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GASTROINTESTINAL RADIOLOGY Table of Contents   
Year : 1999  |  Volume : 9  |  Issue : 2  |  Page : 53-58
Non-breath-hold magnetic resonance cholangiography-preliminary results and review of literature


Department of Radiodiagnosis, CMC hospital, Vellore-632004, Tamil Nadu, India

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Keywords: MRC, Jaundice, Obstructive, Biliary Tree, Pancreas

How to cite this article:
Justus A, Govil S, Korah I. Non-breath-hold magnetic resonance cholangiography-preliminary results and review of literature. Indian J Radiol Imaging 1999;9:53-8

How to cite this URL:
Justus A, Govil S, Korah I. Non-breath-hold magnetic resonance cholangiography-preliminary results and review of literature. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Nov 12];9:53-8. Available from: http://www.ijri.org/text.asp?1999/9/2/53/28333
Magnetic resonance cholangiography (MRC) is a recently described non-invasive technique with excellent accuracy in the diagnosis of bile duct obstruction and its causes [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]. Visualization of bile ducts without contrast agents is possible with the use of heavily T2W sequences. This highlights the long T2 relaxation of bile present within the biliary tree. Literature reports MRC to be a practical, non-invasive method of imaging of the biliary tree [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

We evaluated the quality of biliary tree delineation by MRC in five patients with suspected biliary obstruction. We compared the MRCs with ultrasound (US), endoscopic retrograde cholangio-pancreaticography (ERCP), percutaneous transhepatic cholangiography (PTC), computed tomography (CT), routine MR axial and coronal MR images along with findings at surgery. The following is a description of these five patients.


   Case Reports Top


Four patients detected to have biliary dilatation on ultrasound and one patient found to have pancreatic duct dilatation underwent MRC and routine MR abdomen as part of their imaging workup. MR imaging was performed on a 0.5 Tesla scanner (Gyroscan, Philips, Eindhoven), with a body coil. An inversion recovery turbo spin-echo (IRTSE) sequence was performed in the coronal plane (source images) followed by reconstruction using a maximum intensity projection (MIP) algorithm. Image processing methods with 3-dimensional display and rotation of the images were used. IRTSE enabled strong T2 weighting with multi-slice imaging and fast scan times. Cardiac gating and respiratory triggering via an ECG and respiratory sensor were used to synchronize scanning to the patient's cardiac and respiratory cycles. Imaging parameters used included the following: TR of 8000 -11,000 ms, TE of 1000 ms, TI of 90 ms, slice thickness of 1.2 mm, number of slices - average - 80, interslice gap - none, total examination time of 14 mins, matrix 256 x 256, routine axial, coronal and/or sagittal images. Routine T1 and /or T2 weighted images of the abdomen were also obtained during the same examination. Intravenous contrast was not used at all.

Patient 1:

An elderly lady presented to the hospital with obstructive jaundice and a history of carcinoma of the gall bladder discovered during a cholecystectomy for gallstones. US revealed intrahepatic biliary dilatation and a mass at the porta hepatis obstructing the common hepatic duct. ERCP showed a long irregular stricture involving the common hepatic duct (CHD) with proximal dilatation. CT was not done. PTC, done as part of a percutaneous trans-hepatic biliary drainage procedure (PTBD), showed narrowing of the confluence, the right hepatic duct (RHD), left hepatic duct (LHD) and proximal CHD with non-visualization of the distal common bile duct (CBD) [Figure - 1]. The MRC showed intrahepatic biliary dilatation, abrupt narrowing of the RHD, LHD, confluence and CHD [Figure - 2]

The distal bile duct was not visualized. The MRC correlated well with the PTC findings. The sectional MR images revealed an 8 x 4-cm mass at the porta, infiltrating the liver and pancreatic head and obstructing the right and left hepatic ducts [Figure - 3]. Surgery was not performed. The final diagnosis in this patient was a recurrent carcinoma gall bladder causing obstruction of the CHD, RHD and LHD.

