Evaluation of Common Pancreatic Condition | Pancreatic Cancer | Pancreas

Radiol Clin N Am 41 (2003) 97 – 114

MR cholangiopancreatography: evaluation of common pancreatic diseases
Laura M. Fayad, MDa,*, Thomas Kowalski, MDb, Donald G. Mitchell, MDa

Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 North Wolfe Street, Baltimore, MD 21287, USA b Gastrointestinal Endoscopy, Division of Gastroenterology and Hepatology, 132 South 10th Street, 480 Main Building, Philadelphia, PA 19107, USA

In the initial evaluation of common pancreatic disorders, MR cholangiopancreatography (MRCP) has replaced the use of diagnostic endoscopic retrograde cholangiopancreatography (ERCP) at many institutions. MRCP is a heavily T2-weighted MR sequence that depicts the fluid-containing pancreatic duct in a noninvasive manner, avoiding potential complications associated with ERCP. MRCP is useful in the setting of pancreatitis for the identification of aberrant ductal anatomy and complications, and is valuable for detecting and characterizing cystic pancreatic masses. Furthermore, with the addition of conventional T1-weighted, T2-weighted, and gadolinium-enhanced sequences to MRCP, pancreatic adenocarcinoma can also be detected and staged. This article reviews MRCP with regard to the evaluation of common pancreatic diseases, with emphasis on its use for guiding treatment options.

Technique The normal pancreatic duct is a small structure, with a diameter of 3 mm or less, and is challenging to visualize completely by MR imaging. Because pancreatic ductal fluid has a long T2 relaxation time, a heavily T2-weighted sequence will result in high signal within the pancreatic duct, whereas background tissue, which has a shorter T2 relaxation

* Corresponding author. E-mail address: lfayad1@jhmi.edu (L.M. Fayad).

time, is suppressed. The ideal sequence will provide fast imaging, heavy T2 weighting for good duct-tobackground contrast and adequate spatial resolution for identification of subtle ductal pathology. A number of techniques have been employed to achieve heavy T2 – weighting, including steady-state free precession gradient-recalled echo imaging [1 – 4], twodimensional fast spin echo (2D FSE) [5 – 12], three-dimensional fast spin echo (3D FSE) [13 – 15], single-shot fast spin echo (SSFSE) [16 – 24], and a recently described method combining 3D FSE with echo-planar imaging [25]. SSFSE has become the most widely used sequence, because it provides ultrafast, reliable, MRCP imaging. Unfortunately, the trade-off of fast sequences is a loss of spatial resolution. Although ERCP offers superior spatial resolution, the resolution of SSFSE is increased when a 512 matrix acquisition or a small field of view is employed. In our experience, a duct with a diameter less than 1 mm can be seen, using a field of view of 24 cm2 and a matrix size of 256 Â 224 pixels. This level of resolution is acceptable for the evaluation of adults, but is insufficient for pediatric pancreaticobiliary imaging [26]. MRCP in the pediatric population requires a higher matrix or a smaller field of view. The SSFSE sequence can be implemented as a series of single thick-slab acquisitions [18,19] or as a thin multislice acquisition [18 – 21]. Single and multislice acquisition methods have been shown to provide complementary data for the evaluation of the pancreas [27,28], and are superior to older techniques of pancreatic evaluation [26].

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It may also demonstrate changes in the pancreatic duct following secretin administration [29 – 31]. 2). oblique. a multislice thin-section acquisition can be performed. Thin-section MRCP. images may be acquired at end expiration during relaxed natural breathing. The main drawback of the single-section acquisition is that ductal visibility may be degraded by overlap with other fluid-containing structures or ascites included in the field of view (Fig. (B) Coronal. 2). Overlap also can be overcome by tailoring the orientation and positioning of the thick slab to the patient’s ductal anatomy. to allow for recovery from the previous overlapping radial excitation. With intermediate TE. 1). common hepatic duct (H ). oblique. as defined by the white rectangle. A significant advantage of the single-slice method is its short acquisition time. The single-slice thick-slab acquisition method is attractive because a snapshot of the pancreaticobiliary system is obtained while respiratory and bowel motion is virtually eliminated.M. performed over several minutes. ideally. it is important to wait at least 10 seconds between acquisitions. Also shown are the common bile duct (B). which allows for the performance of a dynamic MRCP. Alternatively. (100 – 300 milliseconds). A multislice acquisition is typically performed with 4-mm or 5-mm thick slices with a shorter echo time (TE) than is used for single-section thick-slab acquisition (see Fig. thin-section SSFSE image showing a dilated pancreatic duct (arrow). To overcome overlap by fluid in the stomach. acquired at a different obliquity. Typically. Repeated sequential imaging of the same slab demonstrating the pancreatic duct and extrahepatic biliary tree. 1. showing unfolding of the pancreatic duct loop configuration (L). . patients should fast 4 hours before the examination or be given a T2-negative oral contrast agent such as high- concentrate ferric ammonium citrate [32]. 1. will resolve the possibility of sphincter of Oddi dysfunction. however.98 L. each requiring less than a 2-second breath hold. Regardless. fluid is bright and periductal structures are well seen. and no postprocessing of the images is required (Fig. (A) Coronal. Thick-section MRCP. thick-section SSFSE image of the patient in Fig. 30-mm to 50-mm thick slabs are prescribed in several oblique planes to depict the extrahepatic biliary and pancreatic ducts. chemically selective fat saturation is utilized to increase duct-to-background contrast. Alternatively. An imaging plane parallel to the pancreatic duct in the body and tail of the pancreas is employed and prescribed from an axial image (Fig. Because fat is bright on SSFSE images. Negative oral contrast may interfere with identification of the duodenum and ampulla of Vater. 2. Axial. and the cystic duct (C ). thick-section SSFSE image showing a normal pancreatic duct ( P) with a loop configuration (L). A thicksection coronal oblique image may be prescribed parallel to the main pancreatic duct. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig. Fig. 3). a feature particularly useful when malignant obstruction is suspected or an overlap artifact is noted on single-section acquisition.

sepsis (0. At many institutions. and no exogenous contrast is needed.40 – 43]. thick-section SSFSE image in a patient with autosomal-dominant polycystic kidney disease and multiple small liver cysts (small arrows) and renal cysts (R) depicted on the thick-section MRCP. ERCP may be technically impossible and fail in up to 20% of cases (Fig. with a consequent increase in the volume of fluids inside the pancreatic ducts [33]. MRCP with overlap of fluid-containing structures. In the first 5 minutes. Administration of secretin also provides an estimate of pancreatic exocrine function [31.15. and duodenum in one projection. 4) . showing the full length of the pancreatic duct. Secretin stimulates the secretion of fluid and bicarbonate by the exocrine pancreas. thin-section SSFSE image of the same patient shows delineation of the pancreatic duct ( P) in the pancreatic tail. MRCP shows the ductal diameter more accurately than does ERCP.47]. periampullary diverticula. In the case of duodenal and gastric obstruction. but motion will cause slice-to-slice misregistration.M.5%).9. and even death in up to 0. hemorrhage (1%). can be performed and used for reconstructing a 3D data set in any plane via maximum-intensity projection.L. In addition. A thick-slab acquisition. (A) Coronal.45].5% of cases [44. MRCP has a high success rate. MRCP has replaced ERCP for some indications. MRCP is noninvasive. and is less dependent on the operator’s skill. resulting in temporary increased pancreatic ductal pressure in healthy subjects [34].37 – 39] and better evaluation of sphincter and ductal anatomy. although the quality of projection images is usually superior with a fast thick-slab acquisition. The main limitation to the performance of s-MRCP is the additional cost and limited availability of secretin.20. Evaluation of pancreatic disease: MRCP or ERCP? Several studies have found MRCP comparable with ERCP for diagnosing extrahepatic biliary and pancreatic ductal abnormalities [2. however. 3. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 99 Fig. oblique. because contrast injection during ERCP may increase biliary duct caliber by as much as 6 mm [46. extrahepatic biliary tree. falsely giving the impression of ductal dilation. Secretin improves visualization of the pancreatic duct and reduces the false-positive depiction of strictures [29. Enlarged kidneys containing multiple cysts (R) are noted bilaterally.36]. uses no ionizing radiation. Image quality is unaffected by motion because each slice is acquired in less than 1 second. with potential complications including pancreatitis (3.31. secretin also causes the sphincter of Oddi to contract. Furthermore. perforation (1%). Secretin-enhanced dynamic MRCP (s-MRCP) is a technique for functional imaging and improved anatomic depiction of the pancreatic ductal system. No preparation is required for MRCP (other than brief fasting at some centers).29.48]. These fluid-containing structures obscure view of the pancreatic duct ( P) in the pancreatic tail. whereas ERCP failure rates range between 3% and 10% [44. and in patients who have had an operative choledochoenteric or pancreaticoenteric anastomosis. including pancreas divisum. the risk of sedation-related complications looms.9%). Even thinner sections of the pancreaticobiliary tree (as thin as 2 mm).35. can be performed dynamically with good temporal resolution to evaluate flow of pancreatic fluid from the pancreatic ducts into the duodenum. MRCP is also less expensive than is ERCP. whereas ERCP-related morbidity and mortality is not trivial. (B) Axial. Failure of ERCP may be due to limited operator skill.

