Magnetic Resonance Cholangiopancreatography (MRCP): Biliary and Pancreatic Ducts

216 Pages·2013·11.448 MB·English

by  Riccardo Manfredi, Roberto Pozzi Mucelli (auth.)

Riccardo Manfredi
Roberto Pozzi Mucelli
Magnetic Resonance

Cholangiopancreatography
Biliary and Pancreatic Ducts
123
Magnetic Resonance
Cholangiopancreatography (MRCP)
Riccardo Manfredi
Roberto Pozzi Mucelli
Magnetic Resonance
Cholangio-
pancreatography
(MRCP)
Biliary and Pancreatic Ducts
Presentazione di
Lisa Licitra, Patrizia Olmi
123
Riccardo Manfredi Roberto Pozzi Mucelli
Department of Radiology Department of Radiology
G.B. Rossi University Hospital G.B. Rossi University Hospital
Verona, Italy Verona, Italy
ISBN 978-88-470-2843-2 ISBN 978-88-470-2844-9(eBook)
DOI 10.1007/978-88-470-2844-9
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Preface
It is now well accepted that magnetic resonance imaging (MRI) has be-
come an important imaging modality for study of the pancreas and the
bile ducts, yet this success story was probably not predictable. The
marked change in the role of MRI is attributable to the greater efficacy
of modern MRI systems and improved knowledge of diseases; particu-
larly important advances in MRI include the advent of rapid imaging, im-
proved image quality and the development of sequences suitable for the
study of the biliary tree and pancreatic ducts. As a consequence, while
there is no doubt that ultrasound and computed tomography continue to
represent the imaging methods of choice for most diseases, MRI can offer
invaluable support when the diagnosis is unclear and can supply signifi-
cant additional information of assistance in patient management.
In general, in diagnostic imaging, special emphasis is placed on the
technological evolution of imaging modalities; however, in the case of
this book, I have wished to put more emphasis on knowledge. The book
is in fact the result of a long journey in the study of pancreatic diseases
that began many years ago at the Policlinico G. B. Rossi and has in-
volved a variety of distinguished gastroenterologists, surgeons, pathol-
ogists and radiologists whose expertise is recognized beyond the
boundaries of Italy. As a result of the progress made, the Pancreas Cen-
ter in Verona is today recognized as the “Istituto del Pancreas” – it is a
well-known and much-appreciated referral center both in Italy and
worldwide. Working in this context, much experience in MRI has been
gathered, such that a large series of cases is available for the different
pancreatic diseases, including even the rare ones.
The book is divided into two parts covering, respectively, the biliary
tree and the pancreatic ducts. Special attention is devoted to the
methodology and the applications of magnetic resonance cholangiopan-
creatography (MRCP), from both the morphological and the functional
point of view. The MR/MRCP imaging findings are reported for diverse
conditions, including anatomical variants, inflammatory disease and
neoplasms, with highlighting of findings important for differential di-
agnosis with other entities. Although MRCP is important, however, it
should be recognized that it cannot be considered separately from the
other imaging sequences normally employed for the examination of the
pancreas as part of the MR study.
v
vi Preface
I would like to thank Prof. Riccardo Manfredi for his efforts in
preparing this book and his enthusiasm in coordinating the young doc-
tors, most of them radiology residents at the University of Verona, who
helped in the preparation of the volume.
November 2012 Prof. Roberto Pozzi Mucelli
Department of Radiology
G.B. Rossi University Hospital
Verona, Italy
Contents
Section I - Magnetic Resonance Cholangiopancreatography
01 Magnetic Resonance Cholangiopancreatography:
Technical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Riccardo Manfredi, Massimiliano Bellotti, Alessandra Brandalise,
and Roberto Pozzi Mucelli
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Imaging Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 MRCP Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.1 Multislice Half-Fourier Acquistion Single-Shot
Turbo-Spin-Echo (HASTE) . . . . . . . . . . . . . . . . . . . . . 6
1.3.2 Thick-Slab Single-Shot Fast-Spin-Echo/
Turbo-Spin-Echo Sequence . . . . . . . . . . . . . . . . . . . . . 7
1.3.3 Three-Dimensional Turbo-Spin-Echo (3D-TSE)
Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3.4 Secretin-Enhanced Dynamic MRCP . . . . . . . . . . . . . . 12
1.4 Pitfalls and Artifacts of MRCP . . . . . . . . . . . . . . . . . . 14
1.5 Hepatobiliary Contrast Media T1-weighted Gradient-Echo 17
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Section II - Biliary Ducts
02 Normal Anatomy of the Biliary Tree, Gallbladder and
