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Magnetic Resonance Cholangiography: Past, Present and Future: a Review

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Magnetic Resonance Cholangiography: Past, Present and Future: a Review European Review for Medical and Pharmacological Sciences 2010; 14: 721-725 Magnetic Resonance Cholangiography: past, present and future: a review F. MACCIONI*, M. MARTINELLI*, N. AL ANSARI*, A. KAGARMANOVA*, V. DE MARCO*, M. ZIPPI°, M. MARINI* *Department of Radiological Sciences, School od Medicine, “Sapienza” University, Policlinico Umberto I, Rome (Italy) °Clinical Science, Gastroenterology Unit, Ospedale S. Pertini, Rome (Italy) Abstract. – Introduction: Magnetic reso- Introduction nance cholangio-pancreatography (MRCP) is a valuable method for the evaluation of biliary and Since its first clinical introduction, dated pancreatic diseases and a valuable alternative to 1 endoscopic retrograde cholangiopancreatogra- 1991 , magnetic resonance (MR) cholangio-pan- phy (ERCP). It is noninvasive and does not re- creatography (MRCP) has proved to be a reliable quire the use of contrast material or ionizing ra- technique in the evaluation of biliary and pancre- diation. Since its introduction in 1991, this tech- atic ducts obstruction. In the early phases of its nique has significantly improved in spatial reso- clinical application it was considered as a second lution, now allowing the accurate assessment of level examination in the diagnostic work up of the major bilio-pancreatic diseases. the obstructive jaundice, following percutanous State of the Art: MRCP is commonly per- formed with heavily T2-weighted sequences in or- trans-hepatic cholangiography (PTC) and endo- der to highlight static fluids, as those contained in scopic retrograde cholangio-pancreatography dilated pancreatic and biliary ducts. Newest MR (ERCP), considered as first level examinations. equipments allow to perform MRCP within 10-15 During the last two decades, this imaging minutes, due to the availability of ultra-fast se- technique has significantly increased its diagnos- quences. Currently, MRCP is widely performed as a tic role in the diagnosis of obstructive jaundice. primary imaging modality for the assessment of 2-5 obstructive jaundice and other benign or malig- Several papers have demonstrated the extreme- nant bilio-pancreatic ducts abnormalities. The pri- ly high diagnostic accuracy of MRCP in the de- mary MRCP application is the evaluation of biliary tection of biliary duct stones, benign biliary stric- obstructions due to choledocholithiasis, iatrogenic tures as well as malignant lesions of the biliary strictures, cholangiocarcinoma or pancreatic carci- tree, particularly the Klatskin tumor. noma. Other MRCP applications include the as- MRCP is nowadays widely diffuse and used as sessment of the exocrine pancreatic function, fol- a primary non invasive imaging modality in the lowing secretin stimulation. Whenever needed, the MRCP may be completed with a conventional con- diagnosis of obstructive jaundice. It plays a pri- trast-enhanced magnetic resonance imaging (MRI) mary role in the work up and therapeutic opera- of the upper abdomen and functional studies as tive planning of the obstructive jaundice. In pres- well, thus providing an all-in-one mophological and ence of a severe obstructive jaundice, the choice functional study of the pancreas and biliary sys- of a surgical, rather than an endoscopic or percu- tem. More recent applications include the possibili- taneous treatment is usually founded on the ty of 3D reconstructions and the use of hepato-bil- iary contrast agents, that provide a higher defini- analysis of MRCP results. Currently, the role of tion of the biliary tree, both in pathologic and nor- invasive procedures, such as PTC or ERCP, is in- mal conditions. The introduction of 3Tesla mag- terventional rather than diagnostic. nets could provide higher anatomic detail. The objective of this paper is to review the Conclusions: In the next years the role of main current indications of MRCP and to show MRCP will further expand, due to the availability its future perspectives in the evaluation of biliary of faster sequences, 3D imaging and functional and pancreatic diseases. studies. Key Words: State of the Art The magnetic resonance imaging (MRI) display MRCP, Bile ducts, Biliary stones, Pancreatic ducts. of the biliary tree is usually obtained by acquiring Corresponding Author: Francesca Maccioni, MD; e-mail: [email protected] 721 F. Maccioni, M. Martinelli, N. Al Ansari, A. Kagarmanova, V. De Marco, M. Zippi, M. Marini heavily T2-weighted sequences. Such sequences pancreatic ductal system (main and secondary highlight static fluids, including those present in the ducts). Moreover, by acquiring consecutive MR- dilated pancreatic and biliary ducts, that appear CPs every 10 seconds from time 0 to 10 minutes markedly