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Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.

Imaging of the biliary system has improved and has allowed MR to become a key noninvasive tool for evaluation of the biliary system. A variety of magnetic resonance cholangiopancreatography techniques have been developed, with improved visualization of the biliary system and biliary pathology. Key avenues of advancement include increasing the speed of acquisition, improving spatial resolution, and reducing artifacts. T1-weighted imaging using gadolinium-based hepatobiliary contrast agents allows for evaluation in additional indications, such as liver donor evaluation, biliary leak identification, and choledochal cyst confirmation. There is potential for further increased utility of MR in the evaluation of the biliary system., Competing Interests: Disclosure B.M. Yeh disclosures: Grants: General Electric Healthcare, Guerbet, Philips Healthcare, NIH. Consultant: General Electric Healthcare. Speaker: General Electric Healthcare, Philips Healthcare. Shareholder: Nextrast, Inc. Book Royalties: Oxford University Press. No Other Disclosures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To determine the incremental value of hepatobiliary-phase-MRC (HBP-MRC) added to T2-magnetic resonance cholangiography (T2-MRC) for evaluating biliary anatomy in living donor liver transplantation (LDLT) and to correlate T2+HBP-MRC findings with surgical results., Methods: A total of 276 donors who underwent T2 and gadoxetic acid-enhanced MRI before right hemihepatectomy for LDLT between January and December 2016 were retrospectively enrolled. Two reviewers evaluated biliary anatomy classification using T2-MRC in the first session and T2+HBP-MRC in the second session. The sensitivity, specificity, and confidence level (5-point scale) of T2-MRC and T2+HBP-MRC for variant biliary anatomy were evaluated. The agreement rates between MRC and operative cholangiography for each biliary anatomy classification and the underestimation rates for multiple bile duct openings (BDOs) for both MRC techniques were evaluated., Results: Of the 276 donors, variant biliary anatomy was observed in 36.2% (100/276). T2+HBP-MRC showed a significantly higher sensitivity for diagnosing variant biliary anatomy than T2-MRC alone (99.0% [99/100] vs. 89.0% [89/100], p = 0.006), with better observer confidence level (4.9 ± 0.3 vs. 4.6 ± 0.7, p < 0.001) and inter-observer agreement (kappa, 0.902 vs. 0.730). Compared with T2-MRC alone, T2+HBP-MRC provided significantly higher agreement with operative cholangiography in biliary anatomy classification (98.6% [272/276] vs. 89.9% [248/276], p < 0.001), and significantly lower underestimation rate for multiple BDOs (5.8% [16/276] vs. 9.4% [26/276], p = 0.002)., Conclusion: T2+HBP-MRC might be considered than T2-MRC alone, as a better depiction of biliary anatomic variations, correlated with surgical findings., Key Points: •T2+HBP-MRC predicted variant biliary anatomy more accurately than T2-MRC alone. •T2+HBP-MRC might have clinical usefulness by reducing the underestimation rate of multiple bile duct openings, which requires more complicated biliary anastomoses.

Purpose: This study aimed to evaluate image quality and diagnostic performance of a recently developed navigated three-dimensional magnetic resonance cholangiopancreatography (3D-MRCP) with compressed sensing (CS) based on parallel imaging (PI) and conventional 3D-MRCP with PI only in patients with abnormal bile duct dilatation., Methods: This institutional review board-approved study included 45 consecutive patients [non-malignant common bile duct lesions (n = 21) and malignant common bile duct lesions (n = 24)] who underwent MRCP of the abdomen to evaluate bile duct dilatation. All patients were imaged at 3T (MR 750, GE Healthcare, Waukesha, WI) including two kinds of 3D-MRCP using 352 × 288 matrices with and without CS based on PI. Two radiologists independently and blindly assessed randomized images., Results: CS acceleration reduced the acquisition time on average 5 min and 6 s to a total of 2 min and 56 s. The all CS cine image quality was significantly higher than standard cine MR image for all quantitative measurements. Diagnostic accuracy for benign and malignant lesions is statistically different between standard and CS 3D-MRCP., Conclusions: Total image quality and diagnostic accuracy at biliary obstruction evaluation demonstrates that CS-accelerated 3D-MRCP sequences can provide superior quality of diagnostic information in 42.5% less time. This has the potential to reduce motion-related artifacts and improve diagnostic efficacy.

Ectopic pancreas (EP) is defined as pancreatic tissue found outside its usual anatomical position, with no ductal or vascular communication with the native pancreas.We report the case of a 59-year-old woman with a mesenteric jejunal EP initially suspected on computed tomography and confirmed by secretin-enhanced magnetic resonance cholangiopancreatography.Mesenteric EP is a very rare finding with nonspecific clinical presentation, so that, classic radiological findings have not been well described previously.

Objective: To assess the diagnostic value of dynamic T 1 weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography (MRC) for the detection of active bile leaks., Methods: A total of 28 patients with suspected biliary leakage who underwent routine T 2 weighted (T2w) MRC and T1w GD-EOB-DTPA-enhanced MRC at our institution from February 2013 to June 2016 were included in this study. The image sets were retrospectively analyzed in consensus by three radiologists. T1w Gd-EOB-DTPA-enhanced MRC findings were correlated with clinical data, follow-up examinations and findings of invasive/surgical procedures. Patients with positive bile leak findings in Gd-EOB-DTPA-enhanced MRC were divided into hepatobiliary phase (HBP) (20-30 min) and delayed phase (DP) (60-390 min) group according to elapsed time between Gd-EOB-DTPA injection and initial bile leak findings in MRC images. These groups were compared in terms of laboratory test results (total bilirubin, liver enzymes) and the presence of bile duct dilatation in T2w MRC images., Results: In each patient, visualization of bile ducts was sufficient in the HBP. The accuracy, sensitivity and specificity of dynamic Gd-EOB-DTPA-enhanced T1w MRC in the detection of biliary leaks were 92.9%, 90.5% and 100%, respectively (p < 0.001). 19 of 28 patients had bile leak findings in T1w Gd-EOB-DTPA-enhanced MRC [HBP group: N = 7 (36.8%), DP group: N = 12 (63.2%)]. There was no statistically significant difference in terms of laboratory test results and the presence of bile duct dilatation between HBP and DP group (p > 0.05). Three patients, each of them in DP group, showed normal laboratory test results and bile duct diameters., Conclusion: Dynamic T1w Gd-EOB-DTPA-enhanced MRC is a useful non-invasive diagnostic tool to detect bile leak. Advances in knowledge: Prolonged DP imaging may be required for bile leak detection even if visualization of biliary tree is sufficient in HBP and liver function tests, total bilirubin levels and bile duct diameters are normal.

Purpose: To evaluate the value of adding single-shot balanced turbo field-echo (b-TFE) sequence to conventional magnetic resonance cholangiopancreatography (MRCP) for the detection of common bile duct (CBD) stone., Methods: One hundred thirty-seven consecutive patients with suspected CBD stone underwent MRCP including single-shot b-TFE sequence. Twenty-five patients were confirmed with CBD stone by endoscopic retrograde cholangiopancreatography or ultrasonography. Two radiologists reviewed two image protocols: protocol A (conventional MRCP protocol: unenhanced T1-, T2-, and respiratory-triggered three-dimensional fat-suppressed single-shot turbo spin-echo MRCP sequence) and protocol B (protocol A plus single-shot b-TFE sequence). The sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the receiver-operating-characteristic (ROC) curve (AUC) for the detection of CBD stone were compared., Results: The sensitivity (72%) and NPV (94%) were the same between the two protocols. However, protocol B was greater in the specificity (99%) and PPV (94%) than protocol A (92% and 67%, respectively) (P = 0.0078 and 0.031, respectively). The AUC was significantly greater for protocol B (0.93) than for protocol A (0.86) (P = 0.026)., Conclusions: Inclusion of single-shot b-TFE sequence to conventional MRCP significantly improved the specificity and PPV for the detection of CBD stone.