less than 3 mm in caliber. unlike ERCP. Duodenal diverticulum. Thus. Such options include sphincterotomy. Coronal. 5. and cyst enucleation. A duodenal diverticulum is a common cause for ERCP failure. but further technical developments are needed to adequately rival the spatial resolution of ERCP. a duct can be visualized beyond an obstructing lesion. With MRCP. is visualized in more than 80% of patients. and especially in the 40% to 70% of patients who undergo ERCP who have normal studies [50. First. [18. segmental pancreatic resection. Second.49]. Patterns of drainage of the pancreas also vary. but it most commonly descends. The pancreatic duct course varies greatly. It can have a loop configuration. The pancreatic duct ( P) also appears normal. however. and hemorrhage. oblique. The development of s-MRCP may offset the Fig. abscess. Combined with traditional T1-weighted and T2-weighted sequences. endoscopic lithotomy. Usually. and biopsy. due to its limited spatial resolution. more precise definition of the pancreatic side branches can be attained by ERCP than by MRCP [54]. The caliber of the duct increases slightly from the pancreatic tail to the head. is challenging to visualize completely by MRCP. depending on the Fig. argue that MRCP provides guidance for these therapeutic alternatives. thick-section SSFSE image showing an anomalous union of the common bile duct with the pancreatic duct ( P) and a long common channel (long arrow). Fayad et al / Radiol Clin N Am 41 (2003) 97–114 lack of spatial resolution of conventional MRCP [30]. stricture dilation. Coronal. Proponents of MRCP. however. in a patient with a choledochal cyst (C ). the pancreas drains primarily through the duct of Wirsung.53]. oblique. The main duct receives 20 to 35 short tributaries that enter perpendicularly.M. 1) [28]. thicksection SSFSE image showing a duodenal diverticulum with an air-fluid level (long arrow) lateral to a normal common bile duct (B). which joins the bile duct at the major papilla [28]. Choledochal cyst and anomalous pancreaticobiliary junction. stent placement. brush cytology. MRCP also allows for complementary imaging of extraductal disease.100 L. An accessory duct of Santorini that drains through the minor papilla is present in 44% of individuals. Such situations include the recently advocated lessinvasive pancreatic surgeries. in which management of the pancreatic duct and its ductules is vital to prevent postoperative pancreatic leaks leading to fistula formation. . MRCP appears to be an excellent first choice in the workup of patients with pancreatic disease and should be considered the test of choice in all patients with failed or incomplete ERCP [49. the higher level of spatial resolution achievable by ERCP may be of critical importance in situations in which precise delineation of the pancreatic side branches is needed. and is not always visualized by MRCP.51]. but are not usually seen in the normal pancreas by MRCP.52. In 90% of cases. 4. in most patients. Pancreatic ductal anatomy and the significance of anatomic variants The normal pancreatic duct. There are two main limitations of MRCP. MRCP offers no therapeutic options at the time of diagnosis. collection of pancreatic juice. particularly at the point of fusion of the ducts of Santorini and Wirsung in the pancreatic neck (see Fig. The normal main pancreatic duct.

This channel is present in 33% to 83% of patients with choledochal cysts and is important to identify. There is no consensus regarding the appropriate endoscopic treatment for recurrent pancreatitis associated with pancreas divisum. there is an anomalous union of the pancreatic and bile ducts. Cannulation of the major papilla (long arrow) during ERCP results in opacification of the small ventral duct only. A potential role of MRCP in the diagnosis of pancreas divisum is to identify a subset of patients with pancreas divisum and pancreatitis who may benefit from these invasive treatments. 6). An astute endoscopist will recognize this pattern. potentially mimicking pancreatic cancer. only the ventral duct is opacified. The role of MRCP in pancreatitis Fig.55]. The termination of the ventral duct can be mistaken for occlusion of the main duct.60]. and placement of a transpapillary pancreatic stent has been touted as a safe and effective endoscopic treatment [66]. but it occurs more frequently in patients who present with acute recurrent pancreatitis than in the general population [61 – 65]. Sica et al [69] showed sensitive detection . because it shows a continuous dominant dorsal pancreatic duct. Pancreas divisum. resulting in elevated pancreatic duct pressure that may precipitate pancreatitis. When standard cannulation of the major papilla is performed on ERCP. after sphincterotomy of the minor papilla. when the dorsal (Santorini) and ventral (Wirsung) pancreatic ducts fail to fuse (Fig. Fortunately. and patients had symptomatic improvement. 5) [56. What is the state of the pancreaticobiliary tree in patients with acute and chronic pancreatitis? This frequent indication for ERCP may now be answered by MRCP. because no communication with the major papilla exists for adequate decompression. Elnemr et al [58] reported that 18. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 101 MRCP sequence used [28. thick-section SSFSE image showing pancreas divisum with the dorsal (D) and ventral (V ) ducts. resulting in incomplete ductography.68].3% of patients with gallbladder cancer had an anomalous union. In a patient with pancreas divisum. A santorinicele is believed to result from relative obstruction and weakness of the distal ductal wall and has been suggested as a possible cause of relative stenosis of the accessory papilla [67. Fulcher and Turner [28] depicted the main pancreatic duct in the head and body in 97% of cases and in the tail in 83% of cases. Coronal. but MRCP can easily demonstrate the anomaly and is an accurate method for diagnosing pancreas divisum. Papillotomy of the minor papilla appears to yield improvement in most cases. Manfredi et al [30] showed that a santorinicele is associated with a partial functional obstruction at the level of the minor papilla. oblique. Following secretin administration. Such a subset includes patients with a true functional obstruction at the level of the minor papilla with or without a ‘‘santorinicele’’—a cystic dilation of the distal dorsal duct just proximal to the minor papilla. 6.M. conventional MRCP detected fewer cases of pancreas divisum with or without santorinicele compared with s-MRCP (50% and 57%. the onset of duodenal filling was delayed significantly in patients with pancreas divisum and a santorinicele compared with patients with pancreas divisum alone. In this study [30]. respectively). Gallbladder carcinoma is also more frequent in patients with an anomalous union than in those without such a union.57]. an abnormally dilated duct can be seen in 100% of cases [40].L. The most common anatomic abnormality of the pancreas—pancreas divisum—occurs in 5% to 14% of the population [59. the size of the main pancreatic duct and of the santorinicele was significantly reduced. because its presence may alter the operative approach undertaken at surgical resection (Fig. In 1. The accuracy of MRCP in the diagnosis of pancreas divisum has been demonstrated to be 100% [41]. the minor papilla may provide a functional obstruction.5% to 3% of individuals. which results in an unusually long common channel proximal to the duodenum. Furthermore. Pancreas divisum is commonly detected incidentally in asymptomatic patients.

