MRCP Early Diagnosis of Pancreatobiliary Diseases

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Jinkan Sai, M.D.
Department of Gastroenterology
Juntendo University
2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

Joe Ariyama, M.D.

Professor, Department of Gastroenterology
Juntendo University
2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

ISBN 978-4-431-65903-7 ISBN 978-4-431-65901-3 (eBook)

DOI 10.1007/978-4-431-65901-3
Printed on acid-free paper
© Springer-Verlag Tokyo 2000
Softcover reprint of the hardcover 1st edition 2000
This English translation is based on the Japanese original, J. Sai; Magnetic Resonance
Cholangiopancreatography
Published by Chugai Igaku
© 1998 Chugai Igaku

This work is subject to copyright. All rights are reserved, whether the whole or part of
the material is concemed, specifically the rights oftranslation, reprinting, reuse ofillus-
trations, recitation, broadcasting, reproduction on microfilms or in other ways, and stor-
age in data banks.
The use of registered names, trademarks, etc. in this publication does not imply, even in
the absence of a specific statement, that such names are exempt from the relevant protec-
tive laws and regulations and therefore free for general use.

SPIN: 10743846
Foreword

This book serves as a comprehensive and up-to-date guide to magnetic resonance cholangiopancreatography
(MRCP). MRCP is a newly developed technique which is noninvasive and does not require administration
of contrast materials. MRCP is an application ofMR imaging that provides both high-quality cross-sec-
tional images of ductal structures and projectional images ofthe pancreatobiliary ducts. The technique is
based on a heavily T2-weighted sequence, as a result ofwhich stationary fluid including bile and pancreatic
juice has a high signal intensity, while solid organs have a low signal intensity. Due to rapid evolution of
the technology, high- quality 2-D or 3-D MRCP images are now available.
Since the introduction of MRCP, there has been a significant decrease in the use of diagnostic endo-
scopic retrograde cholangiopancreatography (ERCP) at our institution. MRCP is now indicated following
ultrasound and computed tomography in patients with suspected pancreatobiliary diseases. MRCP has
routinely replaced diagnostic ERCP because ofhigh sensitivity and specificity ofMRCP in the diagnosis of
pancreatobiliary diseases.
I would like to express my considerable gratitude to Professor Hitoshi Katayama, Dr. Masahiro Irimoto,
and Chief Radiographer Eiju Itsumi and other radiographers in the Department ofRadiology; to Mr. Juni chi
Makita of the MR Engineering Department ofToshiba Corporation; to Assistant Professor Masafumi Suyama
and staff members of the Department of Gastroenterology; to Professor Shunji Futakawa and Associate
Professor Tomoe Beppu of the 2nd Department of Surgery; and to Professor Koichi Suda of the Department
of Pathology.
We hope that this book may serve many readers and we look forward to receiving constructive criti-
Clsm.

October 1999
Joe Ariyama, M.D.
Professor of Gastroenterology
Juntendo University School of Medicine
Tokyo
Preface

Magnetic resonance cholangiopancreatography (MRCP) is a truly innovative noninvasive diagnostic tech-

nique which pennits the visualization ofthe anatomy and pathology ofthe pancreatobiliary tree. The major
benefit for patients is that MRCP enables the early diagnosis of pancreatobiliary diseases in a noninvasive
manner, and the results obtained are directly applicable to a treatment plan.
Based on our clinical experience of 3000 MRCP studies, we are convinced of the clinical usefulness of
MRCP for the diagnosis of a variety of pancreatobiliary diseases. This book presents many clinical cases to
illustrate the effectiveness ofthis new diagnostic modality. It is our hope that this book will help to promote
the acceptance of MRCP in routine clinical practice.
I dedicate this book to my parents, Sang-U Sai and Yang-Ja Son; to my wife, Hae-Ran Kim; and to my
children, Sung-Kyu and Myeung-Hwa, for their support, understanding, and encouragement.

October 1999
Jinkan Sai
Contents

Foreword v
Preface vii

Chapter 1 Concept of Magnetic Resonance Cholangiopancreatography 1

1.1 Introduction to Magnetic Resonance Cholangiopancreatography 3

1.2 Comparison of MRCP with Conventional Cholangiopancreatic Imaging Techniques 4
1.3 Role and Indications of MRCP 5
References 7

Chapter 2 Imaging Techniques of MRCP 9

2.1 Technical Development 11

2.1.1 Gradient Echo Sequence 11
2.1.2 Spin Echo Sequence 11
2.2 Imaging Procedures 13
2.2.1 Patient Preparation 13
2.2.2 Patient Position 13
2.2.3 Breathing Methods 13
2.2.4 Receiver Coils 13
2.2.5 Scanning Parameters 14
2.2.6 Scanning Planes 14
2.2.7 Maximum Intensity Projection 14
2.2.8 Fat Saturation 14
2.2.9 Administration ofFerric Ammonium Citrate 14
2.2.10 Intravenous Injection of Secretin 17
2.3 Two-dimensional versus three-dimensional images 18
References 19
x Contents