Purpose: To define imaging criteria of benign and malignant nature in patients with main pancreatic duct (MPD) stenosis., Materials-Methods: S-MRCPs of 35 patients with pancreatitis and 14 with adenocarcinoma were evaluated., Results: Adenocarcinoma caused higher prevalence of complete stenosis (14/14-100% vs 17/35-49%), dilated side-branches (14/14-100% vs 18/35-51%) and lower prevalence of duct-penetrating sign (0/14-0% vs 31/35-89%). The number of stenoses was higher in benign conditions (mean 1.4 Vs 1). Upstream MPD diameter was higher in cancer-induced stenoses (4.5 vs 2.9mm)., Conclusions: Single complete stenosis with dilated side branches, increased MPD caliber and absent duct-penetrating sign are suggestive of malignancy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: To evaluate the effectiveness of motion-sensitised driven-equilibrium (MSDE)-prepared balanced magnetic resonance cholangiopancreatography (MRCP) in a gadolinium ethoxybenzyl diethylene triamine pentaacetic acid (Gd-EOB-DTPA)-enhanced study compared to conventional T2-weighted MRCP., Materials and Methods: Fifteen patients (seven male and eight female patients) prospectively underwent conventional three-dimensional turbo spin-echo T2-weighted MRCP and MSDE-balanced MRCP using a 1.5 T MRI system after hepatobiliary phase image acquisition. For quantitative evaluation, the contrast-to-noise ratio (CNR) of the common hepatic duct to liver tissue was calculated. For qualitative analysis, two radiologists evaluated the depiction of the biliary system and main pancreatic duct (MPD) using a scoring system. Signal suppression of the portal vein (PV) and hepatic vein (HV) on MSDE-balanced MRCP was also scored., Results: MSDE-balanced MRCP showed significantly higher CNR than T2-weighted MRCP. For all biliary structures, the mean depiction scores of MSDE-balanced MRCP were significantly higher than those of T2-weighted MRCP, whereas the mean depiction score of MPD with MSDE-balanced MRCP was significantly lower than that of T2-weighted MRCP. Signal suppression of the PV and HV was thought to be clinically sufficient., Conclusions: MSDE-balanced MRCP more clearly depicted biliary structures compared with T2-weighted MRCP in a Gd-EOB-DTPA-enhanced study. This sequence may be utilised for routine MRCP on Gd-EOB-DTPA-enhanced MRI., (Copyright © 2016 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Objectives: We evaluated prospectively the clinical use of the short-echo time (TE) Cube sequence for magnetic resonance cholangiopancreatography (MRCP) at 3 T., Methods: Using a 3-T unit, we subjected 41 consecutive patients to short-TE Cube MRCP and conventional 3-dimensional fast spin-echo (3D-FSE) MRCP. Two radiologists independently rated the image quality and the visibility of the right and left hepatic, cystic, common bile, and main pancreatic ducts and the gallbladder on a 4-point scale. The averaged visual scores by 2 readers for the image quality were calculated, and the artifacts were evaluated in cases with relatively lower (<3) score. The signal-to-noise ratio, contrast-to-noise ratio, and acquisition time were evaluated by quantitative analysis., Results: The visual scores of the common bile duct (P < 0.05), cystic duct (P < 0.01), and gallbladder (P < 0.01) were significantly higher for Cube than 3D-FSE MRCP. Signal-to-noise ratio was also significantly higher for Cube than 3D-FSE MRCP (P < 0.01). There was no significant difference in the image acquisition time (352.1 ± 93.0 vs 314.1 ± 126.2 seconds, P = 0.059). Four cases on 3D-FSE MRCP and 2 cases on Cube MRCP have relatively lower image quality; however, the difference was not significant (P = 0.18)., Conclusions: The visibility of biliary structures is significantly better on short-TE Cube MRCP than conventional 3D-FSE MRCP images at a clinically acceptable acquisition time.

Purpose: We retrospectively evaluated the incidence and related factors of obliteration of the lower bile duct after oral administration of contrast medium (OCM) probably resulting from its regurgitation into the biliary system (OCMRB) as observed on images of MR cholangiopancreatography (MRCP)., Methods: We retrospectively analyzed 305 MRCP images in 278 patients obtained between February 2010 and March 2011 using negative OCM with 1.0- and 1.5-tesla clinical units. OCMRB was defined as positive when visualization of the common bile duct was clear on precontrast 2-dimensional (2D) MRCP but obliterated on postcontrast 3-dimensional (3D) MRCP. Two abdominal radiologists reviewed all images in consensus. The incidence of OCMRB was correlated to various clinicoradiological factors., Results: We observed OCMRB on 11 MRCP images in 10 patients (3.6%). Among various clinicoradiological factors, the presence of juxtapapillary diverticula, pneumobilia, and history of intervention to the papilla were suggested as significant factors related to positive OCMRB with multivariate analysis (P < 0.05)., Conclusion: OCMRB occurs in about 4% of the patients who undergo MRCP, typically in those with juxtapapillary diverticula, pneumobilia, and history of papillary intervention. Acquisition of MRCP images before OCM may secure visualization of the common bile duct in these patients.