Pancreatic Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Riccardo Manfredi, Alessandra Brandalise,
Massimiliano Bellotti, and Roberto Pozzi Mucelli
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1.2 Embryological Development . . . . . . . . . . . . . . . . . . . . 21
2.1.3 Biliary Tree Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.1.4 Anatomy of the Gallbladder, Cystic Duct and
Common Bile Duct . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.1.5 Pancreas and Vaterian Sphincter Complex . . . . . . . . . 24
2.2 Anatomical Variants of the Intrahepatic and Extrahepatic
Biliary Tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.2.1 Common Anatomical Variants of the Intrahepatic
and Extrahepatic Biliary Tree . . . . . . . . . . . . . . . . . . . 25
vii
viii Contents
2.2.2 Uncommon Anatomical Variants of the Intrahepatic
and Extrahepatic Biliary Tree . . . . . . . . . . . . . . . . . . . 27
2.2.3 Biliary Hamartomatosis . . . . . . . . . . . . . . . . . . . . . . . . 30
2.3 Anatomical Variants of the Gallbladder, Cystic Duct
and Common Bile Duct . . . . . . . . . . . . . . . . . . . . . . . . 31
2.3.1 Anatomical Variants of the Gallbladder . . . . . . . . . . . . 31
2.3.2 Anatomical Variants of the Cystic Duct . . . . . . . . . . . 34
2.3.3 Congenital Diseases of the Biliary System . . . . . . . . . 38
2.4 Anatomical Variants of Pancreatic Ducts and the Vaterian
Sphincter Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.4.1 Pancreas Divisum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.4.2 Annular Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.4.3 Ductal Configuration . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.4.4 Anomalous Vaterian Sphincter Complex . . . . . . . . . . . 48
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
03 Magnetic Resonance Cholangiopancreatography in Biliary
Lithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Riccardo Manfredi, Mariacristina Munafò, Teresa Milazzo,
Lisa Nicolì, and Roberto Pozzi Mucelli
3.1 Physiology of the Biliary Tract . . . . . . . . . . . . . . . . . . 51
3.2 Pathogenesis of Biliary Lithiasis . . . . . . . . . . . . . . . . . 51
3.3 Natural History and Clinical Presentation of Biliary
Lithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3.1 Cholelithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3.2 Choledocholithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
3.3.3 Intrahepatic Duct Stones . . . . . . . . . . . . . . . . . . . . . . . 53
3.4 Diagnostic Imaging of Biliary Lithiasis . . . . . . . . . . . 54
3.4.1 Cholelithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3.4.2 Common Bile Duct Stones . . . . . . . . . . . . . . . . . . . . . 55
3.4.3 Intrahepatic Duct Stones . . . . . . . . . . . . . . . . . . . . . . . 56
3.5 MRCP Imaging in Choledocholithiasis . . . . . . . . . . . . 58
3.5.1 MRCP Signs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
3.5.2 Advantages of MRCP . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.6 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.6.1 Endoluminal Causes of Obstruction . . . . . . . . . . . . . . 64
3.6.2 Parietal Causes of Obstruction . . . . . . . . . . . . . . . . . . . 65
3.6.3 Extrinsic Causes of Obstruction . . . . . . . . . . . . . . . . . 67
3.7 Complications of Biliary Lithiasis . . . . . . . . . . . . . . . . 69
3.7.1 Complications of Cholelithiasis . . . . . . . . . . . . . . . . . . 69
3.7.2 Complications of Choledocholithiasis . . . . . . . . . . . . . 70
3.7.3 Complications of Intrahepatic Duct Stones . . . . . . . . . 72
3.8 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.8.1 Treatment of Cholelithiasis . . . . . . . . . . . . . . . . . . . . . 73
3.8.2 Treatment of Common Bile Duct Stones . . . . . . . . . . . 73
3.8.3 Treatment of Intrahepatic Duct Stones . . . . . . . . . . . . 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Contents ix
04 Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Riccardo Manfredi, Ilaria Baglio, Matteo De Iorio,
Lucia Camera, and Roberto Pozzi Mucelli
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2 Infectious Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.1 Acute Bacterial Cholangitis . . . . . . . . . . . . . . . . . . . . . 77
4.2.2 Recurrent Bacterial Cholangitis . . . . . . . . . . . . . . . . . . 80
4.2.3 Diagnostic Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.2.4 Parasitic Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.2.5 HIV-related Cholangitis . . . . . . . . . . . . . . . . . . . . . . . . 85
4.3 Autoimmune Cholangitis . . . . . . . . . . . . . . . . . . . . . . . 86
4.3.1 Primary Sclerosing Cholangitis . . . . . . . . . . . . . . . . . . 86
4.3.2 IgG4-related Sclerosing Cholangitis . . . . . . . . . . . . . . 89
4.3.3 Cholangitis After Hepatic Transplantation . . . . . . . . . 89