Chapter 3 Biliary Tract 21

3.1 Normal Biliary Traet 23

3.2 Anatomie Variants of the Biliary Tree 24
3.3 Panereatobiliary Maljunetion 26
3.3.1 Panereatobiliary Junetion 26
3.3.2 Panereatobiliary Maljunetion 27
3.4 Cholelithiasis 29
3.4.1 Choleeystolithiasis 29
3.4.2 Choledoeholithiasis 32
3.4.3 Intrahepatie Gallstones 35
3.5 Aeute Choleeystitis 37
3.6 Adenomyomatosis ofthe Gallbladder 40
3.7 Polypoid Lesions ofthe Gallbladder 43
3.8 Careinomas ofthe Biliary Traet 44
3.8.1 Careinomas ofthe Gallbladder 44
3.8.2 Extrahepatie Bile Duet Careinomas 46
3.8.3 Early Careinomas ofthe Extrahepatie Bile Duet 48
3.8.4 Hilar Cholangioeareinomas (Klaskin's Tumors) 51
3.8.5 Careinomas ofthe Papilla ofVater 53
3.8.6 Early Careinomas ofthe Papilla ofVater 56
3.9 Benign Stenosis ofthe Bile Duet 58
3.9.1 Mirizzi's Syndrome 58
3.9.2 Primary Sclerosing Cholangitis 59
3.9.3 Bile Duet Stenoses Assoeiated with Chronie Panereatitis 60
3.9.4 Dysfunetion ofthe Sphineter ofOddi 61
3.9.5 Postoperative Bile Duet Strieture 62
3.10 Biliary-Enterie Anastomoses 63
3.11 Other Biliary Traet Conditions 65
3.ll.l Pneumobilia 65
3.ll.2 T2-Shortening Bile 66
3.ll.3 Biliary Stent 68
3.l1.4 Hepatie Arterial Compression of the Common Hepatie Duet 69
3.1l.5 Artifaets Created by Metal Clips 70
Referenees 71

Chapter 4 The Pancreas 77

4.1 Normal Panereatie Duet 79

4.2 Panereas Divisum 81
 Contents Xl

4.3 Pancreatitis 82
4.3.1 Acute Pancreatitis 82
4.3.2 Chronic Pancreatitis 83
4.3.3 Pancreatic Duct Calcu1i 87
4.3.4 Inflammatory Pancreatic Masses 89
4.3.5 Focal Stenosis ofthe Main Pancreatic Duct Masquerading as Pancreatic Carcinoma 91
4.3.6 Groove Pancreatitis 93
4.4 Cystic Lesions of the Pancreas 95
4.4.1 Pancreatic Pseudocysts 96
4.4.2 Solitary True Cyst 98
4.4.3 Intraductal Papillary Mucinous Tumors 99
4.4.4 Mucinous Cystic Neoplasm ofthe Pancreas 109
4.4.5 Serous Cystadenoma of the Pancreas 113
4.5 Pancreatic Ductal Adenocarcinomas 114
References 122

Chapter 5 The Liver 127

5.1 Simple Hepatic Cysts 129

5.2 Hepatic Peribiliary Cysts and Polycystic Kidney 130
5.3 Von Meyenburg Complexes (Microhamartomas) 131
5.4 Biliary Cystadenoma and Cystadenocarcinoma 132
5.5 Intrahepatic Cholangiocarcinoma 133
5.6 Hepatocellular Carcinoma 136
5.7 Pyogenic Liver Abscesses 137
References 138

Chapter 6 Applications ofMagnetic Resonance Cholangiopancreatography 141

6.1 Dynamic MRCP by Secretin Injection 143

6.2 Measurement ofVolume ofPancreatic Juice Secretion 144
6.3 MR Virtual Cholangiopancreatoscopy 148
References 151

Index 153
Chapter 1 Concept of Magnetic Resonance
Cholangiopancreatography
 Introduction to Magnetic Resonance Cholangiopancreatography 3

1.1 Introduction to Magnetic Resonance

Cholangiopancreatography

Magnetic resonance cholangiopancreatography (MRCP) is a new imaging technique for visualizing the
biliary tract and pancreatic duct using the principle ofmagnetic resonance imaging. Using heavily T2-
weighted images to visualize only stationary fluid such as bile and pancreatic juice, this technique enables
the visualization ofthe morphology ofthe pancreaticobiliary tree [1,2].
This innovative technique is noninvasive, requires no injection of contrast medium, and offers the unique
ability to acquire both projectional and cross-sectional images ofthe ductal system [3,4]. Since MRCP has
high sensitivity to water, it provides more information than the cholangiopancreatographic images obtained
by endoscopic retrograde cholangiopancreatography (ERCP) (Table 1-1). As a result, a better understand-
ing of a pancreatobiliary disease and its detailed pathology can be obtained, which enables accurate diagno-
sis and formulation of an appropriate treatment plan. Therefore, MRCP is expected to replace diagnostic
ERCP for the screening ofpancreatobiliary diseases [5, 6].
MRCP has gained popularity rapidly due to its usefulness in routine clinical practice, and is becoming
an indispensable diagnostic modality for pancreatobiliary diseases.

