‡ ‡ ‡ ‡ ‡ Introduction Technique Advantages Limitations Clinical applications

anatomic variants. and chronic pancreatitis . malignant obstruction. and the pancreatic duct ‡ Equivalent diagnostic accuracy to ERCP in the evaluation of a broad spectrum of benign and malignant pancreatic and biliary ductal diseases ± Including. gallbladder.INTRODUCTION ‡ Introduced in 1991 ‡ Noninvasive. and sensitive alternative to diagnostic ERCP ‡ Allows rapid evaluation of the intrahepatic and extrahepatic bile ducts. choledocholithiasis. less costly.


TECHNIQUE ‡ Basic principle: body fluids (bile and pancreatic secretions) have high signal intensity on heavily T2weighted MR sequences therefore. appear white ± Background tissues generate little signal appear dark ‡ Stationary or slow-flowing fluid within the bile and pancreatic ducts appears bright relative to low signal intensity produced by adjacent solid tissues .

TECHNIQUE ‡ New MR advancements allow faster imaging in which imaging is performed during single breathholding session to reduce motion artifact due to respiration ‡ New variants such as rapid acquisition with relaxation enhancement (RARE) and half-Fourier acquisition single-shot turbo spin-echo (HASTE) can be performed in a breath-hold period with a scan time of <20 seconds provide superior images .

perforation. sepsis.ADVANTAGES ‡ Does not require intravenous or oral contrast material to be administered into the ductal system ‡ Avoids complications of ERCP such as pancreatitis (3-5%). easily performed as outpatient examination . hemorrhage. sedation ‡ Can be completed in 10 minutes.

or segments may be underdistended because of the operator's fear of inducing cholangitis or pancreatitis. segments may be overdistended because of attempt to visualize the duct upstream from a stricture.ADVANTAGES ‡ Passive procedure. displays the ducts in the resting state and more accurately displays native caliber of the duct than ERCP. . ± In ERCP.

LIMITATIONS ‡ Purely diagnostic. or biopsy) ‡ Image artifact due to other structures in abdomen with high fluid content ± stationary fluid within the adjacent duodenum. inability to breath-hold . stone extraction. claustrophobia.g. stent insertion. duodenal diverticulae. does not provide access for therapeutic intervention (e. and ascitic fluid ‡ Lack of patient compliance.

and strictures of the ducts . crossing defects induced by the right hepatic artery. primary sclerosing cholangitis. or from severely narrowed ducts. such as occurs with primary sclerosing cholangitis ‡ Lower resolution than direct cholangiography ± Can miss small stones (<4 mm).LIMITATIONS ‡ Dropout of signal can be caused by metallic clips. small ampullary lesions.

CLINICAL APPLICATIONS: DISEASES DIAGNOSED BY MRCP Biliary Disease ‡ Screening examination in patients with low or intermediate probability of choledocholithiasis ‡ ‡ ‡ ‡ ‡ ‡ Cholangiocarcinoma Anatomic variants (low or medial duct insertion. aberrant right hepatic duct) Failed or incomplete ERCP Post-operative anatomy or screening for biliary complications Primary sclerosing cholangitis Cystic disease of bile duct (choledochal cyst. choledochocele. Caroli¶s disease) Pancreatic Disease ‡ Anatomic variants (pancreas divisum) ‡ ‡ Chronic pancreatitis Pancreatic cancer .


‡ Cause of biliary strictures may be more difficult to determine on the basis of MRCP alone. and with aid of conventional MRI or CT .OBSTRUCTION OF THE COMMON BILE DUCT ‡ MRCP can visualize the normal or dilated common bile duct in 96 to 100 percent of patients. ‡ Strictures typically appear as focal areas of ductal narrowing or signal void with proximal dilatation. radiographic. pancreatic adenocarcinoma. and pathological data ‡ Obstruction 2° to calculi. ± lacks specificity ± differentiation between benign and malignant causes is based on a combination of clinical. or pancreatitis is usually obvious with MRCP.

and the pancreaticduct obstruction by the straight arrow. The mass was identified on axial. . contrastenhanced. T1-weighted images (not shown) obtained by routine MRI during the same examination. The biliary-duct obstruction is indicated by the curved arrow.OBSTRUCTION Combined Biliary-Duct Obstruction and Pancreatic-Duct Obstruction Due to a Small Mass in the Pancreatic Head. Arrowheads indicate the pancreatic duct.