Purpose: To show the feasibility of motion-sensitized driven-equilibrium-balanced magnetic resonance cholangiopancreatography and to determine the optimal velocity encoding (VENC) value., Materials and Methods: Sixteen healthy volunteers underwent MRI study using a 1.5-T clinical unit and a 32-channel body array coil. For each volunteer, images were obtained using the following seven respiratory-triggered sequences: (1) balanced magnetic resonance cholangiopancreatography without motion-sensitized driven-equilibrium, and (2)-(7) balanced magnetic resonance cholangiopancreatography with motion-sensitized driven-equilibrium, with VENC=1, 3, 5, 7, 9 and ∞cm/s for the x-, y-, and z-directions, respectively. Quantitative evaluation was obtained by measuring the maximum signal intensity of the common hepatic duct, portal vein, liver tissue including visible peripheral vessels, and liver tissue excluding visible peripheral vessels that were evaluated. We compared the contrast ratios of portal vein/common hepatic duct, liver tissue including visible peripheral vessels/common hepatic duct and liver tissue excluding visible peripheral vessels/common hepatic duct among the five finite sequences (VENC=1, 3, 5, 7, and 9cm/s). Statistical comparisons were performed using the t-test for paired data with the Bonferroni correction., Results: Suppression of blood vessel signals was achieved with motion-sensitized driven-equilibrium sequences. We found the optimal VENC values to be either 3 or 5cm/s with the best suppression of relative vessel signals to bile ducts. At a lower VENC value (1cm/s), the bile duct signal was reduced, presumably due to minimal biliary flow., Conclusion: The feasibility of motion-sensitized driven-equilibrium-balanced magnetic resonance cholangiopancreatography was suggested. The optimal VENC value was considered to be either 3 or 5cm/s. The clinical usefulness of this new magnetic resonance cholangiopancreatography sequence needs to be verified by further studies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Using hepatocyte-specific magnetic resonance imaging (MRI) contrast agents such as gadoxetate disodium, MRI can provide functional information regarding the patency of the cystic duct similar to hepatobiliary scintigraphy in addition to anatomic images., Purpose: To describe the gadoxetate disodium enhanced MR cholangiography (GDE-MRC) findings in patients with acute cholecystitis and to compare them with findings in patients without acute cholecystitis and with normal hepatobiliary scintigraphy., Material and Methods: This study was HIPAA compliant and institutional review board approved. Twenty-three patients (n = 14 diagnosed with acute calculous cholecystitis based on ultrasound [US] or computed tomography [CT]; n = 9 controls with normal hepatobiliary scintigraphy) were prospectively enrolled. All patients underwent GDE-MRC within 2 days of the US, CT, or hepatobiliary scintigraphy. GDE-MRC included axial gradient echo T1-weighted images before and 3, 10, 20, 30, and 60 min after injection of 10 mL of gadoxetate disodium. If excretion of contrast into the gallbladder was not noted at 60 min, intravenous morphine was administered (0.04 mg/kg) and images were acquired 30 min later., Results: In all nine controls, gadoxetate disodium was excreted into the gallbladder within 60 min (7/9 in <30 min). Twelve out of 14 patients with acute cholecystitis completed the study. Six out of 12 (50%) patients demonstrated contrast in their gallbladder within 1 h of administration similar to the control group (2/6 in <30 min). In the remaining 6/12 patients, contrast was not present in the gallbladder within 1 h from injection. Following morphine augmentation, contrast was subsequently noted in the gallbladder in 2/6 patients., Conclusion: GDE-MRC can assess the patency of the cystic duct. Delayed (>60 min) or lack of filling of the gallbladder during GDE-MRC supports the diagnosis of acute cholecystitis. However, filling of the gallbladder with contrast in <60 min does not exclude the diagnosis of acute calculous cholecystitis., (© The Foundation Acta Radiologica 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: T2 hyperintensity of pancreatic acini during secretin-enhanced MRCP is called "acinarization." We sought to determine the clinical significance of this finding., Materials and Methods: Patients were selected if the radiology report included the phrases "acin*" (where * represented a wild card search) or "blush" using the institution's customized lexicon-search software. Sixty-seven consecutive patients without acinarization on secretin-enhanced MRCP who also underwent ERCP were enrolled as the control group. The intensity of acinarization was classified into three groups: grade 0, no visible acinarization; grade 1, barely visible parenchymal hyperintensity; or grade 2, easily visible parenchymal hyperintensity. ERCP findings of ductal abnormalities and basal pancreatic sphincter manometry were recorded., Results: There were higher frequencies of divisum (p = 0.001) and of a clinical history of recurrent acute pancreatitis (p < 0.001) and higher basal pancreatic sphincter of Oddi manometric pressure measurements (p = 0.008) in the acinarization group. There was no difference in the frequency of ERCP-defined chronic pancreatitis (p = 0.10) between the groups. In patients with acinarization, a higher mean sphincter pressure was seen in patients with more intense acinarization than in those with faint acinarization, but this difference was not significant (p = 0.22). Ampullary tumors were found in four patients with acinarization., Conclusion: Acinarization probably occurs in patients with a propensity for increased pancreatic ductal pressure (i.e., patients with divisum, elevated basal pancreatic sphincter pressure, ampullary tumor) and adequate exocrine function (absence of severe chronic pancreatitis).

The widespread adoption of multidetector computed tomography and magnetic resonance imaging (MRI) for evaluation of intraabdominal pathology has resulted to a steady increase in the number of incidentally discovered pancreatic cysts in clinical practice during the last decades. The differential diagnosis of these cysts is broad including pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. The MRI has an important role both in the initial characterization of incidentally detected pancreatic cysts and the follow-up of these lesions and has become an integral part of the diagnostic algorithm for pancreatic cysts at many institutions. The inherent soft-tissue contrast of magnetic resonance cholangiopancreatography provides the vehicle for providing a specific diagnosis in many pancreatic cysts. Furthermore, an MRI-based characterization of pancreatic cysts allows for selection of those cysts that are more likely to benefit from endoscopic ultrasound and fine-needle aspiration for analysis of the fluid contents. Moreover, small asymptomatic incidental pancreatic cysts without concerning MRI features such as internal septae and/or nodularity may be safely followed with serial imaging. The lack of risk associated to repeated exposure to ionizing radiation and its ability to characterize pancreatic cysts are strong arguments for selecting MRI as the preferred imaging modality for following up these lesions. However, the recommendations for imaging follow-up continue to evolve, and several of the proposed guidelines are reviewed in this manuscript.

Purpose: To evaluate the effect of parallel imaging (PI) with different acceleration factors on the image quality and duct visibility of breathhold two-dimensional (2D) thick-slab single-shot turbo spin-echo (SSTSE) MR cholangiopancreatography (MRCP) images., Materials and Methods: Breathhold 2D thick-slab SSTSE MRCP was performed three times, i.e., without PI, with PI factor 2, and with PI factor 3, at 1.5 Tesla (T) for each of 85 patients. Two, independent readers evaluated the image quality and the visibility of five duct segments and ranked their preference of the three MRCP sequences. The data were analyzed using the repeated-measures analysis of variance test, the Friedman test, and the linear-by-linear chi-square test., Results: MRCP sequences with PI factor 2 or 3 generated better image quality (P < 0.001) and an improved duct visibility for all duct segments (P ≤ 0.01), while no significant difference was noted between the MRCP sequences with PI factor 2 and PI factor 3 (P > 0.05). Among the three sequences, both readers most often preferred the MRCP with PI factor 3, followed by the MRCP with PI factor 2 (P < 0.001)., Conclusion: The application of PI improves the image quality and duct visibility in breathhold 2D thick-slab SSTSE MRCP., (Copyright © 2013 Wiley Periodicals, Inc.)

Objectives: The purpose of this study was to assess the value of contrast-enhanced magnetic resonance cholangiography (MRC) performed in different time delays after injection of gadoxetic acid disodium (Gd-EOB-DTPA) for the diagnosis of active bile leak., Methods: This retrospective analysis included Gd-EOB-DTPA enhanced MR images of 34 patients suspected of bile leak. Images were acquired 20-25 min after Gd-EOB-DTPA injection. If there was inadequate contrast in the bile ducts then delayed images after 60-90 min and 150-180 min were obtained. Results were correlated with intraoperative findings, ERCP results, clinical data, laboratory tests, and follow-up examinations., Results: Gd-EOB-DTPA enhanced MRC yielded an overall sensitivity of 96.4%, specificity of 100% and accuracy of 97.1% for the diagnosis of an active bile leak. The sensitivity of 20-25 min delayed MR images was 42.9%, of combined 20-25 min and 60-90 min delayed images was 92.9% and of combined 20-25 min, 60-90 min and 150-180 min delayed images was 96.4%., Conclusions: Gd-EOB-DTPA enhanced MRC utilizing delayed phase images was effective for detecting the presence and location of active bile leaks. The images acquired 60-180 min post-injection enabled identification of bile leaks even in patients with a dilated biliary system or moderate liver dysfunction., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy., (© RSNA, 2013.)

Magnetic resonance cholangiopancreatography (MRCP) is an extremely useful tool for evaluating a wide variety of disorders affecting the pancreaticobiliary system in neonates/infants, children, and adolescents. This imaging technique has numerous distinct advantages over alternative diagnostic modalities, such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography, including its noninvasive nature and lack of ionizing radiation. Such advantages make MRCP the preferred first-line method for advanced imaging the pediatric pancreaticobiliary tree, after ultrasonography. This article presents a contemporary review of the use of MRCP in the pediatric population, including techniques, indications, and the imaging appearances of common and uncommon pediatric disorders., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To prospectively evaluate the image quality and image acquisition time at 3D magnetic resonance cholangiopancreatography (MRCP) using sampling perfection with application optimized contrasts (SPACE) and conventional turbo-spin-echo (TSE) sequences., Materials and Methods: We acquired navigator-triggered SPACE and conventional 3D-TSE MRCP images using the same parameters where possible for 30 patients and compared the image acquisition time, contrast, and contrast-to-noise ratio (CNR) of the common bile duct (CBD). Two radiologists performed qualitative analyses using a 4-point scale., Results: Image acquisition time was 31% shorter with the SPACE than the conventional TSE sequence (248.9 ± 73.0 sec vs. 360.5 ± 99.9 sec, P < 0.01). The contrast and CNR was significantly higher with the SPACE technique than conventional TSE (39.4 ± 14.7 vs. 33.5 ± 14.2, P < 0.01 and 18.6 ± 7.8 vs. 15.5 ± 9.3, P = 0.03). All visual scores were higher for the SPACE than the conventional TSE sequence; there was a significant difference in motion artifacts and the depiction of the CBD and the left hepatic and main pancreatic duct (P < 0.05)., Conclusion: On the 1.5T MR scanner, 3D-MRCP with the SPACE sequence significantly improved the contrast and CNR of CBD. In addition, it yielded images of better quality at 30% shorter acquisition time than constant refocusing pulse flip angle TSE., (Copyright © 2013 Wiley Periodicals, Inc.)