(A) Coronal. thick-section SSFSE image showing gallstones (short arrows) and common bile duct stones (long arrows) in the setting of acute pancreatitis. especially in the early stages of chronic pancreatitis. MRCP can be used to support a clinical diagnosis.102 L. MRCP may be used to suggest its cause and to detect complications of pancreatitis. Remaining cases are idiopathic. oblique. Nonalcoholic duct- Fig. thick-section SSFSE image showing a markedly dilated pancreatic duct (large arrow) with markedly dilated side-branches (small arrows) in a patient with chronic alcoholic pancreatitis. oblique. inflammatory disease. MRCP is focused on the noninvasive detection or exclusion of choledocholithiasis. pancreatic cancer. Possible causes of recurrent acute pancreatitis include choledocholithiasis. in some instances. 8). Chronic pancreatitis. Chronic pancreatitis is a chronic inflammatory process that results in pancreatic parenchymal atrophy and fibrosis. 7. thin-section SSFSE image showing gallstones (short arrow) and common bile duct stones (long arrow). 8. Acute pancreatitis secondary to stones. Alcoholism is the cause of at least 70% of cases. representing pancreatic duct stones (arrows) in a patient with chronic alcoholic calcific pancreatitis.M. may be suggested by MRCP [70]. In the setting of a single episode of acute pancreatitis. 7) [50]. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig. noting that only 30% to 52% of suspected calculi are present in patients referred for ERCP (Fig. and inherited diseases causing abnormal pancreatic enzymes or ductal secretion. autoimmune disorders. The high incidence of negative results using ERCP suggests that a noninvasive test such as MRCP should be used to screen these patients to avoid unnecessary morbidity and mortality. (B) Axial. (A) Coronal. lacks calcifications. and is associated more often with main duct dilation. In patients with chronic pancreatitis. fat-suppressed. and accurate characterization of duct segments with MRCP that were comparable with ERCP. (B) Axial. . Sphincter of Oddi dysfunction is also a cause of recurrent pancreatitis that. In the setting of recurrent acute pancreatitis. Approximately 10% of cases are attributed to chronic ductal obstruction. whereas obstructive pancreatitis is more homogeneous. or an anatomic abnormality such as pancreas divisum. 2D FSE image showing small hypointense filling defects in the pancreatic duct and its side branches. Alcoholic pancreatitis is usually heterogeneous and characterized by side-branch dilation and ductal calcifications (Fig. The pancreas ( P) is enlarged and heterogeneous in this patient with acute pancreatitis. thinsection.

At a later stage. MRCP may be used in conjunction with other MR sequences. Areas of focal narrowing produce a characteristic beaded ‘‘chain of lakes’’ appearance. thin-section SSFSE image acquired more anteriorly.37]. 9. the main pancreatic duct is dilated with loss of the normal tapering of the duct in the tail. 9). thin-section SSFSE image showing the findings in Fig. loses distensibility and has decreased exocrine function [31. Side-branch ectasia is the most specific and prominent feature of alcoholic chronic pancreatitis. pseudocysts. T1-weighted. including a dilated pancreatic duct (large arrow) with filling defects representing mucus (small arrows). MRCP is not only important for detecting chronic pancreatitis. without ductal calcifications [71. (A) Coronal. (B) Coronal.M. degree of ductal dilation. Even the biliary tract may become dilated as a result of fibrosis in the head of the pancreas. MRCP has demonstrated the pancreatic duct. . nonenhanced. presence of ductal filling defects. Early alcoholic chronic pancreatitis manifests as irregularities and dilation of the ductal side branches. MRCP agrees with ERCP in 83% to 100% of ductal Fig. thick-section SSFSE image showing changes of chronic pancreatitis. (C) Coronal. These side branches may be below the limits of resolution of MRCP. so ERCP is generally more sensitive to early side-branch changes. and associated complications such as pseudocysts all influence the therapy of patients with chronic pancreatitis. after stimulation with secretin. (D) Axial.L. In addition. The dilated pancreatic duct (arrow) and two pseudocysts (C ) are again noted. Chronic pancreatitis. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 103 destructive pancreatitis—or autoimmune pancreatitis—is characterized by a narrow pancreatic duct and diffuse parenchymal abnormality. especially nonenhanced T1-weighted images. typically involving the pancreatic body and tail. C. which show low pancreatic signal intensity in patients with chronic pancreatitis. gradient echo image showing decreased signal in the pancreas ( P) from fibrosis. 9A in greater detail. oblique. but is also valuable for the identification of a surgically or endoscopically correctable lesion (Fig. and two pseudocysts (C ).72]. The location of strictures.

and in 92% to 100% of filling defect cases [36. On MRCP. filling defects—representing mucus. compared with chronic obstructive pancreatitis due to adenocarcinoma. Also. (A) Coronal. with a main duct diameter of less than 3 mm. dilation cases. calculi and debris—can be reliably identified with a diameter as small as 2 mm [40]. although ERCP can consistently determine the presence or site of communication of a pseudocyst with the main pancreatic duct. particularly those tumors arising in the head. partial pancreatectomy. when using MRCP it is important to fully describe the state of the pancreatic duct in the setting of chronic pancreatitis to adequately guide treatment options. on the size of the main pancreatic duct. MRCP may be helpful to aid in this differentiation. . MRCP is. as well as endocrine dysfunction that occurs in 33% of patients with chronic pancreatitis [74]. 3D. duct-destructive chronic pancreatitis. Unfortunately. For example. the degree of enhancement cannot be used to reliably distinguish these entities because abundant fibrosis is seen in both chronic pancreatitis and carcinoma. which relieve pain in 75% to 90% of patients. Duct decompression by surgery depends. and debris may be removed endoscopically through a pancreatic duct sphincterotomy. total pancreatectomy. in 70% to 92% of ductal narrowing cases. (B) Axial. an obstructing lesion should be suspected (Fig. gradient echo image of the pancreas obtained in the arterial phase following the administration of intravenous gadolinium shows a hypoenhancing mass (arrow) that is responsible for obstruction of the pancreatic duct with resultant obstructive pancreatitis distally. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig.43]. the chronically inflamed pancreas will enhance more than will pancreatic tumors on immediate postgadolinium images. which are missed approximately 50% of the time by ERCP [73]. because chronic alcoholic pancreatitis. because early decompression delays the onset of exocrine dysfunction. The ratio of duct caliber to pancreatic gland width is higher in patients with carcinoma [80]. Differentiating adenocarcinoma from mass-forming chronic pancreatitis with MR imaging is sometimes difficult. mucus.104 L. accounting for their similar appearances [78]. Pancreatic ductal adenocarcinoma is the usual cause of chronic obstructive pancreatitis and comprises 75% to 90% of all pancreatic carcinomas [77]. Focal obstructive pancreatitis due to adenocarcinoma of the pancreas. Filling defects such as calculi. requires a drainage procedure different from that required for a duct diameter over 7 mm [75. 10). 10. and endoscopic decompression. Hence. and strictures can be dilated with short-term stent placement to improve pain [75]. however.M. T1-weighted. superior for detecting pseudocysts. Therapeutic options for chronic pancreatitis include surgical decompression. Typically. thick-section SSFSE image showing a dilated pancreatic duct (thick arrows) in the body and tail of the pancreas with termination (thin arrow) of the duct in the body. Ductal decompression is the main principle of therapy. is more frequently associated with an irregularly dilated duct with intraductal calcification [79].76]. in part. Chronic pancreatitis or carcinoma? When findings of chronic pancreatitis are identified in a patient without a prior history of chronic pancreatitis or of ethanol abuse.