Patient 2:

A young man presented with obstructive jaundice. US showed intrahepatic biliary dilatation with obstruction at the confluence. ERCP showed an abrupt irregular cut-off of the CBD with non-visualization of the gall bladder [Figure - 4]. CT showed an enhancing 2.0cm mass at the porta obstructing the confluence. The gall bladder was contracted and there was no evidence of metastases. A PTC was not performed because of bleeding parameter dysfunction. MRC showed intrahepatic biliary dilatation due to obstruction of the confluence, RHD and LHD [Figure - 5]. The CHD and GB were devoid of signal. The CBD was normal in calibre. The sectional MR images showed a 2.0cm mass suggestive of a Klatskin tumor at the porta hepatis obliterating the confluence and obstructing the RHD and LHD. These findings were confirmed at surgery.

Patient 3:

A young man had a US and CT done outside our hospital and was found to have an extrahepatic cystic mass suggestive of a choledochal cyst involving the CBD and CHD. The CBD could not be cannulated on ERCP. A PTC was not performed since two previous patients had been satisfactorily and non-invasively imaged with MRC. MRC showed a fusiform dilatation of the CBD, CHD and proximal cystic duct. Sectional MR images confirmed this and also showed an ectopically located gall bladder within the liver [Figure - 6]. The findings were confirmed at surgery.

Patient 4:

A young man on ultrasound had a dilated, beaded pancreatic duct with intraductal calculi and no biliary dilatation. This was interpreted as chronic pancreatitis. ERCP also showed a dilated, beaded pancreatic duct with intraductal calculi. The CBD, however, could not be cannulated. MRCP showed a normal CBD, CHD, GB, confluence and main hepatic ducts [Figure - 7]. The pancreatic duct was dilated and beaded, measuring 10 mm. MR sectional images showed evidence of chronic pancreatitis with normal intrahepatic biliary radicles [Figure - 8]. A final diagnosis of chronic pancreatitis and a normal biliary tree was made.

Patient 5:

A middle-aged man presented with obstructive jaundice. US revealed gross intrahepatic biliary dilatation due to obstruction at the level of the confluence [Figure - 9]. ERC, PTC and CT were not performed. MRC showed an abrupt cut-off of the RHD and LHD with obliteration of the confluence and CHD and marked intra-hepatic biliary dilatation [Figure - 10]. Sectional MR scans revealed a 2.5 x 1.5-cm mass suggestive of a Klatskin tumor at the porta hepatis obstructing the RHD, LHD and quadrate lobe duct. Atrophy of the left lobe of the liver was present. The findings were confirmed at surgery.


   Discussion Top


Non-breath-hold MRC is reputed to be comparable to ERCP and PTC for consistency of depiction of the biliary tree [1],[2],[3]. Although the number of patients studied is too small to evaluate the sensitivity, specificity and accuracy of MRC, this preliminary evaluation in five patients demonstrates the excellent intrahepatic and extrahepatic biliary ductal detail possible with MRC.

Intra-hepatic bile ducts

The good visualization of the proximal bile ducts, in patients with high malignant biliary obstructions on MRC as compared with the poor intrahepatic ductal visualization on ERC, correlates well with the experience of other authors [2]. This is especially important in patients awaiting biliary-enteric surgery, since an accurate demonstration of the proximal bile ducts for the potential site and number of anastomoses, is essential for surgical planning. The combination of the MRC and MR axial and coronal images provides an accurate depiction of the cause, site and extent of the biliary obstruction. Guibaud et al in 1995 [1] reported a sensitivity of 91% and specificity of 100% for biliary obstruction; 81% sensitivity and 98% specificity for choledocholithiasis; 86% sensitivity and 98% specificity for malignant obstruction with MRC. In one patient (patient 4), the peripheral ducts in the undilated biliary system were not visualised on the MRC but were completely visualised on the T2 weighted MR axial and coronal images. Macaulay et al found that 82 % (9/11) of undilated intrahepatic ducts could be visualized in the peripheral third of the liver on MRC [2].

Extra-hepatic bile duct and gall bladder

Bile duct visualization with MR cholangiography requires that a small amount of bile be present within the ducts. In patients 1 and 5, the common duct distal to the site of obstruction was not visualized probably due to the absence of bile in that segment. The GB and any intraluminal pathology are frequently visualized due to the large amount of bile within [2] especially when MRC is done in the fasting state.