Objective: To evaluate the added role of T1-weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance cholangiography (MRC) compared with T2-weighted MRC (T2w-MRC) in the detection of biliary leaks., Methods: Ninety-nine patients with suspected biliary complications underwent routine T2w-MRC and T1w contrast-enhanced (CE) MRC using Gd-EOB-DTPA to identify biliary leaks. Two observers reviewed the image sets separately and together. MRC findings were compared with those of surgery and percutaneous transhepatic cholangiopancreatography. The sensitivity, specificity and accuracy of the techniques in identifying biliary leaks were calculated., Results: Accuracy of locating biliary leaks was superior with the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC (P < 0.05).The mean sensitivities were 79 % vs 59 %, and the mean accuracy rates were 84 % vs 58 % for combined CE-MRC and T2w-MRC vs sole T2w-MRC. Nineteen out of 21 patients with biliary-cyst communication, 90.4 %, and 12/15 patients with post-traumatic biliary extravasations, 80 %, were detected by the combination of Gd-EOB-DTPA-enhanced MRC and T2w-MRC images, P < 0.05., Conclusions: Gd-EOB-DTPA-enhanced MRC yields information that complements T2w-MRC findings and improves the identification and localisation of the bile extravasations (84 % accuracy, 100 % specificity, P < 0.05). We recommend Gd-EOB-DTPA-enhanced MRC in addition to T2w-MRC to increase the preoperative accuracy of identifying and locating extravasations of bile., Key Points: • Magnetic resonance cholangiography (MRC) does not always detect bile leakage and cysto-biliary communications. • Gd-EOB-DTPA-enhanced MRC helps by demonstrating extravasation of contrast material into fluid collections. • Gd-EOB-DTPA-enhanced MRC also demonstrates the leakage site and bile duct injury type. • Combined Gd-EOB-DTPA-enhanced and T2w-MRC can provide comprehensive information about biliary system. • Gd-EOB-DTPA-enhanced MRC is non-invasive and does not use ionising radiation.

A novel 3D breath-held Dixon fat-water separated balanced steady state free precession (b-SSFP) sequence for MR cholangiopancreatography (MRCP) is described and its potential clinical utility assessed in a series of patients. The main motivation is to develop a robust breath-held alternative to the respiratory gated 3D Fast Spin Echo (FSE) sequence, the current clinical sequence of choice for MRCP. Respiratory gated acquisitions are susceptible to motion artifacts and blurring in patients with significant diaphragmatic drift, erratic respiratory rhythms or sleep apnea. A two point Dixon fat-water separation scheme was developed which eliminates signal loss arising from B0 inhomogeneity effects and minimizes artifacts from perturbation of the b-SSFP steady state. Preliminary results from qualitative analysis of 49 patients demonstrate robust performance of the 3D Dixon b-SSFP sequence with diagnostic image quality acquired in a 20-24s breath-hold., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To prospectively compare the navigator-echo triggering technique (navigator technique) and the conventional respiratory triggering technique using bellows (bellows technique) for free-breathing three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP) under clinical conditions., Materials and Methods: Forty patients referred for evaluation of biliary or pancreatic diseases underwent 3D MRCP examination using both navigator and bellows techniques. Two independent radiologists visually evaluated the image quality of 12 segments of the pancreaticobiliary tree in a blinded manner. In addition, the clarity of the lesion was compared between the two techniques in a side-by-side manner., Result: MRCP images were successfully acquired using both techniques in all patients. No significant difference in acquisition time was found between the two techniques. The image quality was significantly better using the navigator technique than using the bellows technique for the following seven segments: the head, body, and tail of the pancreatic duct; right hepatic duct; anterior and posterior segments of the right hepatic duct; and cystic duct. The other segments (common hepatic and bile duct, left hepatic duct, medial and lateral segments of left hepatic duct, gallbladder) showed no significant difference. The clarity of lesion depiction was significantly better using the navigator technique than using the bellows technique., Conclusion: Respiratory-triggered 3D MRCP using the navigator technique was shown to be feasible in routine clinical practice. The navigator technique improved the image quality of free-breathing 3D MRCP compared with the bellows technique. The clarity of lesion visualization was also better using the navigator technique than using the bellows technique., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Secretin--a hormone that stimulates pancreatic exocrine secretion--is described to improve visualization of the pancreatic duct by magnetic resonance cholangiopancreatography (MRCP). In our pediatric practice, however, we have not observed substantial benefit with the use of secretin., Objective: To determine whether secretin dilates and improves visualization of the pancreatic duct in pediatric MRCP., Materials and Methods: Retrospective evaluation of secretin-enhanced MRCPs performed over a 15-month period. One reviewer measured the pancreatic duct pre- and post-secretin and two reviewers, blinded to the administration of secretin, assessed image quality and subjective duct visibility. Similar assessments of the biliary tree served as internal controls., Results: We reviewed 20 MRCPs in 17 children. Following secretin administration, there was a small (0.3 mm) but statistically significant increase in pancreatic duct diameter (P = 0.002) and small (<0.2 mm) but significant increase in intrahepatic bile duct diameter (P = 0.0104). On subjective review, there was no significant difference in image quality or duct visibility based on the administration of secretin., Conclusion: Secretin induces dilatation of the pancreatic duct but the value of that effect in pediatric MRCP is suspect given the small change in duct diameter and the lack of improvement in image quality and duct visibility.

Purpose: To determine if excreted contrast is consistently visualized in the gallbladder and duodenum after a 30-minute delay using gadoxetate disodium-enhanced MRI in patients without hepatobiliary disease., Materials and Methods: Twenty-two patients without evidence of liver or biliary disease underwent gadoxetate disodium-enhanced magnetic resonance imaging (MRI) from February 17, 2009 through October 3, 2011. The mean age was 45 years (range 25-72). T1-weighted hepatobiliary phase images at 5, 10, 20, and 30 minutes after contrast injection were reviewed in consensus by two radiologists to determine the delay at which enhancement of the gallbladder and duodenum first occurred., Results: Thirteen of 22 (59.1%) patients demonstrated duodenal filling by 20 minutes and 16/22 (72.7%) filled by 30 minutes. The mean time to duodenal enhancement was 19.9 minutes (range 11.4-30.2 min). Seventeen of 22 (77.3%) patients demonstrated gallbladder filling by 20 minutes and 21/22 (95.5%) filled by 30 minutes. The mean time to gallbladder enhancement was 16.5 minutes (range 4.4-30.2 min)., Conclusion: A significant number of normal patients do not show duodenal filling by 30 minutes, while the majority fill the gallbladder by 30 minutes using functional MR cholangiography (fMRC) with gadoxetate disodium. These findings will guide fMRC protocol design for patients with suspected acute cholecystitis and sphincter of Oddi dysfunction., (Copyright © 2012 Wiley Periodicals, Inc.)