Table 1-1 Information acquired from MRCP, which is superior to ERCP

The biliary tract and pancreatic duct both proximal and distal to a site of obstruction Fig. 3-12,13,14,29,30,31, Fig. 4-13, 25
The gallbladder in cases of cystic duct obstruction Fig. 3-10, 16, 34, 44
Inflammatory effusion in cases of cholangitis or pancreatitis Fig. 3-16, 17; Fig. 4-4
Visualizing cysts with no communication with the biliary tract and pancreatic duct Fig. 4-6, 7, 13, 14,22,24, Fig. 5-3,4
Internal structure of cystic lesions from review of source images Fig. 4-16, 19,22, Fig. 5-4
Visualizing the biliary tract and pancreatic duct in cases of mucin-producing tumor, Fig. 4-16,17,19
which is not satisfactorily imaged by ERCP due to the presence ofmucin
Cholangiopancreatography after reconstruction of the upper gastrointestinal tract Fig. 3-39,40,41
Rokitansky-Aschoff sinus (RAS) of the gallbladder Fig. 3-20, 21, 22, 23
Patency of the stent Fig.3-45
Functional image of the pancreas Fig. 6-1, 2
Cystic lesions in the liver and kidney Fig.5-1,2
Liver abscess with no communication with the biliary duct Fig.5-8
4 I. Concept of Magnetic Resonance Cholangiopancreatography

1.2 Comparison of MRCP with Conventional

Cholangiopancreatic Imaging Techniques

MRCP offers various advantages over conventional cholangiopancreatic imaging techniques such as intra-
venous cholangiography, percutaneous transhepatic cholangiography, computed tomographic (CT) cholan-
giography, and endoscopic retrograde cholangiopancreatography (ERCP) [6-8].
In terms of safety and comfort to patients, MRCP requires no injection of contrast medium or ionizing
radiation and involves no pain or complication [9,10]. It can be performed even during the acute phase of
pancreatitis and cholangitis, and the result is not affected by serum bilirubin level as is intravenous cholan-
giography or CT cholangiography [11]. It provides more information about the pancreatobiliary pathology
than ERCP (Table 1-1) and can be performed in patients who present difficulties with ERCP examination,
such as those who have undergone biliary enteric anastomosis or those with stenosis of the upper gas-
trointestinal tract preventing passage of the endoscope. It can also be performed in patients with poor
clinical performance status. A higher success rate is therefore achieved. Technically, MRCP does not de-
pend on the operator's skill. There is also no need for premedication before examination [5].
On the other hand, MRCP has some disadvantages [5]. For example, spatial resolution is lower than
ERCP. And while biopsy, cytology, or therapeutic intervention can be performed with ERCP, they are not
possible with MRCP. Overlapping offluid collection or cystic structure may disturb the visualization ofthe
pancreatobiliary tree. Direct visualization ofthe papilla ofVater is impossible. It is also difficult to confirm
the patency ofthe cystic duct or the communication between cysts and the duc tal system. In addition, the
image quality is deteriorated by artifacts derived from some types of surgical clips, coils, or metallic stents
in the abdomen. MRCP is contraindicated in patients having certain types of implants such as pacemakers
and same types of intracranial clips and heart valves. And MRCP cannot be used to study patients with
claustrophobia.
 Role and Indieations of MRCP 5

1.3 Role and Indications of MRCP

MRCP has been found to have wide clinieal indieations due to its ability to depiet the physiologie and
pathologieal state ofthe panereatie duet and biliary traet. An important role ofMRCP is in replaeing diag-
nostie ERCP as a noninvasive modality [8, 12]. Unsueeessful or ineomplete ERCP eases are satisfaetorily
examined by MRCP [13]. Furthermore, MRCP provides detailed information on the panereatieobiliary tree
not obtainable by tomographie imaging teehniques sueh as ultrasonography (US) and CT. Beeause MRCP
ean be eondueted conveniently and safely in the outpatient clinic, it is extremely useful as a screening
(Table 1-2) and follow-up method for pancreatobiliary diseases [6], although its eost effectiveness and
aecessibility remain as problems.