4.3.4 Primary Biliary Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . 91
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
05 Neoplasms of the Biliary Tree . . . . . . . . . . . . . . . . . . . . . . . 95
Riccardo Manfredi, Alberto Contro, Maria Chiara Ambrosetti,
Ugolino Alfonsi, Valerio Di Paola, and Roberto Pozzi Mucelli
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.2 Cholangiocarcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . 95
5.2.1 Intrahepatic Cholangiocarcinoma . . . . . . . . . . . . . . . . 96
5.2.2 Hilar Cholangiocarcinoma: Klatskin Tumor . . . . . . . . 96
5.2.3 Distal Extrahepatic Cholangiocarcinoma . . . . . . . . . . 103
5.3 Classification of Cholangiocarcinoma According to
the Liver Cancer Study Group of Japan . . . . . . . . . . . 107
5.3.1 Mass-Forming Cholangiocarcinoma . . . . . . . . . . . . . . 107
5.3.2 Periductal-Infiltrating Cholangiocarcinoma . . . . . . . . 109
5.3.3 Intraductal-Growing Cholangiocarcinoma . . . . . . . . . 110
5.4 Papillary Tumors of the Bile Ducts . . . . . . . . . . . . . . . 113
5.5 Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.5.1 Benign Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
5.5.2 Malignant Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Section III - Pancreatic Ducts
06 Acute Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Riccardo Manfredi, Francesco Principe, Riccardo De Robertis
Lombardi, Lucia Camera, and Roberto Pozzi Mucelli
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.2 Acute Pancreatitis: Clinical Aspects . . . . . . . . . . . . . . 123
6.2.1 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.2.2 Clinical Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
6.3 Acute Pancreatitis: Pathological Findings . . . . . . . . . . 124
x Contents
6.4 Acute Pancreatitis: MRI Findings . . . . . . . . . . . . . . . . 125
6.4.1 Non-Severe Acute Pancreatitis: MRI Findings . . . . . . 125
6.4.2 Severe Acute Pancreatitis: MRI Findings . . . . . . . . . . 125
6.4.3 Severe Acute Pancreatitis: MRCP Findings . . . . . . . . 128
6.5 Pancreatic Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
6.5.1 Differentiation Between Pancreatic Necrosis and
Peri-pancreatic Fluid Collection . . . . . . . . . . . . . . . . . 128
6.6 Acute Pancreatitis: Etiology . . . . . . . . . . . . . . . . . . . . 128
6.7 Biliary Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
6.8 Pancreatic Duct Disruption . . . . . . . . . . . . . . . . . . . . . 132
6.9 Intraductal Papillary Mucinous Neoplasms and Acute
Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
6.10 Pancreas Divisum and Acute Pancreatitis . . . . . . . . . . 137
6.11 Acute Pancreatitis: Complications . . . . . . . . . . . . . . . . 137
6.11.1Pseudocyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
6.11.2 Pancreatic Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
6.11.3 Vascular Complications . . . . . . . . . . . . . . . . . . . . . . . . 140
6.12 Peculiar Forms of Acute Pancreatitis . . . . . . . . . . . . . . 140
6.12.1 Acute Pancreatitis in Children . . . . . . . . . . . . . . . . . . . 140
6.12.2 Acute Pancreatitis During Pregnancy . . . . . . . . . . . . . 142
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
07 Chronic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Riccardo Manfredi, Livia Bernardin, Simona Mautone,
Alessandro Zaccarella, and Roberto Pozzi Mucelli
7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
7.1.1 Role of Standard MRI and MRCP in Assessing
Chronic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
7.1.2 Role of Secretin-Stimulated MRCP in Assessing
Chronic Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
7.2 Main Causes of Primary Chronic Pancreatitis . . . . . . . 152
7.2.1 Chronic Pancreatitis Associated With Genetic
Mutations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
7.2.2 Autoimmune Chronic Pancreatitis . . . . . . . . . . . . . . . . 155
7.3 Main Causes of Secondary Chronic Pancreatitis . . . . . 155
7.3.1 Pancreatitis Associated with Sphincter of Oddi
Dysfunction or Biliary Lithiasis . . . . . . . . . . . . . . . . . 156
7.3.2 Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
7.3.3 Anatomical Variants . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
7.3.4 Paraduodenal Pancreatitis . . . . . . . . . . . . . . . . . . . . . . 161
7.3.5 Necrotizing Acute Pancreatitis . . . . . . . . . . . . . . . . . . 162
7.4 Alcoholic and Metabolic Chronic Pancreatitis . . . . . . 162
7.5 Chronic Pancreatitis: Natural History . . . . . . . . . . . . . 163
7.5.1 Recurrent–Early Pancreatitis . . . . . . . . . . . . . . . . . . . . 163
7.5.2 Advanced Chronic Pancreatitis . . . . . . . . . . . . . . . . . . 163
7.6 Differential Diagnosis of Obstructing Chronic
Pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164