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Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopan­ Creatography in Characterization1

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Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopan­ Creatography in Characterization1 Note: This copy is for your personal non-commercial use only. To order presentation-ready copies for distribution to your colleagues or clients, contact us at www.rsna.org/rsnarights. GASTROINTESTINAL IMAGING 565 Adult Bile Duct Strictures: Role of MR Imaging and MR Cholangiopan- creatography in Characterization1 Venkata S. Katabathina, MD Anil K. Dasyam, MD Bile duct strictures in adults are secondary to a wide spectrum Navya Dasyam, MBBS of benign and malignant pathologic conditions. Benign causes Keyanoosh Hosseinzadeh, MD2 of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, Abbreviations: AIDS = acquired immunodefi- IgG4-related sclerosing cholangitis, liver transplantation, recurrent ciency syndrome, AIP = autoimmune pancreati- pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficien- tis, CBD = common bile duct, CHD = common hepatic duct, ERCP = endoscopic retrograde cy syndrome cholangiopathy, and sphincter of Oddi dysfunction. cholangiopancreatography, MIP = maximum in- Malignant causes include cholangiocarcinoma, pancreatic adeno- tensity projection, MPD = main pancreatic duct, carcinoma, and periampullary carcinomas. Rare causes include PSC = primary sclerosing cholangitis, RARE = rapid acquisition with relaxation enhancement, biliary inflammatory pseudotumor, gallbladder carcinoma, hepato- RHD = right hepatic duct, RPC = recurrent cellular carcinoma, metastases to bile ducts, and extrinsic bile duct pyogenic cholangitis, SOD = sphincter of Oddi dysfunction, 3D = three-dimensional, 2D = compression secondary to periportal or peripancreatic lymphade- two-dimensional nopathy. Contrast material–enhanced magnetic resonance (MR) RadioGraphics 2014; 34:565–586 imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an Published online 10.1148/rg.343125211 obstructive pattern of liver function, or incidentally detected biliary Content Codes: duct dilatation. Some of these conditions may show characteristic 1From the Department of Radiology, University findings at MR imaging–MR cholangiopancreatography that help of Texas Health Science Center at San Antonio, San Antonio, Tex (V.S.K.); and Department of in making a definitive diagnosis. Although endoscopic retrograde Radiology, University of Pittsburgh Medical cholangiopancreatography with tissue biopsy or surgery is needed Center, Presby South Tower, Suite 4895, 200 for the definitive diagnosis of many of these strictures, certain MR Lothrop St, Pittsburgh, PA 15213 (A.K.D., N.D., K.H.). Recipient of a Certificate of Merit imaging characteristics of the narrowed segment (eg, thickened award for an education exhibit at the 2009 wall, long-segment involvement, asymmetry, indistinct outer mar- RSNA Annual Meeting. Received December 3, 2012; revision requested February 8, 2013; final gin, luminal irregularity, hyperenhancement relative to the liver revision received June 28; accepted July 1. For parenchyma) may favor a malignant cause. Awareness of the vari- this journal-based SA-CME activity, the authors, ous causes of bile duct strictures in adults and familiarity with their editor, and reviewers have no financial relation- ships to disclose. Address correspondence to appearances at MR imaging–MR cholangiopancreatography are A.K.D. (e-mail: [email protected]). important for accurate diagnosis and optimal patient management. 2Current address: Department of Radiology, Wake Forest University School of Medicine, ©RSNA, 2014 • radiographics.rsna.org Winston-Salem, NC. See discussion on this article by Taylor (pp 586–588). Introduction SA-CME LEARNING OBJECTIVES Biliary stricture is a fixed narrowing of a focal segment of the bile After completing this journal-based SA- duct that results in proximal biliary dilatation and clinical features of CME activity, participants will be able to: obstructive jaundice. A wide spectrum of hepatobiliary and pancreatic ■■Discuss the wide spectrum of benign diseases, both benign and malignant, can result in the development of and malignant causes of bile duct stric- biliary strictures (Table 1). It is important to differentiate malignant tures in adults. from benign strictures, since their treatment and prognosis vary. Non- ■■Describe salient MR imaging–MR chol- invasive imaging techniques such as ultrasonography (US), computed angiopancreatographic findings of adult bile duct strictures. tomography (CT), and magnetic resonance (MR) imaging play an ■■List the MR imaging–MR cholangio- important role in the evaluation of patients with suspected biliary pancreatographic features of the narrowed stricture. Among these techniques, contrast material–enhanced MR segment that may help differentiate malig- imaging with MR cholangiopancreatography offers the most compre- nant from benign bile duct strictures. hensive evaluation (1,2). Although endoscopic retrograde cholangio- See www.rsna.org/education/search/RG. pancreatography (ERCP) with tissue biopsy or surgery is needed for the definitive diagnosis of many biliary strictures, certain MR imag- ing–MR cholangiopancreatographic features of the narrowed segment may help differentiate malignant from benign causes. 