hyperintense on T2-weighted images. after secretin injection, it is possible to evaluate Coronal T2-weighted images can be viewed as thin the total amount of increased duodenal fluid, collimation sourve images (3-5 mm), and subse- which is a reliable index of the exocrine pancre- quently processed to obtain a MIP (maximum in- atic function7-11. tensity projection) image which is a chilangiogram- The primary current clinical applications of like prjectional image. Otherwise a coronal thick MRCP include all the main causes of ductal ob- slab (30 to 50 mm) can be obtained, to produce the struction, such as main bile duct lithiasis, iatro- same effect in a very short time (<5 seconds). Usu- genic strictures, cholangiocarcinoma, and pan- ally both imaging technique are associated and re- creatic adenocarcinoma. viewed, to achieve the higher accuracy6. The overall accuracy of MRCP in the evalua- The MR cholangiographic effect is therefore tion of bile duct stones is extremely high, with obtained with T2 weighetd sequences in presence sensitivity and specificity values ranging from 96 of moderately to markedly dilated biliary or pan- to 100%2-6. Stones appear as dark filling defects creatic ducts, without the use of any contrast ma- of variable shape, round or prismatic, within the terial or ionizing radiation. Visualization of ducts biliary tree or gallbladder, less frequently in the at MR cholangiography, in fact, exclusively de- pancreatic ducts (Figure 1). pends on the presence of fluid (bile) within the Possible pitfalls include air bubbles, blood lumen: a marked duct dilation contains more bile clots, hypertrophy of the Oddi sphincter, that which provides higher ductal display at MRCP. mimic biliary duct stones. The evidence of dilated ducts is increased by MR cholangiography can accurately evaluate adding suppression of the background fat tissue: malignant obstruction of the biliary ductal system in this way the dilated biliary or pancreatic ducts by identifying the exact site of the obstruction and are greatly enhanced with respect to adjacent tis- the length and type of the stricture. All malignant sues and organs. By using ultrafast T2 weighted strictures usually appear as marked narrowings sequences, nowadays available in the newest MR with proximal bile duct dilatation. The sensitivity equipments, the overall examination time is ap- of MR cholangiography for the detection of bile proximately less than 15-20 minutes. ducts strictures is approximately 95%12. Malig- Contrast agents are not strictly necessary to nant obstruction occurring at the porta hepatis obtain MRCP images. However, negative oral are usually secondary to a cholangiocarcinoma contrast agents (so called “superparamagnetic” (Figure 2), metastatic disease, periportal lymph agents) can be usefully employed to reduce the nodes or invasive gallbladder carcinoma13. The brightness of the gastric and intestinal fluids, in extrahepatic biliary tract may be obstructed by order to enhance the evidence and brightness of lymphadenopathy from neoplasms arising in ad- the biliary tree and pancreatic ducts. jacent organs (e.g., gallbladder, pancreas, stom- MRCP is, therefore, a noninvasive and safe ach, colon)14,15, whereas neoplastic obstructions imaging technique in the evaluation of bile duct of the intrapancreatic distal portion of the com- dilation. New technical advances will likely pro- mon bile duct is more frequently caused by carci- vide a satisfactory visualization of normal anato- noma of the head of the pancreas or ampullary my and non dilated biliary ducts as well. carcinoma14. Malignant lesions usually manifest The MRCP examination can be completed as irregular strictures with shouldered margins, with a conventional MRI examination whenever whereas benign stenoses tend to have smooth bor- needed, with or without intravenous injection of ders with tapered margins12. MR cholangiography a Gadolinium chelate, particularly in presence of can be valuable in the evaluation and therapeutic pancreatic o biliary neoplastic obstruction. planning of patients with biliary-enteric anasto- Finally, MRCP offers the added possibility of moses. The failure rate of endoscopic retrograde a functional study, if performed during the intra- cholangiopancreatography in these patients varies venous administration of secretin, which physio- between 10% and 48%16,17, as compared with 3%- logically stimulates the exocrine pancreas. 5% in patients with normal anatomy17. MR The secretin rapidly increases the production cholangiography clearly depicts the site of the bil- of pancreatic fluids, thus increasing the duct size iaryenteric anastomosis and demonstrates the sta- and producing an excellent display of the entire tus of the intrahepatic ducts18,19. 722 Magnetic Resonance Cholangiography: past, present and future: a review A B Figure 1. CPRM in a patient with
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