP in patients with a low/intermediate risk of CBD stones and the clinic sequelae thereafter
It would be a safe practice to do MRCP in patients with CBD dilatation. CT would not be the best investigation for detecting or diagnosing stone disease in the CBD.
Obviously it depends on the patient age and degree of cbd dilatation. This taken together with LFTs dixtates the need for MRCP. Rightly or wrongly we have a relatively low threshold for MRI but this ends up with alot of negative scans which is a debate in its own right
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