Pancreatic duct

The pancreatic duct was not visualized in patients 1, 3 and 5. Macaulay et al saw the pancreatic duct on MRC in the pancreatic head in 66% and in the pancreatic body in 31% of patients [2].

MRC and Contrast Cholangiography

Advantages:

The non-invasiveness of MRC, as well as its lack of ionizing radiation and use of contrast material offer a definite advantage over direct contrast cholangiography. The complications of ERCP (7-9 %) and PTC (2-9%) in patients with obstructive jaundice are avoided [16]. In patients who have significant coagulopathy, previous upper gastrointestinal surgery or biliary-enteric surgery, contrast cholangiography may be contra-indicated or technically difficult. MRC is unaffected by these problems. MRC is less dependent on the skill of the operator as opposed to ERCP and PTC, the success rates of which have been reported to be as low as 70 and 68% respectively. [9]. In cases of multiple stenoses, there is complete mapping of the bile ducts by MRC [1] unlike ERCP and PTC which will rarely be complete with one study. On MRC, ductal filling is neither dependent on gravitational factors nor limited by intraductal debris or stenosis. Unlike in direct cholangiography, there is no overdistension of the ducts. CBD measurements on MRC are comparable with ERC [1]. In MRC, the ductal imaging is part of a comprehensive sectional MR imaging providing two investigations in one examination [4]. This makes it more cost-effective than combining direct contrast cholangiography with separate cross-sectional imaging. In addition, both ERCP and PTC require hospitalization, antibiotic prophylaxis and sedation. MRC can be done as an outpatient procedure. There is good interobserver agreement in the interpretation of the MRC images [1]. In direct contrast cholangiography, the number of views taken during the procedure limits accurate interpretation of the image. In MRC, 3-dimensional display and rotation of the cholangiogram facilitates interpretation.

Disadvantages:

The main disadvantage of MRC is the lack of access for interventional procedures. MRC cannot be performed on patients with metallic implants especially prosthetic heart valves and aneurysm clips. Images of diagnostic quality may not be obtainable in claustrophobic or restless patients. Uneven breathing and excessive bowel peristalsis can degrade the image. Spatial resolution of the MRC image is less than with direct contrast cholangiography [2]. Minimal irregularities of a strictured segment can therefore be missed. Differentiation between high-grade stenosis and obstruction is difficult on MRC. MIP reconstruction results in degradation of image data [2]. Source images have to be studied for visualization of the peripheral non-dilated intrahepatic ducts and small filling defects. The small calibre of the cystic duct and valves of Heister limit the amount of bile and therefore the signal within the cystic duct, making visualization of the cystic duct and its insertion difficult [2]. Blood or proteinaceous debris can shorten the T2 of bile and lead to focal non-visualization of the duct with the false impression of narrowing, obstruction or calculi [4]. The confluence of the extrahepatic duct and main pancreatic duct is not frequently visualized as the biliary and main pancreatic duct sphincters narrow the terminal portions of the ducts, diminishing intra-luminal bile and signal. Direct mucosal visualisation and biopsy of the peri-ampullary region is not possible with MRC. For these reasons, ERCP remains unchallenged in the diagnosis of peri-ampullary carcinoma [1],[2].

MRC - Future Developments

One of the factors which detracts from the quality of the MRC image is the concomitant visualization of all static fluid-filled structures particularly the bowel which can obscure parts of the biliary or pancreatic ducts [4]. This is partly overcome by 3-dimensional display and rotation of the MRC image [3]. The use of negative bowel contrast media such as ferric ammonium citrate or high-density barium for suppressing bowel luminal signal is under investigation [3],[5].

With improvement in technology, MR cholangiography and conventional MR imaging can be combined with MR angiography, MR spectroscopy and possibly with MR-guided biopsy, so that a comprehensive work-up can be obtained with a single examination. From the standpoint of efficiency and cost-effectiveness, this is one of the greatest potential benefits of MR imaging [3].

In conclusion, MRC with axial and coronal MR images of the abdomen accurately depicted biliary anatomy and demonstrated the site, cause and extent of obstruction in this preliminary evaluation of the five patients. Review of literature and this initial experience suggest that MRC is an excellent non-invasive alternative to direct contrast cholangiography in patients who are not candidates for percutaneous or endoscopic interventional procedures.

