Abdominal

Imaging

Springer Science+Business Media, Inc. 2006

Published online: 7 February 2006

Abdom Imaging (2006) 31:575581

DOI: 10.1007/s00261-005-0118-x

PICTORIAL ESSAY

Secretin-stimulated MRCP
N. J. Lee,1,2 K. W. Kim,1 T. K. Kim,1,3 M. H. Kim,4 S. Y. Kim,1 M.-S. Park,1,5 A. Y. Kim,1
H. K. Ha,1 P. N. Kim,1 M.-G. Lee1
1

Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-gu,
Seoul 138-736, Korea
2
Department of Radiology, Eulgi Medical Center, 280-1, Hagye-dong, Nowon-gu, Seoul 139-711, Korea
3
Department of Medical Imaging, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, Canada M5G2C4
4
Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong,
Songpa-gu, Seoul 138-736, Korea
5
Department of Radiology, Yong Dong Severance Hospital, 146-92 Dokok-dong, Kangnam-ku, Seoul 137-270, Korea

Abstract
Secretin-stimulated magnetic resonance cholangiopancreatography not only facilitate the depiction of anatomic
variations or morphologic changes of the pancreatic duct
in the normal and diseased pancreas but also help assessing functional abnormalities of the exocrine pancreas. In
this article, we illustrate ndings of normal pancreas and
various pancreatic diseases on magnetic resonance cholangiopancreatography after secretin stimulation.
Key words: Magnetic
resonanceCholangiopancreatography, pancreasMagntic resonance, pancreatic
ductsMagnetic resonance, pancreatic function
Secretin

The accuracy of magnetic resonance cholangiopancreatography (MRCP) for assessing pancreatic ductal
abnormalities improves after intravenous secretin
administration because it leads to accumulation of uid
and bicarbonates within the pancreatic ducts. In addition
to stimulation of exocrine pancreatic glands, intravenous
administration of a bolus of secretin increases the tonus
of the sphincter of Oddi during the rst 5 to 6 min, which
inhibits release of uid through the papilla of Vater, and
then the tonus of the sphincter decreases [1]. Thus,
enlargement of the pancreatic ducts and an increased
amount of protons within the ducts may improve
depiction of the pancreatic ducts on MRCP [2]. Further,
dynamic MRCP after secretin administration allows
noninvasive functional evaluation of the pancreatic
exocrine gland because the extent of positive duodenal

Correspondence to: K. W. Kim; email: kimkw@amc.seoul.kr

contrast induced by drainage of pancreatic fluid through

the papilla can be assessed semiquantitatively.

Techniques
All examinations were performed by using a 1.5-T MR
system (Magnetom Vision, Siemens, Erlangen, Germany) with a phased array body coil. Coronal and oblique coronal T2-weighted images with single-shot rapid
acquisition with relaxation enhancement (RARE) were
repeatedly obtained to nd a proper view to cover and
display the entire main pancreatic duct. In general, the
coronal view was selected because it clearly depicted not
only the main pancreatic duct but also the biliary tract
and duodenum. For dynamic study, T2-weighted singleshot RARE images were obtained every minute after an
intravenous injection of secretin (1 U/kg body weight;
Secrepan, Eisai, Tokyo, Japan) for 10 min. MR imaging
parameters for the single-shot RARE sequence were an
innite repetition time, 1080-ms effective echo time, 240
echo train length, 30- to 50-mm slab thickness, 300-mm
eld of view, 240 times; 256 matrix size, and 3-s
acquisition time.

Normal findings
Although MRCP before secretin stimulation may display
the full length of the normal-caliber main pancreatic duct
in about 85% to 90% of normal individuals or patients
devoid of pancreatic disease, secretin stimulation clearly
improves delineation of the main pancreatic and Santorini ducts in all patients who have normal pancreatic
exocrine function [2]. Side branches are not seen in
healthy individuals. Chronologically, a progressive
measurable dilatation of the main pancreatic duct is
observed mostly within 2 to 6 min and peaks 2 to 3 min

576

N. J. Lee et al.: Secretin-stimulated MRCP

sequently, the caliber of the main pancreatic duct returns

to the baseline value as pancreatic juice flows out
through the papilla and progressively fills the duodenum.
Progressive filling of the duodenal lumen is best visualized 6 to 9 min after secretin injection (Fig. 1). In some
individuals, there may be no change in the diameter of
the main pancreatic duct after secretin stimulation, but
duodenal filling occurs.

