Magnetic Resonance Cholangiopancreatography (MRCP)

Transcription

1 Magnetic Resonance Cholangiopancreatography (MRCP)

2 Riccardo Manfredi Roberto Pozzi Mucelli Magnetic Resonance Cholangiopancreatography (MRCP) Biliary and Pancreatic Ducts Presentazione di Lisa Licitra, Patrizia Olmi 123

3 Riccardo Manfredi Department of Radiology G.B. Rossi University Hospital Roberto Pozzi Mucelli Department of Radiology G.B. Rossi University Hospital ISBN ISBN (ebook) DOI / Springer Milan Dordrecht Heidelberg London New York Library of Congress Control Number: Springer-Verlag Italia 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through Rights - Link at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein Cover design: Ikona S.r.l., Milan, Italy Typesetting: Graphostudio, Milan, Italy Springer-Verlag Italia S.r.l. Via Decembrio 28 I Milan Springer is a part of Springer Science+Business Media (

4 Preface It is now well accepted that magnetic resonance imaging (MRI) has become 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; particularly important advances in MRI include the advent of rapid imaging, improved 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 significant 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 involved a variety of distinguished gastroenterologists, surgeons, pathologists and radiologists whose expertise is recognized beyond the boundaries of Italy. As a result of the progress made, the Pancreas Center 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 cholangiopancreatography (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 diagnosis 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

5 vi Preface I would like to thank Prof. Riccardo Manfredi for his efforts in preparing this book and his enthusiasm in coordinating the young doctors, 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

6 Contents Section I - Magnetic Resonance Cholangiopancreatography 01 Magnetic Resonance Cholangiopancreatography: Technical Considerations Riccardo Manfredi, Massimiliano Bellotti, Alessandra Brandalise, and Roberto Pozzi Mucelli 1.1 Introduction Imaging Protocol MRCP Techniques Multislice Half-Fourier Acquistion Single-Shot Turbo-Spin-Echo (HASTE) Thick-Slab Single-Shot Fast-Spin-Echo/ Turbo-Spin-Echo Sequence Three-Dimensional Turbo-Spin-Echo (3D-TSE) Sequence Secretin-Enhanced Dynamic MRCP Pitfalls and Artifacts of MRCP Hepatobiliary Contrast Media T1-weighted Gradient-Echo 17 References Section II - Biliary Ducts 02 Normal Anatomy of the Biliary Tree, Gallbladder and Pancreatic Duct Riccardo Manfredi, Alessandra Brandalise, Massimiliano Bellotti, and Roberto Pozzi Mucelli 2.1 Introduction Embryological Development Biliary Tree Anatomy Anatomy of the Gallbladder, Cystic Duct and Common Bile Duct Pancreas and Vaterian Sphincter Complex Anatomical Variants of the Intrahepatic and Extrahepatic Biliary Tree Common Anatomical Variants of the Intrahepatic and Extrahepatic Biliary Tree vii

7 viii Contents Uncommon Anatomical Variants of the Intrahepatic and Extrahepatic Biliary Tree Biliary Hamartomatosis Anatomical Variants of the Gallbladder, Cystic Duct and Common Bile Duct Anatomical Variants of the Gallbladder Anatomical Variants of the Cystic Duct Congenital Diseases of the Biliary System Anatomical Variants of Pancreatic Ducts and the Vaterian Sphincter Complex Pancreas Divisum Annular Pancreas Ductal Configuration Anomalous Vaterian Sphincter Complex References Magnetic Resonance Cholangiopancreatography in Biliary Lithiasis Riccardo Manfredi, Mariacristina Munafò, Teresa Milazzo, Lisa Nicolì, and Roberto Pozzi Mucelli 3.1 Physiology of the Biliary Tract Pathogenesis of Biliary Lithiasis Natural History and Clinical Presentation of Biliary Lithiasis Cholelithiasis Choledocholithiasis Intrahepatic Duct Stones Diagnostic Imaging of Biliary Lithiasis Cholelithiasis Common Bile Duct Stones Intrahepatic Duct Stones MRCP Imaging in Choledocholithiasis MRCP Signs Advantages of MRCP Differential Diagnosis Endoluminal Causes of Obstruction Parietal Causes of Obstruction Extrinsic Causes of Obstruction Complications of Biliary Lithiasis Complications of Cholelithiasis Complications of Choledocholithiasis Complications of Intrahepatic Duct Stones Treatment Treatment of Cholelithiasis Treatment of Common Bile Duct Stones Treatment of Intrahepatic Duct Stones References

8 Contents ix 04 Cholangitis Riccardo Manfredi, Ilaria Baglio, Matteo De Iorio, Lucia Camera, and Roberto Pozzi Mucelli 4.1 Introduction Infectious Cholangitis Acute Bacterial Cholangitis Recurrent Bacterial Cholangitis Diagnostic Imaging Parasitic Cholangitis HIV-related Cholangitis Autoimmune Cholangitis Primary Sclerosing Cholangitis IgG4-related Sclerosing Cholangitis Cholangitis After Hepatic Transplantation Primary Biliary Cirrhosis References Neoplasms of the Biliary Tree Riccardo Manfredi, Alberto Contro, Maria Chiara Ambrosetti, Ugolino Alfonsi, Valerio Di Paola, and Roberto Pozzi Mucelli 5.1 Introduction Cholangiocarcinoma Intrahepatic Cholangiocarcinoma Hilar Cholangiocarcinoma: Klatskin Tumor Distal Extrahepatic Cholangiocarcinoma Classification of Cholangiocarcinoma According to the Liver Cancer Study Group of Japan Mass-Forming Cholangiocarcinoma Periductal-Infiltrating Cholangiocarcinoma Intraductal-Growing Cholangiocarcinoma Papillary Tumors of the Bile Ducts Differential Diagnosis Benign Diseases Malignant Diseases References Section III - Pancreatic Ducts 06 Acute Pancreatitis Riccardo Manfredi, Francesco Principe, Riccardo De Robertis Lombardi, Lucia Camera, and Roberto Pozzi Mucelli 6.1 Introduction Acute Pancreatitis: Clinical Aspects Pathophysiology Clinical Findings Acute Pancreatitis: Pathological Findings