both the pancreatic duct ( P) and common bile duct (C ) are dilated and abruptly terminate (large arrow) in the head of the pancreas. T1-weighted. including MR imaging pulse sequences. Comprehensive MR imaging is also useful to accurately determine resectability [85]. giving MR imaging a large advantage for their diagnosis. Because morphologic features of benign and malignant strictures overlap.83]. A normal-sized pancreatic duct is present in up to 20% of patients with adenocarcinoma. thick-section SSFSE image showing the classic ‘‘double-duct’’ sign of pancreatic carcinoma. [81].L. 11) [82]. as well as malignant lesions. The surgical definition of a pseudocyst requires that it be present for at least 6 weeks. Cystic pancreatic lesions include benign entities such as pseudocysts and epithelial pancreatic cysts. Less than 50% of pseudocysts are detected at ERCP [73]. In this case. These latter signs are useful when present. Furthermore. and should not dissuade its diagnosis in the setting of common bile duct dilation. helps to distinguish an inflammatory pancreatic mass from pancreatic carcinoma. Pseudocysts are usually accompanied by a clinical history of pancreatitis and are associated with pancreatic parenchymal and ductal . 12).M. the ‘‘duct-penetrating sign. nontender gallbladder caused by an obstructing tumor) (Fig. unlike its usual obstruction by pancreatic carcinoma. 11. (A) Coronal. gradient echo image showing an ill-defined hypointense mass (arrow) in the head of the pancreas. however.83]. The ‘‘duct-penetrating sign’’ refers to a nonobstructed main pancreatic duct penetrating an inflammatory pancreatic mass. (B) Axial. These lesions may communicate with the main pancreatic duct and may be identified on ERCP (Fig.’’ seen in 85% of chronic pancreatitis and in only 4% of patients with cancer. Other cystic lesions are discussed below. and microperforation of the pancreatic duct in chronic pancreatitis. A biopsy of this mass revealed pancreatic adenocarcinoma. caused by pancreatic duct disruption and tissue dissolution in acute pancreatitis. MRCP can depict the classic ‘‘double duct sign’’ of pancreatic carcinoma (enlargement and noncommunication of the pancreatic and common bile ducts) and the imaging counterpart of Courvoisier’s sign (an enlarged. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 105 Fig. has a sensitivity of 84% for diagnosing pancreatic carcinoma. Adding MRCP to conventional T1-weighted and T2-weighted sequences improves specificity by depicting extra- ductal structures not seen with ERCP [84]. however. Pancreatic pseudocysts occur as a complication of acute or chronic pancreatitis and represent 90% of cystic pancreatic masses [86]. however. the intrahepatic biliary ducts are also dilated. Epithelial cysts are usually associated with entities such as polycystic kidney disease and von Hippel-Lindau disease. ERCP may be the imaging modality of choice because of its ability to obtain a diagnostic sample with brush cytologic biopsy [75. Pancreatic adenocarcinoma. They are encapsulated collections of pancreatic fluid. but MRCP (like ERCP) is thought to be a poor way to differentiate benign from malignant strictures. Cystic pancreatic masses The incidence of detected cystic pancreatic masses is increasing because of the widespread use of cross-sectional imaging. whereas the corresponding sensitivity for ERCP with brush cytology varies between 33% and 85% [42. nonenhanced. MRCP.

Enlargement and hemorrhage are two factors that can be determined with MR imaging (Fig. 13). (A) Axial. thin-section SSFSE image showing a large complex cystic collection with a fluid – fluid level (arrow) representing a hemorrhagic pseudocyst in a patient with pancreatitis. These must be considered cautiously. making their differentiation from pancreatic neoplasms possible in most cases. Classification of cystic neoplasms is based on the location of the lesion. almost any pancreatic neoplasm can present as a cystic mass. gradient echo image showing hyperintensity (arrows) at the posterior aspect of the pseudocyst. (B) Axial. the size of the cysts. thin-section SSFSE image showing an uncomplicated pseudocyst (C) with communication to the pancreatic duct (arrow) in a patient with pancreatitis. Axial. Hemorrhage pseudocyst. Communicating pseudocyst. Treatment is considered when the patient is symptomatic.93]. The traditional approach for treating pseudocysts that require drainage has been surgical. . The head of the pancreas ( P) is denoted. the serous or mucinous nature of the contents. or if there is suspicion of a malignancy [88]. Fig. 13. representing hemorrhage. and surgical drainage. and the most dedifferentiated epithelial change recognizable at pathology [92. Pseudocysts resolve spontaneously in 60% of cases [87]. radiologic. Misdiagnosis. The head of the pancreas (P) is again denoted. 12. representing 10% of cystic lesions [86]. changes that suggest pancreatitis. in the event that a cystic neoplasm is misdiagnosed as a pseudocyst [88]. Cystic neoplasms of the pancreas are uncommon. Additionally. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig.M. which is the most common pancreatic neoplasm. Treatment options for persistent pseudocysts include endoscopic. usually by CT.106 L. has been reported as high as one third of the time [89 – 91]. T1-weighted. if the pseudocyst demonstrates enlargement or complications including hemorrhage. including adenocarcinoma.

Fayad et al / Radiol Clin N Am 41 (2003) 97–114 107 Parenchymal cystic lesions include serous and mucinous cystic neoplasms. Cystic neoplasms can easily be detected on MRCP because of their high fluid content. with a good prog- Fig. they may be confused with pseudocysts. thick-section SSFSE image showing a round. 14). characteristic of a serous tumor. with strict histologic criteria. this neoplasm was subcategorized into macrocystic adenomas and adenocarcinomas. Most mucinous cystic neoplasms have fewer than six cysts. and cystic duct (C) are denoted on this image. Although typically appearing solid on CT or US. each greater than 2 cm in diameter. this subcategorization is not appropriate. 15). The common bile duct (B). Mucinous neoplasms. usually grow slowly. changes of pancreatitis should be sought to confirm the possibility of a pseudocyst (Fig. and the soft tissue component is hypovascular. (B) Axial. pancreatic duct ( P). . A small serous tumor adjacent to the main pancreatic duct or a branch duct may be difficult to distinguish from an intraductal neoplasm. each measuring less than 2 cm in diameter. previously described in the literature under different names such as ductectatic mucinous cystadenocarcinomas. Their soft tissue component is typically hypervascular and aspirated contents contain glycogen [94]. well-defined. and postgadolinium sequences. now referred to as IPMTs. which are indistinguishable on the basis of imaging. In the past. Mucinous cystic neoplasms are also parenchymal lesions. Twenty-five percent of these lesions have calcification. Serous tumor. cystic mass (large arrow) in the head of the pancreas with a conglomerate of small cysts measuring less than 2 cm each. Intraductal tumors.L. but full examination requires T1-weighted. thus. In such cases. all mucinous cystic neoplasms should be considered malignant or potentially malignant. These tumors. Because these lesions are frequently unilocular. probably occur only in women and are usually located in the pancreatic body and tail. a serous adenoma is cystic with more than six internal cysts. Approximately 40% of these tumors have calcifications and 15% have a central stellate scar (Fig. Aspiration of these lesions yields mucin [92]. Serous microcystic adenomas are benign pancreatic parenchymal lesions with a relatively equal distribution throughout the pancreas. thin-section SSFSE image showing the cystic mass (thick arrow) with a suggestion of a central scar (thin arrow). Intraductal neoplasms are referred to as intraductal papillary mucinous tumors (IPMTs).M. In fact. T2-weighted. predominate in men and older individuals. (A) Coronal. 14.