Purpose: To investigate the value of gadoxetic acid-enhanced three-dimensional T1-weighted MR cholangiography (T1w-MRC) in comparison to three-dimensional T2-weighted MR cholangiopancreaticography (T2w-MRCP) in patients with primary sclerosing cholangitis (PSC)., Materials and Methods: Thirty-four MR exams in 29 patients (46.0 ± 16.1 years; 19 men, 10 women) scanned within a 14-month period were retrospectively included. Two abdominal radiologists independently evaluated image quality regarding image contrast, image quality degradation due to artifacts, and visualization quality of ducts. The order of biliary tree branches that were visualized and reader preference toward each method were recorded. Helpfulness of T1w-MRC was scored in consensus. Confirmatory endoscopic retrograde cholangiopancreaticography (ERCP) performed within 3 months of the MR examination was available in 8 patients., Results: Image quality of T1w-MRC and T2w-MRCP was graded good to excellent in all cases. There were advantages for both T1w-MRC (functional information, less degradation due to artifacts) and T2w-MRCP (higher order of visualized branches, better branch depiction). Both readers showed preference for T2w-MRCP; however, both readers found gadoxetic acid-enhanced T1w-MRC helpful in the majority of cases., Conclusion: Gadoxetic acid-enhanced T1w-MRC is complementary to, but should not replace, T2w-MRCP. T1w-MRC is a useful adjunct to T2w-MRCP for morphologic evaluation and provides additional diagnostic information., (Copyright © 2012 Wiley Periodicals, Inc.)

Extrahepatic cholangiocarcinoma (CCA) is a primary bile duct malignant tumour with poor prognosis. Familiarity with their varied imaging characteristics can be helpful in developing a correct diagnosis and in optimal treatment planning, and thus contribute to a better prognosis. The purpose of this article is to illustrate the typical appearances of extrahepatic CCA on magnetic resonance cholangiopancreatography (MRCP) and three-dimensional (3D) LAVA (liver acquisition with volume acceleration) sequences at 3 T magnetic resonance imaging (MRI), and to discuss the superiority of the two techniques in the diagnosis of CCA., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Purpose: To assess the clinical usefulness of free-breathing 3D MRCP in non-cooperative patients compared conventional breath-hold 2D MRCP., Materials and Methods: We performed FB navigator-triggered 3D MRCP using prospective acquisition correction and BH 2D MRCP in 48 consecutive, non-cooperative patients among 772 patients. Thirteen patients had malignant obstruction. Two radiologists independently graded the likelihood of a malignant obstruction, the overall image quality, and the visibility of ten, individual anatomic segments of both the biliary and pancreatic duct in each sequence. The area under the ROC curve and the repeated measures analyses of variance with multiple comparisons were used for the comparison. The κ statistics were used for interobserver agreement., Result: The diagnostic performance for detecting malignancy was significantly higher on FB MRCP (A(z)=0.962) than on either BH SS-RARE (A(z)=0.820, P<0.0185) or MS-HASTE MRCP (A(z)=0.816, P<0.0067). Interobserver agreement was excellent for FB MRCP (κ=0.889) and fair for both BH SS-RARE (κ=0.578) and MS-HASTE MRCP (κ=0.49). FB MRCP had a significantly higher technical quality than BH MRCP (P<0.001). FB MRCP was seen to have statistically better visibility of peripheral IHD, right main IHD, CHD, cystic duct, and CBD than BH MRCP (P<0.001). FB MRCP and BH SS-RARE MRCP had statistically better visibility of both the left main IHD and pancreatic duct than did BH MS-HASTE MRCP (P<0.001)., Conclusion: FB 3D MRCP is useful for non-cooperative patients in whom conventional BH 2D methods cannot be used successfully., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

A profound knowledge of the various benign focal hepatic lesions and selection of the most suitable radiological examination modality is essential for achieving an accurate characterization of a hepatic lesion and in turn will determine the further patient management. This will avoid unnecessary agitation to both patient and the referring clinician and limits time-consuming, costly and risky biopsies to an absolute minimum. The following article will discuss the typical and atypical appearances of the most frequent and clinically relevant benign focal hepatic lesions with ultrasound, computed tomography and magnetic resonance imaging.

Purpose: To compare the image quality and diagnostic performance with T2-weighted magnetic resonance (MR) cholangiopancreatographic images obtained before and after dynamic MR imaging performed with gadoxetic acid., Materials and Methods: This retrospective study was approved by the institutional review board, and informed consent was waived. Fifty-six patients suspected of having pancreatic or biliary disease underwent two-dimensional (2D) single-section and three-dimensional (3D) multisection MR cholangiopancreatography before and after dynamic imaging with gadoxetic acid. One radiologist measured the mean signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs) of the common bile duct on precontrast and postcontrast images. Two radiologists independently reviewed the 2D and 3D MR cholangiopancreatographic images in random order. The depiction of each segment of the pancreaticobiliary duct, the presence of artifacts, background suppression, and overall image quality were assessed according to a four-point scale. Paired t, McNemar, and Wilcoxon signed rank tests were performed with a power analysis. Interobserver agreement was assessed by using the kappa statistic., Results: Mean SNRs at precontrast MR imaging (2D, 50.8 +/- 45.1 [standard deviation]; 3D, 54.7 +/- 25.5) were similar to those at postcontrast MR imaging (2D, 48.5 +/- 45.7; 3D, 51.5 +/- 21.6). Mean CNRs were also similar between precontrast and postcontrast MR imaging (2D, 45.5 +/- 43.0 vs 44.2 +/- 45.2; 3D, 51.4 +/- 24.3 vs 48.7 +/- 21.0). Depiction scores for each segment of the pancreaticobiliary duct were also similar between 2D and 3D precontrast and postcontrast images. Both radiologists found that scores for background suppression were improved on postcontrast 2D MR images (3.79 and 3.84) compared with precontrast images (3.25 and 3.64). One of the two radiologists found that scores for artifacts (precontrast, 1.23; postcontrast, 1.09) and for overall image quality (precontrast, 3.54; postcontrast, 3.71) were improved at 2D postcontrast MR cholangiopancreatography., Conclusion: Both 2D and 3D MR cholangiopancreatography can be effectively performed immediately after gadoxetic acid-enhanced dynamic MR imaging in patients suspected of having biliary or pancreatic disease.

Objective: Opioids are applied to augment visualization of the biliary system in MR cholangiopancreatography (MRCP) to take advantage of a side effect, the constriction of the sphincter of Oddi. This prospective study was performed to determine the effect of IV low-dose morphine on image quality and bile duct delineation in MRCP., Subjects and Methods: Fifteen healthy volunteers and 15 consecutive patients underwent MRCP on a 1.5-T MRI scanner. Strongly T2-weighted 3D single-shot fast spin-echo (SSFSE) sequences were acquired before and 10 minutes after IV administration of morphine (0.04 mg/kg of body weight; mean +/- SD, 2.9 +/- 0.5 mg). Maximum intensity projections were reconstructed from the SSFSE sequence data. Image quality was rated by two independent radiologists using a 4-point scale (1 = excellent, 4 = not diagnostic). Delineation of segmental and subsegmental intrahepatic bile duct orders before and after morphine administration was compared. Volumetry of the common bile duct (CBD) was performed using electronic measurements (AngioTux software, ECCET image processing system)., Results: IV morphine did not significantly improve subjective image quality of the extra- and intrahepatic bile ducts (mean image quality score before vs after morphine administration, 2.3 vs 2.0) or delineation of the intrahepatic bile duct orders. The volume of the CBD remained constant after morphine administration (mean CBD volume before vs after morphine administration, 14.1 vs 13.6 mL). Notable side effects of morphine were seen in two young healthy female volunteers., Conclusion: IV-administered low-dose morphine seems to have no essential influence on image quality or delineation of the bile duct system in MRCP. Therefore, the general advice to perform morphine-augmented MRCP should be discussed critically.