566 May-June 2014 radiographics.rsna.org In this article, we review the spectrum of bile Table 1: Hepatobiliary and Pancreatic Diseases duct strictures in adult patients and discuss the Causing Biliary Strictures MR imaging and MR cholangiopancreatographic findings, with emphasis on differentiation be- Benign conditions tween benign and malignant strictures. Iatrogenic causes Pancreatitis Pathophysiologic Choledocholithiasis Features of Bile Duct Strictures PSC Pathophysiologic mechanisms underlying the IgG4-related sclerosing cholangitis development of biliary strictures are different in Liver transplantation benign and malignant conditions. Injury to the RPC bile ducts is the inciting event in the development Mirizzi syndrome of benign bile duct strictures (3). Inflammatory AIDS cholangiopathy response follows the injury, resulting in collagen SOD deposition, fibrosis, and focal narrowing, lead- Malignant conditions ing to stricture formation (3). The injury may be Cholangiocarcinoma a single event (eg, trauma during surgery, blunt Pancreatic adenocarcinoma trauma, deceleration-related trauma, or penetrat- ing abdominal trauma), or it may be a recurring Ampullary and periampullary carcinomas condition such as pancreatitis or PSC. There may Miscellaneous and rare causes be a single stricture or multiple strictures depend- Biliary inflammatory pseudotumor ing on the type of injury. Biliary insults from Gallbladder carcinoma ischemia are termed ischemic-type biliary lesions. Hepatocellular carcinoma The pathogenesis of these lesions is multifactorial, Metastatic disease to bile ducts but prominent components include injury to the Periportal and peripancreatic lymphadenopathy cholangiocytes, either directly or as a consequence Note.—AIDS = acquired immunodeficiency of damage to arterioles of the peribiliary vascular syndrome, PSC = primary sclerosing cholangitis, plexus, leading to stricture formation (4). Sequelae RPC = recurrent pyogenic cholangitis, SOD = of chronic high-grade strictures may result in atro- sphincter of Oddi dysfunction. phy of the hepatic segment or lobe drained by the corresponding bile ducts (5). Malignant bile duct strictures may be secondary to primary bile duct carcinomas such as cholangiocarcinoma, or to obtained using either of two different techniques: extrinsic compression and invasion by malignan- (a) standard two-dimensional (2D) MR chol- cies of the adjacent organs such as the gallbladder, angiopancreatography, or (b) three-dimensional liver, and pancreas (3). Extrinsic compression or (3D) isotropic MR cholangiopancreatography invasion by porta hepatis lymph nodes and inva- (7). Standard 2D MR cholangiopancreatographic sion by bile duct metastases may on occasion protocols generally consist of the thick-slab sin- cause malignant strictures. gle-section sequence derived from a breath-hold single-shot RARE technique (8,9). A thick-slab MR Imaging–MR (40–90-mm thickness) single-section heavily T2- Cholangiopancreatographic weighted RARE sequence (echo time >700 msec) Technique for Biliary Tract Evaluation yields ERCP-like projectional images of the en- High soft-tissue contrast resolution and the abil- tire biliary tree, thereby providing an overview ity to help accurately assess the extent of periph- of the anatomy and helping identify the presence eral ductal involvement are the major advantages and site of the obstruction (Fig 1). Additional ra- of MR imaging. MR cholangiopancreatographic dially oriented coronal oblique 2D thick-slab im- techniques involve the use of heavily T2-weighted ages can be acquired with the patient holding the sequences to accentuate the high signal from breath and are helpful when part of the anatomy relatively static fluid in the biliary tract while is obscured by overlapping structures (eg, fluid suppressing the signal from background tissues, in the duodenal bulb obscuring the distal CBD) including flowing blood (Table 2) (6,7). Either on a single projection. State-of-the art 3D isotro- rapid acquisition with relaxation enhancement pic MR cholangiopancreatography is performed (RARE) or a variant thereof (eg, single-shot fast using a fast-recovery 3D RARE sequence (eg, spin-echo, half-Fourier acquisition single-shot 3D fast-recovery fast spin-echo), which has two
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