(This study used an early form of the technique. manometry. biopsy of lesions. since it permits direct visualization of the ampulla. 6 cases due to ampullary carcinoma. and results may be more accurate with the currently available technology.) ‡ MRCP performed after pharmacologic stimulation with secretin has been shown to be helpful in evaluating ampullary obstruction . or endoscopic sonography. ± 2 of 6 cases were misdiagnosed as benign obstructions.OBSTRUCTION ‡ ERCP is more beneficial in pts with dilatation of the common bile duct who have obstruction at the ampulla. ‡ MRCP Study of 79 cases of biliary obstruction found 14 due to malignant cause. and 2 cases of benign obstruction were thought to be ampullary cancers.

SECRETIN-ENHANCED MRCP ‡ Visualization of the pancreatic duct can be improved with imaging after administration of IV secretin ‡ Secretin frequently used when pancreatic duct is not apparent on MRCP ‡ Reduces the incidence of false positive findings of strictures .

) In Panel A. B .SECRETIN-ENHANCED MRCP A Dynamic MRCP with Intravenous Injection of Secretin in Patient with Abdominal Pain after a Whipple Procedure. Je denotes jejunum. In Panel B. an MRCP obtained 15 minutes after the administration of secretin shows prominent and prolonged dilatation of the pancreatic duct upstream of a stricture (arrow) at the pancreaticoenteric anastomosis. the pancreatic duct (arrowheads) is incompletely visualized on MRCP before the administration of secretin. (ERCP was not attempted because the patient had a pancreaticoenteric anastomosis.

size. and location ‡ MRCP is as accurate as ERCP for detecting choledocholithiasis ± Sensitivity = 95-100% ± Specificity = 85-100% ‡ Increased sensitivity in pts with suspected gallstone pancreatitis. as well as number. and pts with non-specific abdominal pain and normal LFTs .COMMON DUCT STONES ‡ Displayed by MRCP as a signal void within bright signal arising from bile ‡ MRCP is a useful means of determining presence or absence of CBD stones.

MRCP has a 90 to 95 percent concordance with ERCP in diagnosing CBD stones over 4 mm in diameter ‡ ERCP is preferred in pts with cholangitis because it allows therapeutic drainage .COMMON DUCT STONES ‡ Stones larger than 4 mm are readily seen but difficult to differentiate from filling defects such as blood clots. sludge. and a pseudostone at the ampulla ‡ In the presence of a dilated CBD. biliary air. or parasites ± Other mimickers include flow artifacts. tumor.


CHOLANGIOCARCINOMA ‡ Role of MRCP in the diagnosis and management of bile duct malignancy is not yet defined ‡ Useful noninvasive adjunct ‡ Capability to evaluate the bile ducts both above and below a stricture while also identifying any intrahepatic mass lesions ‡ Study of 126 patients with suspected bile duct obstruction showed that MRCP alone has limited specificity in the diagnosis of malignant strictures ± Malignant obstruction dx by MRCP in 12 out of 14 pts ± Positive predictive value = 86% ± Negative predictive value = 98% .


strictures.PANCREATITIS ‡ Acute pancreatitis ± MRCP is useful for evaluating bile ducts and cystic duct remnants for stones. and pseudocysts ± Defines ductal anatomy and extent of ductal disease prior to surgical drainage . intraductal calculi. and for documenting the presence of cysts in or around the pancreas. ductal dilatation. ‡ Chronic pancreatitis ± MRCP is useful in demonstrating complications such as. ± ERCP is often preferred in patients with gallstone pancreatitis since endoscopic papillotomy can be performed in pts with obstructive jaundice or biliary sepsis. fistulas. for evaluating the pancreatic ducts.