Purpose: The aim of this study was to compare prospectively the image quality of magnetic resonance cholangiopancreatography (MRCP) using manganese chloride tetrahydrate (Bothdel Oral Solution 10) (MCT), a new negative oral contrast agent; ferric ammonium citrate (FerriSeltz powder 20%) (FAC); and no agent., Materials and Methods: MRCP images (TE 970 ms) of patients administered MCT (n = 19) or FAC (n = 20) at random, and 18 patients without an agent were evaluated. The subjective image quality of the overall, extrahepatic bile duct, and pancreatic duct and the degree of elimination of gastrointestinal fluid scored by two radiologists blinded to information regarding the agent were compared using Mann-Whitney's U-test., Results: The degrees of elimination of gastroduodenal fluid of MCT and FAC were significantly better than those without an agent (P < 0.01 and P < 0.01). The subjective image quality of MCT of the overall and extrahepatic bile duct were significantly better, although no significant differences for FAC were observed compared with those without an agent (P < 0.01 and P = 0.21, P = 0.02 and P = 0.16). There were no significant differences for the pancreatic duct (P = 0.12 and P = 0.19), nor were there any significant differences in the evaluations between MCT and FAC (P = 0.19-0.98)., Conclusion: MCT has shown performance comparable to that of conventional FAC in terms of pancreatic and biliary depiction and safety.

Purpose: The aim of this study was to evaluate image quality of 3D MR cholangiography (MRC) using high sampling efficiency technique (SPACE) at 3T compared with 1.5T., Methods and Materials: An IRB approved prospective study was performed with 17 healthy volunteers using both 3 and 1.5T MR scanners. MRC images were obtained with free-breathing navigator-triggered 3D T2-weighted turbo spin-echo sequence with SPACE (TR, >2700ms; TE, 780ms at 3T and 801ms at 1.5T; echo-train length, 121; voxel size, 1.1mmx1.0mmx0.84mm). The common bile duct (CBD) to liver contrast-to-noise ratios (CNRs) were compared between 3 and 1.5T. A five-point scale was used to compare overall image quality and visualization of the third branches of bile duct (B2, B6, and B8). The depiction of cystic duct insertion and the highest order of bile duct visible were also compared. The results were compared using the Wilcoxon signed-ranks test., Results: CNR between the CBD and liver was significantly higher at 3T than 1.5T (p=0.0006). MRC at 3T showed a significantly higher overall image quality (p=0.0215) and clearer visualization of B2 (p=0.0183) and B6 (p=0.0106) than at 1.5T. In all analyses of duct visibility, 3T showed higher scores than 1.5T., Conclusion: 3T MRC using SPACE offered better image quality than 1.5T. SPACE technique facilitated high-resolution 3D MRC with excellent image quality at 3T., (Copyright (c) 2009 Elsevier Ireland Ltd. All rights reserved.)

The rapid evolution of magnetic resonance (MR) imaging technology has produced much-needed improvements in temporal and spatial resolution that have led to greater recognition of diseases of the hepatobiliary and pancreatic ducts at MR cholangiopancreatography. This modality often substitutes for diagnostic evaluations with endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. Recent innovations in whole-body MR imaging, including fast imaging sequences, phased-array coils, parallel imaging techniques, and 3.0-T magnets, allow the acquisition of higher-quality diagnostic images in less time. An understanding of these technical advances and their potential clinical applications, limitations, and pitfalls for cholangiopancreatographic evaluation is as essential as a familiarity with the spectrum of possible findings; both are needed to accurately identify and characterize the disease process and to provide effective guidance for treatment.

Objectives: To prospectively evaluate the image quality and diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) at 3.0 T compared with that at 1.5 T used for patients., Materials and Methods: This study was approved by our institutional review board, and informed consent was obtained from all patients. Three-dimensional MRCP with both a 1.5-T system and a 3.0-T system was administered to 33 consecutive patients suspected of having biliary and/or pancreatic diseases. For 3-dimensional MRCP imaging, a respiratory-triggered Fast Recovery Fast Spin Echo sequence with the parallel imaging technique was used for both systems. The spatial resolution at 1.5 T was matched to that at 3.0 T, and matrix size was 512 x 160, field of view (FOV) 36 x 36 cm, slice thickness 2 mm, and the number of slices ranged from 44 to 54. Repetition time varied according to the patients' respiratory cycles, which ranged from 3000 milliseconds to 6000 milliseconds, and effective echo time, ranging from 391 milliseconds to 482 milliseconds, was automatically determined by the systems. Contrast of imaging of the common bile duct versus that of the periductal tissue was quantitatively evaluated. The image quality for homogeneity of signal intensity, image noise, susceptibility artifacts, and overall imaging quality and diagnostic accuracy for stenoses of bile and main pancreatic ducts and for pancreatic cystic lesions were qualitatively evaluated. The results for 1.5- and 3.0-T were then compared statistically, by using the paired t test for quantitative evaluation of contrast between the common bile duct and the periductal tissue, the Wilcoxon signed rank test for visual evaluation of the image quality, and the McNemar chi2 test for evaluation of sensitivity and specificity for diagnostic purposes. A P value of less than 0.05 was considered to indicate a statistically significant difference., Results: Contrast of the common bile duct versus that of the periductal tissue at 3.0 T was superior to that at 1.5 T (P < 0.001). In the visual evaluation, image quality at 3.0 T was superior to that at 1.5 T for evaluation of image noise (P < 0.001), overall image quality (P < 0.001), and delineation of intrahepatic bile ducts (P < 0.01) and the main pancreatic duct (P < 0.05), whereas there were no significant differences in homogeneity of signal intensity and in susceptibility artifacts. The diagnostic accuracy for 3.0 T was approximately equivalent to that for 1.5 T., Conclusion: Our results for patients with biliary and pancreatic diseases demonstrate a marked improvement in contrast of the common bile duct versus that of the periductal tissue and image quality including image noise at 3.0 T compared by 1.5 T when identical spatial resolution configuration were used. The results suggest that 3.0 T may allow higher spatial resolution and offer promise for improved diagnosis in MRCP, although further investigations using optimize scan parameters will be needed before its full potential can be achieved.

The purpose was to compare two-dimensional (2D) magnetic resonance pancreatography (MRP) with 3D MRP to evaluate intraductal papillary mucinous neoplasm (IPMN). Thirty-four patients (22 men, 12 women; age range, 45-80 years) with IPMN (n = 40) were examined with MRP on 2D and 3D sequences. Two readers independently reviewed the images to assess the overall image quality, artifacts, lesion location, communication with main pancreatic duct, and potential for malignancy. The readers assigned their confidence level (1-5) for predicting ductal communication of the lesion. The results of MRP were compared with endoscopic retrograde pancreatography and surgical and histopathologic findings. Studies obtained with 3D MRP were of significantly higher technical quality than those obtained with 2D MRP. Although 3D MRP showed higher area under the ROC curve (Az) values for predicting ductal communication of the lesion, there was no statistical significance between Az values of 2D and 3D MRP (Az for 2D = 0.821, 0.864 for readers 1 and 2, respectively, and Az for 3D= 0.964, 0.921). Accuracies for discriminating benign from malignant lesions were 70 and 67.5% (reader 1 and 2, respectively, for 2D) and 62.5 and 80.1% (3D). 3D MRP showed superior image quality to that of 2D MRP but did not increase the diagnostic accuracy for predicting ductal communication of the lesion.

Objective: To investigate value of magnetic resonance cholangiopancreatography (MRCP) using oral diluted gadolinium (Gd)-diethylenetriamine penta-acetic acid (DTPA) as negative contrast materials in diagnosis of juxtapapillary duodenal diverticulum with atypical imaging features., Methods: Nineteen patients with juxtapapillary duodenal diverticula of which imaging findings were atypical underwent MRCP using oral diluted Gd-DTPA as negative contrast materials after conventional MRCP without any oral contrast materials., Results: Twenty diverticula were revealed in the 19 patients. At conventional MRCP, the diverticula appeared as rounded lesion with high signal intensity. After oral administration of diluted Gd-DTPA, they disappeared at MRCP. These entities were diagnosed as duodenal diverticula for they communicate with duodenal lumen., Conclusion: MRCP using oral Gd-DTPA as negative contrast materials can be helpful in obtaining definitive diagnosis of those juxtapapillary duodenal diverticula without typical imaging features.