 
   References Top

1.Guibaud L, Bret PM, Reinhold C, Atri M, Barkun AN. Bile duct obstruction and choledocholithiasis: diagnosis with MR cholangiography. Radiology 1995; 197: 109-115.   Back to cited text no. 1  [PUBMED]  
2.Macaulay SE, Schulte SJ, Sekijima JH, et al . Evaluation of a non-breath-hold MR cholangiography Technique. Radiology 1995: 196: 227-32.   Back to cited text no. 2    
3.Meakem TJ 3rd, Schnall MD. Magnetic Resonance cholangiography. GCNA 1995; 24: 221-238.   Back to cited text no. 3  [PUBMED]  
4.Outwater EK, Gordon SJ. Imaging the pancreatic and biliary ducts with MR - an editorial. Radiology 1994; 192: 19-21.   Back to cited text no. 4  [PUBMED]  
5.Takahara T, Saeki M, Nosaka S, et al . The use of high concentration ferric ammonium citrate (FAC) solution as a negative bowel contrast agent: application in MR cholangiography. Nippon Igaku Hoshasen Gakkai Zasshi 1995; 55: 697-9   Back to cited text no. 5    
6.Ohkawa S, Hiramatsu K. 3D MR cholangio-angiography. Nippon Igaku Hoshasen Gakkai Zasshi 1995; 55: 348-349.   Back to cited text no. 6  [PUBMED]  
7.Guibaud L, Bret PM, Reinhold C, Atri M, Barkun AN. Diagnosis of choledocholithiasis: value of MR cholangiography. AJR 1994; 163: 847-850.   Back to cited text no. 7  [PUBMED]  
8.Laubenberger J, Buchert M, Schneider B, Blum U, Hennig J, Langer M. Breath-hold projection magnetic resonance cholangio-pancreaticography (MRCP): a new method for examination of the bile and pancreatic ducts. Magen Reson Med 1995; 33: 18-23.   Back to cited text no. 8  [PUBMED]  
9.Ishizaki Y, Wakayama T, Okada Y, Kobayashi T. Magnetic resonance cholangiography for evaluation of obstructive jaundice. Am J Gastroenterol 1993; 88: 2072-2077.   Back to cited text no. 9  [PUBMED]  
10.Morimoto K, Shimoi M, Shirakawa T, Aoki Y, Choi S, Miyata Y, Hara K. Biliary obstruction: evaluation with three-dimensional MR cholangiography. Radiology 1992; 183: 578-580.   Back to cited text no. 10  [PUBMED]  
11.Hall-Craggs MA, Allen CM, Owens CM, Theis BA, Donald JJ, Paley M. MR cholangiography: clinical evaluation in 40 cases. Radiology 1993; 189: 423-427.   Back to cited text no. 11    
12.Wallner BK, Schumacher KA, Weidenmaier W, Friedrich JM. Dilated biliary tract: evaluation with MR cholangiography with a T2 weighted contrast - enhanced fast sequence. Radiology 1991; 181: 805-808.   Back to cited text no. 12  [PUBMED]  
13.Vogl TJ, Hammerstingl R, Schnell B, Eibl-Eibesfeldt B, Peqios W, Lissner J. Magnetic resonance tomography of the hepatobiliary system: indications, limitations and outlook. Bildgebung 1992; 59:195-199.   Back to cited text no. 13  [PUBMED]  
14.Schumacher KA, Wallner B, Weidenmaier W, Friedrich JM. Biliary obstruction: MR cholangiography with a rapid gradient-echo sequence (2D CE-Fast). Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 1991; 155: 332-336.   Back to cited text no. 14  [PUBMED]  
15.Morimoto K, Aoki Y, Choi S, Miyata Y, Hara K. MR cholangiography. Igaku Hoshasen Gakkai Zasshi 1991; 25; 51: 833-835.   Back to cited text no. 15    
16.Haubrich WS, Schaffner F, Berk J. Bockus Gastroenterology 5th edition, Philadelphia: WB Saunders, p.2612.  Back to cited text no. 16    

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Correspondence Address:
Asha Justus
Department of Radiodiagnosis, CMC hospital, Vellore-632004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]

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