IPMT is associated with excessive mucin secretion. without associated dilation of the pancreatic duct (thin arrow). 16. (A) Coronal.M. (B) Coronal. IPMT may involve the main duct or branch ducts of the pancreas. thin-section SSFSE image showing the cystic mass (thick arrow) with internal complex signal. Multiple IPMTs can be present in an individual—approximately 23% of the time—as described in a series by Megibow et al [99].98]. resulting in progressive ductal dilation or cyst formation (Fig. Resection of this mass yielded a benign mucinous cystic tumor. IPMT. (B) Axial. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig. IPMTs arise from the epithelial lining of the pancreatic ductal system and include lesions representing the histologic progression of epithelial hyperplasia. adenoma. (A) Coronal. and adenoma may undergo malignant transformation over many years [98]. Hyperplasia. thick-section SSFSE image depicting a cystic mass (thick arrow) in the tail of the pancreas. nosis. dysplasia. and invasive carcinoma [95 – 98]. Incidental note is made of a cystic duct remnant (C ). and microcystic or macrocystic masslike lesions involving the branch ducts [95. Mucinous tumor. Imaging patterns include segmental or diffuse involvement of the main pancreatic duct. 15. thick-section SSFSE image showing a cystic mass (large arrow) associated with a dilated pancreatic duct ( P) with dilated side branches. Fig. carcinoma-in-situ. .97. a finding that is highly suggestive of an intraductal papillary mucinous tumor. dysplasia. thin-section SSFSE image showing the cystic mass (large arrow) in communication with a dilated draining pancreatic duct ( P). 16). The pancreatic duct (thin arrows) is not dilated.108 L.

(C) Coronal. the adjacent pancreatic parenchyma is normal or thin. In such cases. is demonstrated with CT imaging approximately 25% of the time (Fig. thick-section SSFSE image showing an IPMT (thick arrow) with a dilated draining pancreatic duct ( P) and bulging papilla (thin arrow). 17. it may be difficult to differentiate between diffuse invasion of the main pancreatic duct and simple ductal dilation from mechanical obstruction. IPMT. mucin can be viscous enough to obstruct the pancreatic duct. minor papilla. thin-section SSFSE image again demonstrating a cystic mass representing an IPMT (thick arrow) with a dilated draining pancreatic duct and bulging papilla (thin arrow). In difficult cases. or both. IPMTs such as this can be difficult to differentiate from localized chronic obstructive pancreatitis.L. (B) Coronal. with bulging into the duodenal lumen. . (A) Coronal. The latter finding is pathognomonic of IPMTs. On occasion. possible papillary projections are noted within the cystic mass. preventing successful ERCP. hypointense filling defects representing mucin facilitate the diagnosis of IPMT. thick-section SSFSE image obtained in a different projection showing the dilated main pancreatic duct (thin arrows) in association with this IPMT (thick arrow). ERCP is valuable to demonstrate intraluminal mucinous filling defects with jellylike mucin leaking from the papilla. A finding virtually pathognomonic of IPMTs is dilation of the major papilla. In this case. When the IPMT is located in the head. another pathognomonic finding for IPMT. the endoscopist can confirm the pres- Fig. With segmental involvement of the main pancreatic duct. a bulging papilla is seen as a filling defect in the duodenum. differentiation from chronic pancreatitis may be difficult [100. Nevertheless. which can be seen on MR imaging and is well appreciated by ERCP. On thin-section MRCP images. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 109 When an IPMT involves the full length of the main pancreatic duct without a localized cystic mass. This finding.101].M. 17) [97].

Summary In the evaluation of common pancreatic diseases. et al. however.12: 2072 – 7. Shimoi M. determining the state of the pancreatic duct in pancreatitis.M. especially combined with other MR imaging sequences. et al. The features described above are influential in deciding whether an IPMT is benign or malignant. Weidenmaier W. which is likely related to chronic obstruction by mucus. ence of an IPMT by observing copious drainage of mucin from the papilla [97. the detection of nodules in the cystic lesion is better accomplished with MRCP than with ERCP [104. imaging cannot reliably distinguish benign from malignant tumors [111 – 113].114. The pancreatic duct (thin arrow) is slightly prominent.5 cm. Allen C. Obara et al [111] found that 83% of tumors larger than 4 cm were malignant.109].108.108. A branch-duct IPMT may be differentiated from a communicating pseudocyst if the IPMT contains papillary proliferations. Friedrich JM. Magnetic resonance cholangiography for evaluation of obstructive jaundice. it can resemble a mucinous cystic tumor or necrotic adenocarcinoma (Fig. The observation of thick walls and mural nodules aids the diagnosis of malignancy [104. [5] Meakem TJ. Because many of these patients are asymptomatic elderly individuals and growth may be slow or negligible over several years. MR cholangiography: Clinical evaluation in 40 cases. as well as diffuse main pancreatic duct dilation with the branch-duct type of IPMT [95]. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 Fig. If an IPMT manifests as a more cystic masslike lesion.115]. With the latter entities. MRCP. and demonstrate no solid components. 18). The size of the main pancreatic duct is References [1] Wallner BK. Branch-duct IPMT is most frequently located in the uncinate process and can have a macrocystic or microcystic appearance [97. Holland GA. [2] Morimoto K. the main pancreatic duct central to the tumor should not be dilated as it is in the presence of an IPMT. Radiology 1993. Generally. et al. techniques requiring endoscopy and percutaneous access are largely reserved for histologic diagnosis and treatment. MRCP is a noninvasive alternative to ERCP. 18. valuable—main pancreatic ductal dilation greater than 15 mm [109]. McDermott VG. spare the main pancreatic duct. Ductal anatomy can be ascertained without risk of complications. or for cases in which MRCP fails to establish a diagnosis. Wakayama T. Radiology 1992. but features have been described that suggest malignancy.105]. A review of cystic pancreatic masses by Megibow et al [99]. but at this time. A number of researchers have concluded that MRCP is more sensitive and effective than is ERCP in evaluating IPMT [54. Shirakawa T. surgical removal may not be the only appropriate management. Dilated biliary tract: evaluation with MR cholangiography with a heavily T2-weighted contrast-enhanced fast-sequence. Okada Y.102]. Schumacher KA. MRCP is valuable in defining common anatomic variants.104 – 107]. concluded that surveillance might be possible if lesions are smaller than 2.183:578 – 80. Surgical management is usually recommended when these lesions are encountered [99. however. does not offer definitive pathologic information to decide whether a lesion is malignant. The pancreas is atrophied.98]. Kobayashi T.181: 805 – 8. Communication with the main pancreatic duct is a valuable finding that is often demonstrated best on ERCP [103] and s-MRCP. representing multiple IPMTs (thick arrows). thin-section SSFSE image showing multiple cystic lesions in the pancreas.110 L. Fast spin-echo multicoil magnetic resonance cholangiog- . and characterizing neoplasms. With the advent of MRCP.110]. [3] Ishizaki Y. Am J Gastroenterol 1993. Multiple IPMTs.189:423 – 7. Radiology 1991. Owens C. however. a less-favorable histology is noted with the main-duct type of IPMT [99. Biliary obstruction: evaluation with three-dimensional MR cholangiography. is associated with malignancy. Axial. It is difficult to differentiate these cystic masses from pseudocysts and other pancreatic cystic lesions. [4] Hall-Craggs M. The size of the lesion is also important: in one series.

