ESGAR consensus statement on MR imaging in primary sclerosing cholangitis

Category	Detail
Condition	Primary sclerosing cholangitis (PSC), a progressive cholestatic liver disease with biliary inflammation and fibrosis
Key Mechanisms	Progressive biliary inflammation and fibrosis causing cholestasis and liver failure; affects intra- and extrahepatic bile ducts
Target Population	Primarily adult men (~60%) with mean diagnosis age of 41 years; worldwide incidence up to 1.3 per 100,000 per year
Care Setting	Specialized radiology and hepatology centers utilizing MRI/MRCP for diagnosis and follow-up

PSC involves both intra- and extrahepatic bile ducts with large-duct and small-duct subtypes; liver biopsy required only for small-duct subtype or suspected overlap syndromes
MR imaging with MRCP is the recommended first-line imaging modality for diagnosis and monitoring, replacing ERCP due to non-invasiveness and superior visualization
ESGAR consensus provides standardized MRI acquisition protocols, interpretation criteria, and structured reporting to improve diagnostic accuracy and communication

Use MR imaging with MRCP as the first imaging modality for suspected or confirmed PSC
Reserve liver biopsy for small-duct PSC diagnosis or when autoimmune hepatitis or primary biliary cholangitis overlap is suspected
Avoid ERCP as a primary diagnostic tool due to invasiveness and risk of complications

Implement standardized MR acquisition protocols including technical considerations, patient preparation, and magnetic field strength
Utilize contrast agents selectively based on clinical context
Apply structured reporting templates to document typical findings, complications, and disease extent

Use MRCP for non-invasive follow-up to assess biliary strictures and liver parenchymal changes
Evaluate bile ducts proximal to strictures that may not be visualized by ERCP
Monitor for disease progression and complications using standardized imaging criteria

Avoid ionizing radiation exposure by preferring MR imaging over ERCP
Prevent endoscopic-related complications by limiting ERCP use to therapeutic interventions
Recognize limitations of imaging in small-duct PSC requiring biopsy confirmation

Adults diagnosed or suspected with large-duct PSC undergoing imaging evaluation

MR imaging with MRCP provides critical diagnostic and monitoring information guiding clinical management without invasive procedures

Adopt ESGAR consensus MR imaging protocols for consistent and high-quality image acquisition
Ensure multidisciplinary collaboration between radiologists and hepatologists for interpretation and management decisions
Use structured reporting to enhance communication and clinical decision-making
Reserve liver biopsy for cases with diagnostic uncertainty or suspected overlap syndromes
Prefer MRCP over ERCP for diagnostic purposes to minimize patient risk

Clinical Scorecard: Consensus Guidelines from ESGAR on MRI Utilization in Primary Sclerosing Cholangitis