Findings of various pancreatic

diseases
Pancreas divisum
Pancreas divisum is the most common pancreatic anomaly, with an incidence of 5% to 10%. It has been suggested
that pancreatic divisum predisposes to an obstructive
pancreatopathy [4], but this assertion remains controversial [5]. The embryologic etiology for pancreas divisum
is the failure of complete fusion of the dorsal and ventral
pancreatic anlages. The duct of Santorini drains the
dorsal pancreas to the minor (or accessory) papilla,
whereas the duct of Wirsung drains the ventral pancreas
to the major papilla. Pancreas divisum is classified into
complete and incomplete types. The complete type is
defined as complete failure in the fusion of the ventral and
dorsal ducts (Fig. 2), whereas incomplete pancreas divisum is defined as communication of the ventral and
dorsal ducts by a small channel, with drainage predominantly through the accessory papilla (Fig. 3).
Secretin administration allows better evaluation of
the vaterian sphincter anatomy and detection of pancreas
divisum. Moreover, secretin-stimulated MRCP is a
physiologic challenge to assess the signicance of any
degree of accompanying stenosis of the minor papilla.
Patients with a positive secretin-stimulation test for
minor papillary stenosis may be more likely to benet
from an endoscopic minor papillotomy [6].

Santorinicele

Fig. 1. Normal secretin-stimulated MRCP in a 22-year-old

man. A On MRCP before secretin administration, the main
pancreatic duct (arrowhead) is faintly visualized. B MRCP
image 5 min after secretin administration improves visualization of the main pancreatic duct with an increase in ductal
diameter (arrowheads). C Pancreatic duct diameter returns to
the baseline value on MRCP 10 min after secretin administration (arrowhead). Progressive filling of the duodenal lumen
(asterisk) is also visualized.

after secretin injection by a secretin-stimulated increase

in fluid secretion by ductal cells and by a simultaneously
increased tonus of the sphincter of Oddi, which inhibits
release of fluid through the papilla of Vater [2, 3]. Sub-

The term Santorinicele has been used to describe a focal

cystic dilatation of the terminal portion of the dorsal
pancreatic duct at the minor papilla. The prevalence of
this rare anomaly is unknown, and it is unclear whether
it is congenital in origin or an acquired lesion secondary
to stenosis of the dorsal duct orifice. Although it has
been assumed that Santorinicele is related to the
obstruction of pancreatic outflow and resultant pancreatitis that occurs in pancreas divisum [7], it has been
reported in a patient without pancreas divisum [8].
Secretin-stimulated MRCP is helpful to assess the significance of a Santorinicele because it strongly indicates
significant papillary stenosis if a Santorinicele becomes
more apparent after secretin administration, which
means that the patient is likely to respond to endoscopic
papillotomy [7] (Fig. 4).

N. J. Lee et al.: Secretin-stimulated MRCP

Fig. 2. Pancreas divisum in a 59-year-old man. A On MRCP

before secretin administration, it is difficult to see the opening
of the pancreatic duct into the duodenum. B MRCP image 5
min after secretin administration clearly shows an abnormal
course of the dorsal pancreatic duct crossing the common bile
duct (arrowheads) to terminate at the minor papilla (short
arrow). The common bile duct terminates normally at the
major papilla (long arrow). The ventral pancreatic duct is not
seen. C MRCP image 10 min after secretin administration
shows persistent dilatation of the dorsal pancreatic duct (arrow) compared with the image before secretin administration.

577

Choledochocele

Fig. 3. Incomplete pancreas divisum in a 53-year-old woman. A MRCP image obtained before secretin administration
shows an abnormal course of the dorsal pancreatic duct
(arrowheads), i.e., crossing the common bile duct to terminate
at the minor papilla. B MRCP image 5 min after secretin
administration clearly shows a small communication (arrowhead) between the dorsal and ventral pancreatic ducts. C
MRCP image 10 min after secretin administration shows
prolonged dilatation of the main and dorsal pancreatic duct
(arrowhead), suggesting functional stenosis of drainage of the
exocrine pancreas.