210:247 – 52.55:425 – 6. Gastroenterology 1996. Yucel EK. Honda H. Am J Roentgenol 1994. Wielopolski DR. Radiology 1996. Takahara T. et al. Barkum AN. Radiology 2000. Urata J. Ferrucci JT. Schneider B.171:1381 – 5. Radiology 2000. Fulcher AS. Takahashi M. Bohlman M. Brkum AN. et al. Breath-hold MR cholangiopancreatography with a long-echo-train fast spin-echo sequence and a surface coil in chronic pancreatitis.206:379 – 87.168(6): 1449 – 54.198:561 – 6. Yucel EK. Sekijima JH. Becker M. Tuchmann A. Urata J. In: Proceedings of the 12th Annual Scientific Meeting of the Society of Magnetic Resonance in Medicine. Irie H. Han JK. Guibaud L. Pancreas divisum and ‘‘santorinicele’’: diagnosis with dynamic MR cholangiopancreatography with secretin stimulation. Cholangiography before biliary surgery: single-shot MR cholangiography versus intravenous cholangiography. et al.70:455 – 79. Optimal MR cholangiopancreatographic sequence and its clinical application. Atri M. MR cholangiopancreatography: comparison between halfFourier acquisition single-shot turbo spin-echo and two-dimensional turbo spin-echo pulse sequences. echo-planar imaging and volume rendering.205:523 – 30. Breathhold MR cholangiography with snapshot techniques: prospective comparison with endoscopic retrograde cholangiography. Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 1995. Costamagna G. 41. Taourel P. Reinhold C. Chuttani R. Yoshikawa T. Blum U. Dreiling DA. MR cholangiography with a fast spinecho sequence [abstract]. MR cholangiopancreatography: efficacy of threedimensional turbo spin-echo technique. Radiology 1998. Soto JA. Bret PM. Naito M. Metens T.163:847 – 50. Radiographics 1999. Choi BI. Langer M. Sacmann M. Yamashita Y. Am J Roentgenol 1998. et al. Radiology 2000. 110:589 – 97. Hennig J.L. California: Society of Magnetic Resonance in Medicine. MR pancreatography: a useful tool for evaluating pancreatic disorders. Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single and multisection half-fourier rapid acquisition with relaxation enhancement sequence. Macaulay SE. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 raphy: initial experience [abstract]. Regan F. et al. Brizi M. Fradin J. Terrier F. Grossholz M. Laubenberger J.M. Berkeley. Geenen JE. Kim SJ. Bae SH.192:74 – 8. Pancreatic duct: morphologic and functional evaluation with dynamic MR pancreatography after secretin stimulation. Radiology 1996. Messer J. Ichijo K. Buchert M. Radiology 1995. The secretin story. Barish MA.209:435 – 42. Am J Roentgenol 1996. Reuther G. Choledocholithiasis: evaluation with MR cholangiography.196:227 – 32. Outwater EK. Chuttani R. Becker CD.166:1297 – 303. Evaluation of a non-breath-hold MR cholangiographic technique. Irie H. Diagnosis of choledocholithiasis: value of MR cholangiography. Abe Y. Tang Y. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Honda H.197: 109 – 15. et al. et al. et al. Nippon Igaku Hoshasen Gakkai Zasshi 1995. Evaluation of the pancreas: a comparison of single thick-slice MR cholangiopancreatography with multiple thin-slice volume reconstruction MR cholangiopancreatography. Reinhold C. Yamamoto H.203:435 – 41. Soto JA. Breath-hold MR cholangiopancreatography with three-dimensional. Costamagna G.165:295 – 300. Kim TK. Alvarez O. Oudkerk M. et al. Mentha G. Breath-hold projection magnetic resonance cholangiopancreatography (MRCP): a new method for the examination of the bile and pancreatic ducts. Deviere J. J Magn Reson Imaging 1993.3(P):131. p. Manfredi R. Ferrucci JT. Radiology 1997.214:849 – 55. Magnetic resonance cholangiography: comparison to endoscopic retrograde cholangiopancreatography. et al.200:85 – 9. Brizi MG. Ichijo K. Khazan R. Yamashita Y. Takehara Y. Abdom Imaging 1998. et al. Severe chronic pancreatitis versus suspected pancreatic disease: dynamic MR cholangiopancreatography after secretin stimulation. 1993. Soto JA. Tooyama N. Wielopolski PA. MR cholangiopancreatography using HASTE (half-fourier acquisition single- 111 [20] [6] [21] [7] [22] [8] [23] [9] [24] [10] [11] [25] [12] [26] [13] [27] [14] [28] [15] [29] [16] [30] [17] [31] [18] [32] [19] [33] [34] shot turbo spin-echo) sequences. Manfredi R. Tsuchigame T. et al. Saeki M. Value of MR cholangiopancreatography in evaluating choledochal cysts. Turner MA. Schulte SJ. Guibaud L. et al. Magnuson T. Am J Gastroenterol 1978. Chan Y. Holzknecht N. de Peyer R. Radiology 1999. Kaneko M. Miyazaki T. Masui T. Bret PM. Watahiki H. Barish MA. Am J Roentgenol 1999. Choledocholithiasis: evaluation of MR cholangiography for diagnosis. Takehara Y. Radiology 1998. segmented. Kiefer B.215:737 – 45. Am J Roentgenol 1995. Lam WWM. Radiology 1997. Radiology 1994. Gaa J. Reinhold C. Takahashi M. Matos C. In vitro and clinical studies of image acquisition in breath-hold MR cholangiopancreatography: single-shot projection technique versus multislice technique. Radiology 1998.33:18 – 23.23:398 – 403. Barish MA. Am J Roentgenol 1997. Sumi S.167:1441 – 5. High concentration ferric ammonium citrate (FAC) solution as a negative bowel contrast agent. Gauger J. Am J Roentgenol 1996.206:657 – 64.217:403 – 8. Choledocholithiasis and bile duct stenosis: accuracy of MR cholangiopancreatography. Tajima T. Magn Reson Med 1995. Bret PM. Dodds WJ. Intraluminal . Medina S.19:5 – 24. Hogan WJ. Jimi M. Atri M. Siegenberg D.173:1519 – 26. Chan ACW.