Table 1-2 Screening for pancreatobiliary diseases using MRCP

Anatomie variants
e.g., pancreaticobiliary maljunction (Figs. 3-6, 7), pancreatic divisum (Fig. 4-3), low cystic duct insertion (Fig. 3-3),
aberrant right hepatic duct (Fig. 3-2)

Stones
e.g., gallstones (Fig. 3-9-16), pancreatolithiasis (Figs. 4-5, 8, 9)

Cystic disease
e.g., choledochal cyst (Fig. 3-7), pancreatic cyst (Figs. 4-13,14,22-24), intraductal papillary mucinous tumor ofthe
pancreas (Fig. 4-16-21), Von Meyenburg complex (Fig. 5-3)

Ductal stenosis
e.g., carcinoma ofthe biliary tract (Figs. 3-25, 26, 27, 29), Mirizzi's syndrome (Fig. 3-34), primary sclerosing cholangitis
(Fig. 3-35), postoperative bile duct stenosis (Fig. 3-38), carcinoma ofthe papilla ofVater (Fig. 3-31,33), benign stenosis
ofthe papilla ofVater (Fig. 3-37), pancreatic carcinoma (Fig. 4-25, 29, 30), chronic pancreatitis (Fig. 4-7,10,11, (3)

Elevated lesions
e.g., carcinoma of the biliary tract (Fig. 3-28), carcinoma of the papilla ofVater (Fig. 3-30, 32), intraductal papillary
tumor of the pancreas (Fig. 4-16, 19)

Acute inflammation
e.g., acute cholecystitis (Fig. 3-16, 17), acute pancreatitis (Fig. 4-4)

Others
e.g., adenomyomatosis ofthe gallbladder (Fig. 3-20-23), biliary sludge (Fig. 3-43,44)
6 1. Concept of Magnetic Resonance Cholangiopancreatography

Clinical Indications for MRCP

1. Early diagnosis ofpancreatobiliary malignancy

2. Evaluation of pancreatobiliary emergency, such as obstructive jaundice, acute pancreatitis, and acute
cholecystitis
3. Examination of the biliary tract before cholecystectomy to detect choledocholithiasis or anatomie
variants of the biliary tree
4. Survey after biliary enteric anastomosis
5. Follow-up study ofpancreatobiliary diseases inc1uding intraductal papillary mucinous tumor ofthe
pancreas, pancreatitis, pancreatic cyst, benign stricture ofthe biliary tract, and patency ofbiliary stent
6. Cases in which ERCP is contraindicated
 References 7

References

1. Wallner B, Schumacher K, Friedrich J (1991) Dilated biliary tract: Evaluation with MR cholangiography with a
T2-weighted contrast-enhanced fast sequence. Radiology 181:805-808
2. Takehara Y, Ichijo K, Tooyama N, et al (1994) Breath-hold MR cholangiography with a 10ng-echo-train fast spin-
echo sequence and a surface coil in chronic pancreatitis. Radiology 192:73-78
3. Morimoto K, Shimoi M, Shirakawa T, et al (1992) Biliary obstruction: evaluation with three-dimensional MR
cholangiography. Radiology 183:578-580
4. Soto JA, Barish MA, Yucel EK, et al (1995) Pancreatic duct: MR cholangio-pancreatography with a three-dimen-
sional fast spin-echo technique. Radiology 196:459-464
5. Reinhold C, Bret PM (1996) Current status of MR cholangiopancreatography. AJR Am J Roentgenol 166: 1285-
1295
6. Sai J, Ariyama J (1999) MRCP in the diagnosis of pancreatobiliary diseases: its progression and limitation (in
Japanese). Jpn J Gastroenterol 96:259-265
7. Reuther G, Kiefer B, Tuchmann A (1996) Cholangiography before biliary surgery: single shot MR
cholangiopancreatography versus intravenous cholangiography. Radiology 198:561-566
8. Takehara Y (1998) Can MRCP replace ERCP? J Magn Reson Imaging 8:517-534
9. Bilbao MK, Dotter CT, Lee TG, et al (1976) Complications of endoscopic retrograde cholangiopancreatography
(ERCP). A study of 10,000 cases. Gastroenterology 70:314-320
10. Ariyama J (1988) Percutaneous transhepatic cholangiography. In: Margulis AR, Burenne HJ (eds) Alimentary
tract radiology. Mosby, St. Louis, pp 2229-2241
11. Stockberger SM, Wass JL, Sherman S, et al (1994) Intravenous cholangiography with helical CT: comparison
with endoscopic retrograde cholangiography. Radiology 192: 675-680
12. Fulcher AS, Turner MA, Capps Gw, et al (1998) Half-Fourier RARE MR cholangiopancreatography: experience
in 300 subjects. Radiology 207:21-32
13. Soto JA, Yucel EK, Barish MA, et al (1996) MR cholangiopancreatography after unsuccessful or incomplete
ERCP. Radiology 199:91-98
Chapter 2 Imaging Techniques of MRCP