9 x Contents 6.4 Acute Pancreatitis: MRI Findings Non-Severe Acute Pancreatitis: MRI Findings Severe Acute Pancreatitis: MRI Findings Severe Acute Pancreatitis: MRCP Findings Pancreatic Necrosis Differentiation Between Pancreatic Necrosis and Peri-pancreatic Fluid Collection Acute Pancreatitis: Etiology Biliary Pancreatitis Pancreatic Duct Disruption Intraductal Papillary Mucinous Neoplasms and Acute Pancreatitis Pancreas Divisum and Acute Pancreatitis Acute Pancreatitis: Complications Pseudocyst Pancreatic Abscess Vascular Complications Peculiar Forms of Acute Pancreatitis Acute Pancreatitis in Children Acute Pancreatitis During Pregnancy References Chronic Pancreatitis Riccardo Manfredi, Livia Bernardin, Simona Mautone, Alessandro Zaccarella, and Roberto Pozzi Mucelli 7.1 Introduction Role of Standard MRI and MRCP in Assessing Chronic Pancreatitis Role of Secretin-Stimulated MRCP in Assessing Chronic Pancreatitis Main Causes of Primary Chronic Pancreatitis Chronic Pancreatitis Associated With Genetic Mutations Autoimmune Chronic Pancreatitis Main Causes of Secondary Chronic Pancreatitis Pancreatitis Associated with Sphincter of Oddi Dysfunction or Biliary Lithiasis Neoplasms Anatomical Variants Paraduodenal Pancreatitis Necrotizing Acute Pancreatitis Alcoholic and Metabolic Chronic Pancreatitis Chronic Pancreatitis: Natural History Recurrent Early Pancreatitis Advanced Chronic Pancreatitis Differential Diagnosis of Obstructing Chronic Pancreatitis

10 Contents xi Obstructing Chronic Pancreatitis Versus Central Intraductal Papillary Mucinous Neoplasm Obstructing Chronic Pancreatitis Caused by Paraduodenal Pancreatitis Versus Adenocarcinoma of the Pancreatic Head Differential Diagnosis of Non-Obstructing Chronic Pancreatitis Focal Autoimmune Chronic Pancreatitis Versus Adenocarcinoma Diffuse Autoimmune Chronic Pancreatitis Versus Lymphoma Hereditary Chronic Pancreatitis with Genetic Mutation Versus Central Intraductal Papillary Mucinous Neoplasm Complications of Chronic Pancreatitis References Pancreatic Tumors Riccardo Manfredi, Federica Castelli, Giovanni Foti, Lisa Zantedeschi, Anna Ventriglia, and Roberto Pozzi Mucelli 8.1 Introduction Solid Pancreatic Tumors Pancreatic Adenocarcinoma Endocrine Pancreatic Tumors Cystic Tumors Introduction Mucinous Cystic Neoplasms Serous Neoplasms of the Pancreas Intraductal Papillary Mucinous Neoplasms References Index

11 Contributors Ugolino Alfonsi Department of Radiology, G.B. Rossi University Hospital, Maria Chiara Ambrosetti Department of Radiology, G.B. Rossi University Hospital, Ilaria Baglio Department of Radiology, G.B. Rossi University Hospital, Massimiliano Bellotti Department of Radiology, G.B. Rossi University Hospital, Livia Bernardin Department of Radiology, G.B. Rossi University Hospital, Alessandra Brandalise Department of Radiology, G.B. Rossi University Hospital, Lucia Camera Department of Radiology, G.B. Rossi University Hospital, Federica Castelli Department of Radiology, G.B. Rossi University Hospital, Alberto Contro Department of Radiology, G.B. Rossi University Hospital, Matteo De Iorio Department of Radiology, G.B. Rossi University Hospital, Riccardo De Robertis Lombardi Department of Radiology, G.B. Rossi University Hospital, Valerio Di Paola Department of Radiology, G.B. Rossi University Hospital, xiii

12 xiv Contributors Giovanni Foti Department of Radiology, G.B. Rossi University Hospital, Riccardo Manfredi Department of Radiology, G.B. Rossi University Hospital, Simona Mautone Department of Radiology, G.B. Rossi University Hospital, Teresa Milazzo Department of Radiology, G.B. Rossi University Hospital, Maricacristina Munafò Department of Radiology, G.B. Rossi University Hospital, Lisa Nicolì Department of Radiology, G.B. Rossi University Hospital, Roberto Pozzi Mucelli Department of Radiology, G.B. Rossi University Hospital, Francesco Principe Department of Radiology, G.B. Rossi University Hospital, Anna Ventriglia Department of Radiology, G.B. Rossi University Hospital, Alessandro Zaccarella Department of Radiology, G.B. Rossi University Hospital, Lisa Zantedeschi Department of Radiology, G.B. Rossi University Hospital,