± In study of 124 patients who were suspected of having pancreatic cancer. ± MRCP sensitivity (84%) and specificity (97%) for diagnosis of pancreatic cancer ± ERCP sensitivity (70%) and specificity (94%) ‡ Secretin-enhanced MRCP is being increasingly studied for evaluation of pancreatic exocrine function and in the early diagnosis of chronic pancreatitis .PANCREATIC CANCER ‡ MRCP is as accurate as ERCP for distinguishing pancreatic cancer from chronic pancreatitis. others had chronic pancreatitis (46 percent) or other causes. including ERCP and MRCP. The correct diagnosis was confirmed histologically and clinically. pts underwent a number of diagnostic studies. 37 patients (30 percent) dx with pancreatic cancer.

VARIANT DUCTAL ANATOMY ‡ MRCP is also useful in demonstrating variant anatomy and congenital anomalies of the biliary tract and pancreatic duct ± ± ± ± ± Pancreas divisum Choledochal cyst Annular pancreas Abnormal pancreaticobiliary junctions Aberrant bile ducts ‡ And in evaluation of pts prior to laparoscopic cholecystectomy .

Magnetic resonance cholangiopancreatography is an accurate method of diagnosing pancreas divisum because it shows the dominant dorsal pancreatic duct (arrowheads) continuously from the tail to the head of the pancreas. crossing the common bile duct (curved arrows) and draining at the minor papilla (straight arrow) superiorly and separately from the common bile duct.VARIANT DUCTAL ANATOMY Normal Extrahepatic Bile Duct and Incidental Pancreas Divisum. GB denotes gallbladder. .

Billroth II) or ductal disruption. sleep apnea. resulting in ducts that can¶t be assessed by ERCP ‡ MRCP also allows evaluation of ducts in pts with contraindications for ERCP: ± Cervical spine fractures.FAILED OR INCOMPLETE ERCP ‡ ERCP is technically challenging ± Associated with 10-20% failed cannulation rate ± Anatomic variants can contribute to failed ERCP attempts ‡ MRCP is useful in demonstrating variant anatomy ± MRCP may have advantages compared to ERCP in specific settings such as pts who have gastric outlet or duodenal stenosis or who have had surgical rearrangement (eg. other diseases/ injuries that preclude placement of endoscope or positioning . head and neck tumors.

Imaging was performed in two seconds with the thick. . Du denotes duodenal bulb. The normal common bile duct (arrow) and pancreatic duct (arrowheads) are clearly visible. single-slice technique.POST-SURGICAL ANATOMY Normal Results of Magnetic Resonance Cholangiopancreatograpy in a Patient after Cholecystectomy.

41(1): 97-114 Fulcher A.C. 56(6 Suppl): S178-82 Karnam U. Yucel E. Gastrointest Endosc 01-DEC-2002. T. Radiol Clin North Am 01-DEC-2002.. K. Radiol Clin North Am 01-JAN-2003.. MR cholangiopancreatography: evaluation of common pancreatic diseases. 41(1): 8996 Romagnuolo J. 61(1): 86-97 Taylor A. selective invasive biliary imaging for acute biliary pancreatitis: an economic evaluation by using decision tree analysis.M. www. A. 341:258-264. Prospective assessment of magnetic resonance cholangiopancreatography for noninvasive imaging of the biliary Motohara T. 40(6): 1363-76 Fulcher A. Gastrointest Endosc 01-JAN-2002. Magnetic resonance cholangiopancreatography.S. MR cholangiopancreatography. Current Concepts: Magnetic Resonance Cholangiopancreatography. et al.S. MRCP and ERCP in the diagnosis of common bile duct stones.uptodate. 55(1): 17-22 ‡ . Gastrointest Endosc 01JAN-2005. Fayad L.. Ferrucci J. MR cholangiopancreatography. Noninvasive vs. Radiol Clin North Am 01-JAN-2003.REFERENCES ‡ ‡ ‡ ‡ ‡ ‡ ‡ Barish M. N Engl J Med 22-JUL-1999.

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