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. 2025 Aug 13;17(8):e89959.
doi: 10.7759/cureus.89959. eCollection 2025 Aug.

Smarter Scanning: Reducing Unnecessary Magnetic Resonance Cholangiopancreatography (MRCP) in Low-Risk Gallstone Patients

Najeeb Aftab  1 , Khalid Sohail  1 , Nicole Handy  1 , Abbie Evans  1 , Helen Rotherforth  2
Affiliations

Smarter Scanning: Reducing Unnecessary Magnetic Resonance Cholangiopancreatography (MRCP) in Low-Risk Gallstone Patients

Najeeb Aftab et al. Cureus. .

Abstract

Background Gallstone disease is a common condition that often requires imaging to exclude choledocholithiasis. Magnetic resonance cholangiopancreatography (MRCP) is a highly accurate but costly scan, increasingly used in low- to moderate-risk patients where its diagnostic yield may be low. Objective This audit evaluated the diagnostic yield of MRCP in low- to moderate-risk gallstone patients and assessed the predictive value of liver function tests (LFTs) and ultrasound (USS) findings to develop a smarter referral approach. Methods A retrospective audit was conducted at a single NHS Trust from January to December 2024. Data on MRCP outcomes, pre-scan LFTs (bilirubin, alkaline phosphatase (ALP)), and USS common bile duct (CBD) diameter were analyzed using chi-squared tests. A composite score (MRCP-RS) combining key predictors was explored to guide smarter MRCP referrals. Results Among 329 MRCPs, 42.2% were normal. Elevated bilirubin and ALP showed no significant association with abnormal MRCPs (p=1.00 and p=0.61). Dilated CBD on USS had limited predictive value (p=0.82). The MRCP-RS composite score demonstrated a trend of increasing abnormal MRCP rates with higher scores but modest discriminative ability. Avoidable normal MRCPs incurred an estimated annual cost of £38,000-65,000. Conclusion Routine use of MRCP in low-risk gallstone patients leads to unnecessary imaging and costs. Neither LFTs nor USS alone is a reliable predictor. A combined approach using a simple composite score may improve referral decisions. Adoption of smarter referral tools and re-audit post-implementation are recommended.

Keywords: gallstone disease (gsd); liver function tests (lfts); magnetic resonance cholangiopancreatography (mrcp); ultrasonography (usg); upper gastrointestinal surgery.

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. MRCP burden
Distribution of MRCP outcomes (normal vs. abnormal) in gallstone patients (n=329). Abnormal MRCP findings included choledocholithiasis, strictures, or biliary dilatation. Percentages represent the proportion of all MRCPs performed. MRCP: magnetic resonance cholangiopancreatography
Figure 2
Figure 2. Average LFT levels in normal vs. abnormal MRCP cases
This bar chart compares the mean values of key LFTs, namely, bilirubin, ALP, and ALT, between patients with normal MRCP results (n=139) and those with abnormal MRCP findings (n=190). Each bar displays the average value for that group, with MRCP abnormal cases shown in red and MRCP normal cases shown in blue. While elevated bilirubin (>36 μmol/L) and ALP (>250 U/L) were numerically higher in the abnormal MRCP group, these differences did not reach statistical significance (p=1.00 for bilirubin; p=0.61 for ALP). LFT: liver function test; MRCP: magnetic resonance cholangiopancreatography; ALP: alkaline phosphatase; ALT: alanine aminotransferase
Figure 3
Figure 3. Ultrasound CBD findings vs. MRCP outcomes
This bar chart compares MRCP outcomes between patients with dilated CBD on USG (n=100) and those with normal CBD diameter (n=229). Each bar segment shows the number of patients (N) and percentage (%) of abnormal and normal MRCP findings within each subgroup. Among patients with dilated CBD on USG, 42 (42.2%) had abnormal MRCP findings, while 57 (57.8%) had normal MRCPs. In the normal CBD group, 48 (21%) had abnormal MRCPs, and 180 (79%) had normal findings. This highlights the limited predictive value of USG findings alone for MRCP outcomes. MRCP: magnetic resonance cholangiopancreatography; CBD: common bile duct; USG: ultrasound
Figure 4
Figure 4. ERCP outcomes following abnormal MRCP findings
This bar chart illustrates the outcomes of ERCP in patients who had abnormal MRCP findings (n=190). Of these, 66 patients underwent ERCP. Among them, 46 patients (69.7%) had positive ERCP findings, confirming biliary pathology (e.g., choledocholithiasis or strictures), while 20 patients (30.3%) had negative ERCP results, indicating that MRCP may overestimate pathology in certain cases. Each bar displays both the number of patients (N) and the percentage (%) relative to total documented ERCPs. ERCP: endoscopic retrograde cholangiopancreatography; MRCP: magnetic resonance cholangiopancreatography
Figure 5
Figure 5. Abnormal MRCP rates by MRCP-RS score
This line chart illustrates the relationship between the MRCP-RS composite score (range 0-3) and the percentage of abnormal MRCP findings among the audited patients (n=329). The MRCP-RS score incorporates three predictors: bilirubin >36 μmol/L, ALP >250 U/L, and CBD diameter >7 mm. The number of patients (N) and the corresponding percentage of abnormal MRCPs are displayed for each score group. Abnormal MRCP rates rose from 16.2% (16/99) at score 0 to 57.7% (15/26) at score 3, demonstrating that higher scores were associated with increased likelihood of abnormal findings. While the overall discriminative power of the score was modest, the trend supports combining biochemical and imaging markers to refine MRCP referral decisions. MRCP: magnetic resonance cholangiopancreatography; ALP: alkaline phosphatase; CBD: common bile duct
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