Purpose: To prospectively measure pancreatic apparent diffusion coefficient (ADC) before and after secretin administration in subjects with and without chronic pancreatitis (CP) who underwent magnetic resonance (MR) cholangiopancreatography with diffusion-weighted (DW) imaging at 3.0 T., Materials and Methods: Institutional review board approval of this HIPAA-compliant study was obtained. Healthy volunteers, and patients with suspected and/or known CP who were scheduled for MR cholangiopancreatography, were recruited and gave written informed consent. All subjects underwent 3.0-T MR cholangiopancreatography, including serial DW imaging sequences (b = 0, 200, and 400 sec/mm(2)) acquired for 15 minutes after secretin administration. The referring gastroenterologist then classified subjects as healthy or with mild or severe CP, given endoscopic retrograde cholangiopancreatographic and/or clinical findings. CP severity was analyzed for sex and age. Mean presecretin and maximum postsecretin ADCs were compared between groups. Pairwise mean ADCs for healthy versus mild CP patient groups, healthy versus severe CP patient groups, and mild versus severe CP patient groups were compared. Presecretin ADC threshold levels for CP discrimination were calculated (P < .05)., Results: Thirty-two subjects were imaged; four CP patients were excluded owing to severe artifact, and the remaining 28 (15 healthy patients, five with mild CP, and eight with severe CP) comprised the study population. All CP patients had endoscopic retrograde cholangiopancreatographic confirmation of CP. Mild or severe CP patients were older than healthy patients; sex distribution did not vary among groups. Mean presecretin and maximum postsecretin ADCs were higher in healthy patients than in either mild or severe CP groups (P < .01), but did not vary between mild and severe CP groups (P = .25-0.28). An ADC of less than 220 x 10(-5) mm(2)/sec was optimal for delineating between healthy and CP patients., Conclusion: Pancreatic ADC obtained with DW imaging at 3.0 T prior to secretin administration may help diagnose CP; postsecretin ADC response does not distinguish CP severity.

Purpose: To qualitatively and quantitatively compare gadoxate-enhanced T 1-weighted MR cholangiography at magnetic field strengths of 1.5 T and 3.0 T., Materials and Methods: A total of 40 patients with a non-dilated biliary system were retrospectively included in the study. T 1-weighted MR cholangiography 20 min after IV administration of 0.025 mmol/kg gadoxate (Primovist) was performed in 20 patients at 1.5 T and in another 20 patients at 3.0 T. Contrast-to-noise ratios (CNR) of the biliary system (common bile duct - CBD, right hepatic duct - RHD, left hepatic duct - LHD) compared to the periductal tissue were measured. Two radiologists also qualitatively assessed the visibility of the intrahepatic and extrahepatic biliary system using a six-point rating scale. The Mann-Whitney U-test and Pearson's correlation coefficient were used for statistical analysis., Results: The CNRs of the intrahepatic and extrahepatic hepatic bile ducts were significantly higher at 3.0 T. Qualitative analysis showed a significant superiority for 3.0 T in the delineation of the intrahepatic biliary system (RHD, LHD, segmental ducts)., Conclusion: Gadoxate-enhanced T 1-w MR cholangiography at 3.0 T offers better delineation of the intrahepatic biliary system in comparison to imaging at 1.5 T.

Background/aims: The aim of this study was to evaluate the effect of Ranitidine and Esomeprazole on the pancreatico-biliary tree and to define their role in improving visualization quality on magnetic resonance cholangiopancreaticography images., Methodology: Magnetic resonance cholangiopancreaticography was done on 70 volunteers before and after using ranitidine for half of them and esomeprazole for the other half of the group. The images were evaluated for contrast effect (signal from stomach and duodenum), and image effect (conspicuousness) at various segments of pancreaticobiliary tree., Results: Improvement of Contrast effect on stomach and duodenum in Esomeprazole group was 72.5% and in Ranitidine group was 28.6%. While image effect of pancreatic duct for Esomeprazole was 60% and for Ranitidine was 17.1%, and their statistical results were in concordance with p value (< 0.01), but the image effect of the biliary tree didn't show any significant improvement or difference between imaging and statistical results., Conclusion: Esomeprazole is superior to Ranitidine in improving the quality of Magnetic Resonance Cholangiopancreaticography images especially the contrast effect of duodenum and stomach and image effect of pancreatic duct.

Gallbladder and biliary system pathologic component is a spectrum of benign and malignant conditions. Standard magnetic resonance imaging techniques when used together with magnetic resonance cholangiopancreatography (MRCP) can evaluate gallbladder and biliary system pathologic conditions. Inflammatory diseases are characterized by thickening and intense mucosal contrast enhancement of the affected bile ducts and or gallbladder wall. Postinflammatory changes can be appreciated on MRCP with short or long segment strictures of the bile ducts. Serial contrast-enhanced images show reactive inflammatory changes in the liver parenchyma. Neoplastic diseases of the gallbladder and the biliary tree are evaluated on T2-weighted fat-suppressed echo train and serial contrast-enhanced images and their obstructive effect can be displayed on MRCP images. In this paper, we will review the spectrum of MRI findings of gallbladder and biliary system pathologic conditions.

Magnetic resonance imaging (MRI) is a valuable tool in the assessment of the full spectrum of pancreatic disease. A standard MR protocol including noncontrast T1-weighted fat-suppressed and dynamic gadolinium-enhanced gradient-echo imagings is sensitive for the evaluation of pancreatic cancer. Optimal use of MRI in the investigation of pancreatic cancer occurs in the following circumstances: (1) detection of small non-contour-deforming tumors, (2) evaluation of local extension and vascular encasement, (3) determination of the presence of lymph node and peritoneal metastases, and (4) determination and characterization of associated liver lesions and liver metastases. The objective of this study was to describe the attribute of MRI for evaluating pancreatic cancer.

Pancreatitis can occur in acute and chronic forms. Magnetic resonance imaging (MRI) plays an important role in the early diagnosis of both conditions and complications that may arise from acute or chronic inflammation of the gland. Standard MRI techniques including T1-weighted and T2-weighted fat-suppressed imaging sequences together with contrast-enhanced imaging can both aid in the diagnosis of acute pancreatitis and demonstrate complications as pseudocysts, hemorrhage, and necrosis. Combined use of MRI and MR cholangiopancreatography can show both parenchymal findings that are associated with chronic pancreatitis including pancreatic size and signal and arterial enhancements, all of which are diminished in chronic pancreatitis. The degree of main pancreatic duct dilatation and/or the number of side branch ectasia determines the diagnosis of chronic pancreatitis and its severity. In this paper, we report the spectrum of imaging findings of acute and chronic pancreatitis on MRI and MR cholangiopancreatography.

Diffusion-weighted imaging (DWI) assesses the random motion of the water protons. The technique is more frequently used in body imaging, and recent investigations showed its use in pancreatic imaging. Diffusion-weighted imaging can be helpful as a complementary imaging method in the differentiation between mass-forming focal pancreatitis and pancreatic adenocarcinoma. The apparent diffusion coefficient (ADC) values derived from DWI can distinguish between simple pancreatic cyst, inflammatory cysts, and cystic neoplasms of the pancreas. Presence of parenchymal fibrosis in chronic pancreatitis causes diffusion restriction and results in lower ADC values on baseline DWI. The ADC values reveal either delayed peak after secretin stimulation or lower peak values in patients with early chronic pancreatitis, which may be helpful to depict chronic pancreatitis in its earliest stage. In this paper, we reviewed the technical aspects of DWI and its use in pancreatic imaging.