Shimizu S. Burhenne HJ. von Numers H. 6. Metens T. In: Berk JE.29:741 – 4. Nakajima Y.144:753 – 5. et al. Cooperberg PL. Radiology 1996. et al. Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study.000 cases.3: 108 – 10. Cappeliez O. Schapiro RH. Hachiya J. Am J Surg 1977. Comparison of endoscopic retrograde and magnetic resonance cholangiopancreatography in the surgical diagnosis of pancreatic disease.215:358 – 64. Doepel M. A historical perspective on the discovery of the accessory duct of the pancreas. Elevated pressure in the dorsal part of pancreas divisum: the cause of chronic pancreatitis. the ampulla of Vater and pancreas divisum. Osborne H. Muller D. Chuttani R. et al.8:16 – 22. Sugiyama M. 199:99 – 103. McCarthy JH. N Engl J Med 1999. Murray FE. Lee MJ.12:856 – 64. Taourel P. Ansel JH. et al. Radiology 2000.218(1):61 – 7. Kayahara M.356:190 – 3. Pancreas 1988. Meyer zum Buschenfelde KH. Am J Roentgenol 1999.135:141 – 4. Breer H. 1985. Ann Chir Gynaecol 1999. Turner MA. A new evaluation of pancreatic function after pancreaticoduodenectomy using secretin magnetic resonance cholangiopancreatography. Startitz M. Millat B.207:21 – 32. Fromkes JJ. Pellet O. Accuracy of common hepatic duct size in the evaluation of extrahepatic biliary obstruction. et al. Mirsa SP. Am J Surg 1999. Diagnosis of anomalous pancreaticobiliary junction: value of magnetic resonance cholangiopancreatography. Half-fourier RARE MR cholangiopancreatography: experience in 300 subjects. Pancreas divisum: its association with pancreatitis. Ohta T. Albert J. Deviere J. 196:459 – 64. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases. Gut 1980. Hanaoka H. Bilbao MK. Am J Surg 1998. Pancreas 1990. Yucel EK. Yamaguchi K. Diagnosis and treatment of common bile duct stones (CBDS): results of a consensus development conference. Mueller PE. Am J Roentgenol 1985.173:1527 – 33. et al. 175(3):203 – 8. et al. MR hydrometry to assess exocrine function of the pancreas: initial results of noninvasive quantification of secretion. Simeone J. Mizutani Y. Barish MA. Bernard JP. Radiology 1995. Cotton PB. Farrell MA. Clinical experience in 82 patients with pancreas divisum: preliminary results of manometry and endoscopic therapy. Radiology 1996. Value of magnetic-resonance cholangiopancreatography (MRCP) after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Radiology 2001. Soto JA. Ferrucci JU. Ferrucci JT. Liu TH. Sonographic measurement of the extrahepatic bile duct before and after retrograde cholangiography. Ferrucci JT. Reinhold C.123(4): 391 – 7.3:248 – 53. Adamek H. Paul A. Anomalous pancreaticobiliary ductal junction without bile duct dilatation in gallbladder cancer. et al. Cohen MM. Chronic pancreatitis: evaluation of pancreatic exocrine function with MR pancreatography after secretin stimulation. Hepatogastroenterology 2001. Breer H. 3569 – 80. Atri M. Lancet 2000. Atomi Y. Barish MA. Hedberg SE. Dotter CT. Barish MA. Adamek HE. Holthausen U. Endoscopic retrograde cholangiography: application in biliary tract disease. Takehara Y.134:539 – 43. Endoscopy 1997. Dwivedi M. Baba M. et al. Surg Endosc 1998. Sarles H. Pancreatic duct: MR cholangiopancreatography with a three-dimensional fast spin-echo technique. Elnemr A.70:314 – 20. et al. Giovanni M. p. Greenen JE. Halme L. Courtney G.21:105 – 14. Surgery 1998. Radiology 1980. Eur Radiol 1998.M. et al. Silvis S. Warshaw AL. Role of MR cholangiopancreatography in patients with failed or inadequate ERCP. Satterfield ST.88:127 – 31. Bret PM.176(3): 279 – 82. Kawashima A. Congenital anomaly of pancreas divisum as a cause of obstructive pain and pancreatitis. Sho M. The efficacy of magnetic resonance cholangiography for the evaluation of patients with suspected choledocholithiasis before laparoscopic cholecystectomy. Jakobs R. vol. Objective evaluation of am- [35] [36] [50] [51] [37] [38] [52] [39] [53] [54] [40] [55] [41] [56] [42] [57] [58] [43] [44] [59] [60] [45] [46] [61] [62] [47] [63] [64] [48] [49] [65] .112 L. Heverhagen JT.5:248 – 54.78:317 – 24. Yucel EK. Barkun AN. Zfass AM. Fulcher AS. Gut 1990. Sahel J. Pancreas divisum: evaluation with MR cholangiopancreatography. Magnetic resonance cholangiopancreatography: interest of IV secretin administration in the evaluation of pancreatic ducts. Complications of endoscopic retrograde cholangiopancreatography (ERCP). Kanehiro H.341(4):258 – 64. Guibaud L. Gastroenterology 1976. Soto JA. Schilling D. Varghese JC.31:1144 – 9. Chang VH. editor. MR cholangiopancreatography after unsuccessful or incomplete ERCP.27:203 – 12. Consorti ET.178:480 – 4.199:91 – 8. Weitz M. Cunningham JJ. Capps GW. Current concepts: magnetic resonance cholangiopancreatography. Philadelphia: WB Saunders. A study of 10. Nicaise N. Li D. Chijiiwa K. Stern CD. Gregg JA. Baker KM. Radiology 1998. Delhaye M. Can MRCP replace ERCP? J Magn Reson Imaging 1998. Yucel EK. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 pressure recording from the human sphincter of Oddi. Riemann J. 4th edition. Gut 1986. Bockus gastroenterology.48(38):382 – 6. Complications of diagnostic and therapeutic ERCP. Pancreaticobiliary ductal union.8:517 – 34. et al. Wong P. Battmann A. Lee TG. Pancreas 1988. Gastroenterology 1980. Am J Surg 1998.