A choledochocele is a rare and easily overlooked

anomaly of unknown etiology. It is a protrusion of a
dilated intramural segment of the common bile duct into
the duodenum, analogous to an ureterocele. Because it is

often seen in patients who have had a cholecystectomy, it

may be partly acquired. Although it can be best diagnosed by endoscopic retrograde cholangiopancreatogra-

578

Fig. 4. Santorinicele in a 42-year-old man. A On MRCP

obtained before secretin administration, the main pancreatic
duct is faintly seen and there is a suspicious small cystic
lesion (arrow) near the second part of the duodenum. B
MRCP image 5 min after secretin administration clearly
visualizes all segments of the main pancreatic duct and an
accessory pancreatic duct. A Santorinicele, a cystic dilatation
of the accessory pancreatic duct (arrow), is also clearly depicted. C MRCP image 10 min after secretin administration
shows prolonged dilatation of the main pancreatic duct (arrow), suggesting functional stenosis of drainage of the exocrine pancreas.

N. J. Lee et al.: Secretin-stimulated MRCP

Fig. 5. Choledochocele in a 61-year-old man. A MRCP image obtained before secretin administration shows a small
cystic lesion (arrow) in the second part of the duodenum. B
MRCP image obtained 5 min after secretin administration
better displays a choledochocele or protrusion of a dilated
intramural segment of the common bile duct into the duodenum (arrow). C Photograph from endoscopy shows cystic
dilatation and protrusion of an intramural segment of the
common bile duct into the duodenum.

N. J. Lee et al.: Secretin-stimulated MRCP

Fig. 6. Chronic pancreatitis with pancreas divisum in a 43year-old woman. A MRCP image before secretin administration shows an abnormal course of the dorsal pancreatic
duct, i.e., crossing the common bile duct. There is irregular
dilatation and multifocal stenosis (arrowheads) of the main
pancreatic duct. B On MRCP 5 min after secretin administration, the diameter of the main pancreatic duct increases
and the ventral pancreatic duct (large arrow) is visualized.
There are multifocal strictures and dilatation of the main
pancreatic duct (small arrows) and dilatation of side branches
in the tail. C Pancreatic duct diameter returns to its baseline
value on MRCP 10 min after secretin administration. Duodenal filling is seen beyond the genu inferius, most likely
indicating a preserved pancreatic exocrine reserve.

579

Fig. 7. Chronic pancreatitis with decreased exocrine reserve in a 41-year-old man. A MRCP image obtained before
secretin administration shows dilatation of the main pancreatic duct in the body and tail and segmental stenosis in the
head and neck (arrowhead). B On MRCP obtained 5 min after
secretin administration, there is no change in the main pancreatic duct caliber. C On MRCP obtained 10 min after
secretin administration, there is no change in the main pancreatic duct caliber. Duodenal filling after secretin stimulation
is not seen, indicating severe impairment of the exocrine
pancreatic reserve.

phy, MRCP sometimes demonstrates the presence of a

choledochocele that presents with a cobra-head
appearance that bulges into the duodenum. With an in-

580

Fig. 8. Leakage of pancreatic juice with necrotizing pancreatitis in a 39-year-old man. A On MRCP obtained before
secretin administration, the main pancreatic duct is only partly
visualized in the tail (arrow). B On MRCP obtained 5 min after
secretin administration, the main pancreatic duct caliber increases in the tail (arrow). However, the main pancreatic duct
in the other part of the pancreas is still not visualized due to
pancreatic necrosis. A linear hyperintensity (arrowhead) is
seen in the pancreas tail, suggesting leakage of pancreatic
juice. C MRCP obtained 10 min after secretin administration
shows improved opacification of the pancreatic duct in the tail
(arrow), nonvisualization of the duct in the other part, and
leakage of pancreatic juice in the tail (arrowhead).

N. J. Lee et al.: Secretin-stimulated MRCP

Fig. 9. Papillary stenosis in a 55-year-old man. A MRCP

image before secretin administration shows mild dilatation of
the main pancreatic duct (arrowhead). B MRCP image 5 min
after secretin administration clearly shows a marked increase
in main pancreatic duct caliber (arrowheads). C MRCP image
10 min after secretin administration shows persistent dilatation of the main pancreatic duct (arrowheads) compared with
image before secretin administration, thus indicating significant papillary stenosis.

creased volume of pancreatic juice, secretin-stimulated

MRCP may improve depiction of a choledochocele
(Fig. 5).