This article describes the appearance of miscellaneous cystic and endocrine neoplasms using magnetic resonance imaging (MRI). Magnetic resonance imaging is a useful diagnostic modality in the assessment of various pancreatic neoplasms. Pancreatic endocrine tumors are moderately low in signal intensity on T1-weighted fat-suppressed images and moderately high in signal intensity on T2-weighted fat-suppressed images and demonstrate homogeneous, ring, or diffuse heterogeneous enhancement on immediate postgadolinium gradient echo images. Cystic pancreatic neoplasms, including intraductal papillary mucinous neoplasm, are well demonstrated and subcategorized according to their characteristic cystic configurations on MRI and MR cholangiopancreatography images. Microcystic serous cystadenomas are demonstrated as a honeycombed appearance on T2-weighted images and have a central stellate scar. Mucinous cystic neoplasms usually appear as multilocular cystic masses, with benign forms of macrocystic tumors possessing uniform thickness septations and malignant forms exhibiting irregular septations and tumor nodules. The presence of tumor stroma, invasion of adjacent tissue, or liver metastases can be assessed by MRI. The connection between the pancreatic duct and the cystic tumor is usually well shown on MR cholangiopancreatography images.

High-quality magnetic resonance (MR) cholangiopancreatographic images are difficult to obtain in children due to the small caliber of the pediatric bile ducts and to motion artifacts. However, there has been ongoing improvement in image quality, thanks to better coil technology, increased speed of acquisition, refinement in respiratory compensation techniques, and newer sequences. Heavily T2-weighted fast spin-echo (FSE) and single-shot FSE MR imaging sequences with long echo times are used to image the biliary and pancreatic ducts. Secretin has been shown to improve the visualization of the pancreatic duct and pancreaticobiliary junction. Factors that affect image quality in pediatric MR cholangiopancreatography include sedation, negative oral contrast material, radiofrequency coil selection, respiratory compensation techniques, echo time, echo train length, section-slab thickness, planes of scanning, field of view, and number of signals acquired. However, giving proper attention to these factors and tailoring the study to the body size of the patient (which varies considerably) can lead to high-quality diagnostic MR cholangiopancreatographic images. Use of MR cholangiopancreatography in children is limited by the need for sedation or anesthesia, high cost, limited availability, and long scanning times. Nonetheless, this modality can be a viable alternative to endoscopic retrograde cholangiopancreatography (ERCP) in the evaluation of various entities such as choledochal cyst, recurrent pancreatitis, primary sclerosing cholangitis, and a transplanted liver, and may obviate ERCP.

Purpose: To confirm the superiority of the navigator-triggered prospective acquisition correction (PACE) technique over the conventional respiratory-triggered (RESP) technique, something that has been perceived experimentally but without definite evidence, for free-breathing three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP) using healthy volunteers., Materials and Methods: Free-breathing 3D turbo spin-echo MRCP using both PACE and RESP techniques were prospectively performed on 25 healthy volunteers. Quantitative analyses of acquisition time, signal-to-noise ratio, contrast-to-noise ratio, and contour sharpness index of each segment of the pancreaticobiliary tree were compared using the paired t-test. Qualitative analyses on a five-point scale (1, excellent; 5, poor) scored by two independent radiologists were compared using the Wilcoxon signed-rank test., Results: The subjective image quality and contour sharpness index of each segment of the PACE technique were found to be significantly better than those for RESP (P<0.05). No significant difference was observed with regard to signal-to-noise and contrast-to-noise ratios except for the pancreatic duct. No significant difference in acquisition times between PACE and RESP techniques was observed., Conclusion: We confirmed the superiority of the image quality of the PACE technique compared to conventional RESP technique for free-breathing 3D MRCP in healthy volunteers., (Copyright (c) 2008 Wiley-Liss, Inc.)

Purpose: To evaluate the image quality of high-spatial-resolution three-dimensional magnetic resonance cholangiography (MRC) with a high-sampling-efficiency technique (sampling perfection with application optimized contrasts using different flip angle evolutions [SPACE]) in comparison with a conventional constant flip angle (FA) sequence at 3T., Materials and Methods: Eighteen volunteers were examined on a 3T MR unit using MRC imaging performed with three different free-breathing three-dimensional T2-weighted turbo spin-echo (TSE) sequences: 1) SPACE (spatial resolution, 1.1x1.0x0.84 mm), 2) constant FA (1.1x1.0x0.84 mm), and 3) SPACE at a higher resolution (SPACE HR; 1.0x0.9x0.644 mm). A five-point scale was used to compare overall image quality and visualization of the third branches of the bile duct (B2, B6, and B8). Depictions of cystic duct insertion and the highest order of bile duct visible were also compared., Results: MRC with SPACE and SPACE HR sequences produced significantly better overall image quality than the constant FA sequence. In all analyses of duct visibility, SPACE and SPACE HR sequences showed higher scores than the constant FA sequence., Conclusion: High-resolution three-dimensional MRC with SPACE at 3T allows high-quality imaging of the biliary tract, and has the ability to depict nondilated intrahepatic bile ducts (IHBD) in healthy volunteers., (Copyright (c) 2008 Wiley-Liss, Inc.)

Background: Even when histologic findings are highly suggestive of primary sclerosing cholangitis (PSC), cholangiographic correlation is required for the diagnosis. The present gold standard, endoscopic retrograde cholangiopancreatography (ERCP), is invasive and associated with complications., Objective: To evaluate the usefulness of magnetic resonance cholangiopancreatography (MRCP) in diagnosing PSC in children., Materials and Methods: MRCP studies were retrospectively reviewed in 20 children with clinical suspicion of PSC and who had undergone liver biopsy. MRCP studies were considered positive or negative for PSC depending on the presence or absence of dilatation, irregularity, multifocal strictures and beading of the bile ducts., Results: Twenty children (14 boys, 6 girls) with an average age of 13 years qualified for the study. Of 19 diagnostic MRCP studies, 16 were called positive and 3 were called negative. An overall diagnosis of PSC-positive was assigned to all 19 patients based on clinical and laboratory findings, biopsy results and cholangiographic data. Based on this overall diagnosis, MRCP was 84% sensitive and accurate to diagnose PSC in children., Conclusion: MRCP can be a valuable tool in diagnosing pediatric PSC that can demonstrate major intra- and extrahepatic ducts in most cases. An unequivocally positive MRCP study should not be followed by ERCP for diagnosing PSC in children.

The purpose of this study was to assess the quality of biliary duct visualization using Gd-EOB-DTPA-enhanced magnetic resonance cholangiography (EOB-MRC) in patients with liver cirrhosis. Forty adult patients with liver cirrhosis (cirrhosis group) and 20 adult individuals with normal liver parenchyma (control group) underwent EOB-MRC using T1-weighted GRE imaging up to 180 min after Gd-EOB-DTPA administration. Two observers assessed the visualization of each biliary structure and the overall anatomical visualization of the biliary tree. Child-Pugh, MELD score and laboratory findings were compared. The grade of visualization for each evaluated biliary structure was statistically different in the two groups (P = 0.004 to <0.001). The overall EOB-MRC quality was rated as sufficient for anatomical visualization of the biliary tree in all individuals of the control group 20 min after Gd-EOB-DTPA application, but in only 16/40 patients (40%) of the cirrhosis group within 30 min after application. Analysis of the ROC curves revealed that the cut-off values, for non-sufficient visualization of the biliary tree 20 min after Gd-EOB-DTPA application, were MELD scores > or =11 and total serum bilirubin levels > or =30 micromol/l. Consecutively, EOB-MRC in patients with liver cirrhosis resulted in a decreased or even non-visualization of the biliary tree in a substantial percentage of patients.