ASGE guidelines for clinical application. 119:271 – 4.40:73 – 6. 148:489 – 93.21(4):174 – 80. Long-term results after endoscopic pancreatic stent placement without pancreatic papillotomy in acute recurrent pancreatitis due to pancreas divisum. Ito K. Albiin N. Van Steenbergen W. Am J Roentgenol 1998. Radiology 1999.52(1):9 – 14. Am J Roentgenol 1999. Problems in differential diagnosis. Sarles HG. Federle MP. [82] Freeny PC. Mosca F.23:410 – 22.174:1403 – 8. Surg Clin North Am 2001.’’ Histochemical and immunohistochemical analysis of 29 cases. Ectors N. Scarpa A. Bastidas JA. Acta Gastroenterol Belg 2000. MR angiography and dynamic helical CT in the evaluation of vascular invasion. [95] Irie H. Thompson JC.19(1):57 – 62. et al. The role of ERCP in diseases of the biliary tract and pancreas. [86] Gasslander T. Radiology 2001.28(3):615 – 39.209:532 – 8. Oyar O.36(6):462 – 6. Chronic calcifying pancreatitis-chronic alcoholic pancreatitis. Di Candio G.149:65 – 71.173:483 – 90. Serous cystic tumors of the pancreas. Campatelli A. Gryspeerdt S. Cooperman AM. Eur J Rad 2001.210:605 – 10. London SS. Karawasa E. Cooney MJ. Bloechle C. Guthrie JA. Ishigame K. Am J Surg Pathol 1995. Nonalcoholic duct-destructive chronic pancreatitis: imaging findings. Wilson D. CT pancreatogram in carcinoma of the pancreas and chronic pancreatitis. Cystadenocarcinoma versus pseudocyst of the pancreas: a difficult differential diagnosis. MR cholangiopancreatographic differentiation of benign and malignant intraductal mucin-producing tumors of the pancreas. Am J Roentgenol 2000. Santorinicele: new evidence for obstruction in pancreas divisum. Sica GT. et al.38(2):151 – 9. Townsend Jr CM. Outwater EK. Pseudocyst or cystic neoplasm? Differential diagnosis and initial management of cystic pancreatic lesions. Sou H. Oran I. Rogiers X. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 pullary stenosis with ultrasonography and pancreatic stimulation. Dynamic contrast-enhanced MR imaging and dual-phase helical CT in the preoperative assessment of suspected pancreatic cancer: a comparative study with receiver operating characteristic analysis.212:213 – 8.170:643 – 7. Blind evaluation of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic carcinoma: the ‘‘double duct’’ and other signs. Adams DF. 221:107 – 16. Matulis SR. [85] Sheridan MB. [87] Yeo CJ. Surg Clin North Am 1999. Baillie J. et al. Gastrointest Endosc 1994. Izbicki JR. Am J Surg 1985. Ozer H. [93] Nagar E. Biliary dilatation: differentiation of benign from malignant causes—value of adding conventional MR imaging to MR cholangiopancreatography. Agarwal N. Spencer JA. et al. Mucinous cystic tumors of the pancreas: clinicopathological features.46(3):202 – 6. Magnetic resonance cholangiopancreatography (MRCP) versus endoscopic retrograde cholangiopancreatography (ERCP): diagnostic usefulness. Ann Surg 1989. Aibe H. Surgery and chronic pancreatitis.21:331 – 3. Van Hoe L. Bilbao MK. Gastrointest Endosc 2000. Radiology 1999. Schutz S.17:43 – 55. Int J Pancreatol 1999. prognosis and relationship to other mucinous cystic tumors. Surgical treatment of chronic pancreatitis and quality of life after operation. Hepatogastroenterology 1989. Santorinicele as a cause of chronic pancreatic pain. Lynch-Nyhan A. [89] Boggi U.M. Am J Surg Pathol 1999.25(2):123 – 33. Metzler D. 113 [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] Ichikawa T. Duct-penetrating sign at MRCP: usefulness for differentiating inflammatory pancreatic mass from pancreatic carcinomas. Radiology 2000. Abdom Imaging 1996. Pamos S. Buanes T. When and how should drainage be performed? Gastroenterol Clin North Am 1999. Gastroenterology 1974.170:411 – 7. Chijiiwa K. Siebert DG.19:576 – 89. Arbab AS. Pancreatic pseudocysts. Ward J. Nealon WH.81(2):431 – 55. Radiology 1976. Knoefel WT. Goldberg HI.66: 604 – 16. 90:121 – 3. [90] Lumsden A. Kuechler T. Arnelo U. Curr Surg 1989. Yorulmaz I.50(6):915 – 20. Ozutemiz O. Katon RM. Chai JL. Nonoperative management of pancreatic pseudocysts. Am J Gastroenterol 1995. Mitchell DG. The natural history of pancreatic pseudocysts documented by computed tomography.63(3):254 – 9. Araki T. Moss AA. [92] Zamboni G. A new criterion in differentiation of pancreatitis and pancreatic carcinoma: artery-to-vein ratio using the superior mesenteric vessels. et al. Honda H. Bogina G. Ueki T. Eisen G. Cameron J. Semin Diagn Pathol 2000. [88] Pitchumoni CS. Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis. et al. et al. American Society for Gastrointestinal Endoscopy. Surg Gynecol Obstet 1990. [94] Compton CC. Elmas N. Braver J. Ertan A. Pancreatic carcinoma versus chronic pancreatitis: dynamic MR imaging. Gastrointest Endosc 1999. Permert J. Pancreatic carcinoma: MR. Geitung JT. Van Aken E. Dig Dis 2001. Radiology 1983. Craven CM. Brush cytology of ductal strictures during ERCP. [91] Lee YT. 214:173 – 81. Fishman E. Drijkoningen M. Miller FH. Johnson PT. Arslan A. Zinner M. .L. Outwater EK. Gastroenterol Hepatol 1998.79(4):913 – 44. Bradley 3rd EL. Yoshikawa T. Canelles P. Pietrabissa A. [84] Kim MJ. [83] Macken E. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with pancreatic pseudocyst associated with resolving acute and chronic pancreatitis. Intraductal papillary mucinous neoplasms of the pancreas associated with so-called ‘‘mucinous ductal ectasia. Rivera P. Cystic tumors of the pancreas. Cotton PB.

Radiology 1998. Radiology 1996. Fayad et al / Radiol Clin N Am 41 (2003) 97–114 [106] Onaya H. Van De Stadt J.26:303 – 7. et al. Payan MJ.48(4): 967 – 71. Carbognin G. et al. [110] Kobayashi G. Niitsu M. et al. Ichiimura T. Maguchi H. Hachiya J.24:1372 – 7. Am J Surg 1999. Biasiutti C. J Comput Assist Tomogr 1999.88: 564 – 9. Guarise A. Ponsot P. [108] Yamaguchi K. et al.23:301 – 5. [114] Horvath KD.M.87:634 – 8. Saitoh Y. Rickaert F.87:235 – 42. Michishita N. Bicego E. An aggressive resectional approach to cystic neoplasms of the pancreas. Mucin-producing tumor of the pancreas: natural history and serial pancreatogram changes. Radiographics 1999. Am J Gastroenterol 1992. Ogawa Y. Cystic pancreatic masses: cross-sectional imaging observations and serial follow-up. [102] Raijman I. Mucin-producing tumor of the pancreas: surgery or follow-up? Nippon Shokakibyo Gakkai Zasshi 1994. Chabot JA.170:815 – 6. Endoscopy 1994. [115] Kanazumi N. Sahel J. Mucin-producing pancreatic tumors: comparison of MR cholangiopancreatography with endoscopic retrograde cholangiopancreatography. et al. Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies. Chijiiwa K. Ogawa Y.19:1447 – 63. Namieno T. Fujiyoshi F. J Comput Assist Tomogr 1999. [107] Fukukura Y. Intraductal papillary tumors of the pancreas: evaluation with magnetic resonance cholangiopancreatography. [105] Koito K. [100] Agostini S.39: 457 – 64. Graziani R. Itai Y. Maguchi H. Nippon Shokakibyo Gakkai Zasshi 1990. Abdom Imaging 2001. et al. HASTE MR cholangiopancreatography in the evaluation of intraductal papillary-mucinous tumors of the pancreas. Gut 1996. Choux R. Chiijiiwa K. Intraductal papillary mucinous tumours of the pancreas: clinical and therapeutic issues in 32 patients. [99] Megibow AJ. Kaneko T. Megibow A. [103] Obara T. Ductectatic mucinous cystic neoplasm of the pancreas: evaluation with MR cholangiopancreatography.91:66 – 74. Mucinhypersecreting tumors of the pancreas: assessing the grade of malignancy preoperatively. 171:427 – 31. et al. Clement JP. Lombardo FP.171:171 – 7. Lee S. [96] Yamaguchi K. et al. Am J Roentgenol 1998. et al. Mucinous ductal ectasia: cholangiopancreatographic and endoscopic findings. Carbognin G. Fujita N. [111] Obara T. Ann Surg 1998. et al. Intraductal mucin-producing tumors of the pancreas: imaging findings. et al. et al. Walden D. Mucinous pancreatic duct ectasia in the body of the pancreas. [104] Sugiyama M. Am J Gastroenterol 1998. [98] Procacci C. Kandel G. Kortan P. [109] Terris B.178:269 – 74.23:906 – 12. Sasaki M.93:156 – 9. Surgical treatment of intraductal papillary-mucinous tumors of the pancreas. Am J Surg Pathol 2000. Correlation between ultrasonographic findings and pathologic diagnosis of the mucin producing tumor of the pancreas. Intraductal papillary mucinous tumors of the pancreas confined to secondary ducts show less aggressive pathologic features as compared with those involving the main pancreatic duct. et al. Intraductal papillary mucinous tumor of the pancreas: a pictorial essay. . Atomi Y. Saida Y. 26:640 – 7. Mucin-hypersecreting tumors of the pancreas. Chiba T.228:658 – 91.208: 231 – 7. Saitoh Y. [112] Sugiyama M. Tanaka M.114 L. Am J Surg 1996. Nakao A. Characterization of cystic tumors of the pancreas: CT accuracy. Atomi Y. Sastre B. [97] Procacci C. [113] Procacci C. Paye F. Radiology 1989.198:249 – 57. [101] Azar C. Hepatogastroenterology 2001. Haber GB. Marcon NE. Am J Gastroenterol 1993.

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