581

N. J. Lee et al.: Secretin-stimulated MRCP

Segmental stenosis of pancreatic

duct in chronic pancreatitis
Morphologic changes to the main pancreatic duct in
chronic pancreatitis include dilatation, irregular contour,
and narrowing or stricture formation. Although insufcient visualization of the downstream pancreatic duct on
MRCP before secretin administration may lead to a
relatively high frequency of overestimation of severe
stenotic portions of the pancreatic duct, the length and
severity of the pancreatic duct stenosis can be better
evaluated with MRCP after secretin stimulation (Fig. 6).
After secretin administration, visualization of the distal
main pancreatic duct to the stenosis improves, as does
visualization of the main pancreatic duct, in patients with
a normal pancreas because normal ductal segments are
considered soft and flexible and therefore are dilated
with secretin. In contrast, segments that are affected by
chronic desmoplastic pancreatitis are not likely to be
dilated with secretin.

Decreased exocrine reserve in

chronic pancreatitis
Secretin-stimulated MRCP can visualize the amount of
pancreatic uid that is excreted into the duodenum and
indirectly estimate the pancreatic exocrine reserve, and
decreased duodenal lling volume after secretin administration is correlated with a decreased pancreatic exocrine reserve (Fig. 7). Changes in the caliber of the
pancreatic duct can be concomitantly observed with a
decreased duodenal filling volume grade. When no ductal changes are observed at MRCP after secretin
administration, depiction of decreased duodenal filling
likely represents the only way to diagnose early chronic
pancreatitis [9]. It may be assumed that exocrine insufficiency precedes ductal morphologic changes in chronic
pancreatitis, but discrepancies between morphologic and
functional changes in chronic pancreatitis remain a
matter of debate. Nevertheless, because endoscopic retrograde cholangiopancreatography and secretin stimulation test are invasive and time-consuming procedures,
secretin-stimulated MRCP is potentially useful for the
noninvasive assessment of pancreatic exocrine functional
changes.

Leakage of pancreatic juice

associated with acute pancreatitis
Intraparenchymal and extrapancreatic extravasations of
activated pancreatic digestive enzyme are responsible

for pancreatic tissue injury and damage to the pancreatic ductal system. Dynamic MRCP after secretin
administration sometimes facilitates the diagnosis of
leakage of pancreatic juice associated with severe acute
pancreatitis, which appears as an abnormal stulous
tract from the pancreatic duct and gradual accumulation of extraluminal pancreatic uid on serial MRCP
images (Fig. 8).

Papillary stenosis
In patients with papillary stenosis, the caliber of the
pancreatic duct increases dramatically after secretin
stimulation and remains enlarged for 10 min. Prolonged
ductal dilatation after stimulation has been demonstrated to be a specic nding in pancreatic outlet
obstruction of various causes [10]. The delay of the
pancreatic duct to reach its maximum diameter after
secretin stimulation does not provide specific independent information except when papillary stenosis occurs
in the absence of pancreatic exocrine insufficiency
(Fig. 9).

References
1. Geenen JE, Hogan WJ, Dodds WJ, et al. (1980) Intraluminal
pressure recording from the human sphincter of Oddi. Gastroenterology 78:317324
2. Matos C, Metens T, Deviere J, et al. (1997) Pancreatic duct:
morphologic and functional evaluation with dynamic MR
pancreatography after secretin stimulation. Radiology 203:435
441
3. Cappeliez O, Delhaye M, Deviere J, et al. (2000) Chronic pancreatitis: evaluation of pancreatic exocrine function with MR
pancreatography after secretin stimulation. Radiology 215:358
364
4. Warshaw AL, Richter JM, Schapiro RH (1983) The cause and
treatment of pancreatitis associated with pancreas divisum. Ann
Surg 198:443452
5. Delhaye M, Engelholm L, Cremer M (1985) Pancreas divisum:
congenital anatomical variant or anomaly? Gastroenterology
89:951958
6. Warshaw AL, Simeone JF, Schapiro RH, Flavin-Warshaw
B (1990) Evaluation and treatment of dominant dorsal duct
syndrome (pancreas divisum redefined). Am J Surg 159:59
64
7. Eisen G, Schutz S, Metzler D, et al. (1994) Santorinicele: new
evidence for obstruction in pancreas divisum. Gastrointest Endosc
40:7376
8. Byeon JS, Kim MH, Lee SK, et al. (2003) Santorinicele without
pancreas divisum. Gastrointest Endosc 58:800803
9. Kloppel G (1994) Pathology of severe acute pancreatitis. In:
Bradley EL, (ed).. Acute pancreatitis: diagnosis and therapy. New
York: Raven, pp 3546
10. Warshaw AL, Simeone J, Schapiro RH, et al. (1985) Objective
evaluation of papillary stenosis with ultrasonography and pancreatic stimulation. Am J Surg 149:6572