Biliary MRI w Eovist Is there any added value? Elmar M. Merkle, MD Director of MR Imaging Duke University Medical Center elmar.merkle@duke.edu
Declaration of Conflict of Interest or Relationship Research Support Siemens Advisory Board Bayer, Siemens Speaker s Bureau Bayer
RT 3D T2w MR Cholangiography (MRC) 3D datasets with isotropic voxels z 1 mm y x 1 mm 1 mm
T2w MR Cholangiography Remaining Problems Choledochoduodenal Junction Functional Information Biliary Dynamics Communication of Fluid Collections
MRC Remaining Problems Choledochoduodenal junction
MRC Remaining Problems Functionally relevant stenoses?
Time resolved MRC o Pharmaceutical stimulation o Biliary excreted contrast agents
Uptake Mechanism of HB Contrast Agents Gadoxetate disodium (EOVIST ) Biliary Elimination Biliary canaliculi Hepatocyte 50%
Portal venous Cystic Duct Filling 6 min P.I. 14 min P.I.
Gallbladder Filling 14 min P.I.
Duke Experience September 2008 to September 2009 505 patients w Gd-EOB-DTPA 61 patients (39 women, mean age 53y) Normal renal function Normal liver function tests No history of biliary surgery or intervention Ringe KI et al, Eur J Radiol 2010
Duke Experience Biliary Excretion in 20 Minutes Intrahepatic bile ducts Common bile duct Gallbladder Duodenum 61/61 61/61 53/61 40/61 100% 100% 87% 66% Ringe KI et al, Eur J Radiol 2010
49 year-old-female, 15 min post Gd-EOB-DTPA Ringe KI et al, Eur J Radiol 2010
Duke Experience 8/61 patients had no GB reflux 6/8 patients showed duodenal excretion Ringe KI et al, Eur J Radiol 2010
31 year-old-man, 13 min post Gd-EOB-DTPA Ringe KI et al, Eur J Radiol 2010
Physiology of the Biliary System 600 ml bile/day 97% water 3% bile acids, phospholipids, cholesterol, bile pigment, and electrolytes
Physiology of the Biliary System Fasting state 10 cm H2O ~90% of water can be absorbed from the GB 15 cm H2O 30 cm H2O
Various SI of Bile on T1w GRE T1w GRE in phase T1w GRE out of phase postprandial fasting
Physiology of the Biliary System Postprandial 10 cm H2O Contraction ~75% of GB volume is excreted Relaxation 15 cm H2O 30 cm H2O
Duke Experience 8/61 patients had no GB reflux 6/8 patients showed duodenal excretion 4/6 patients had a full stomach Ringe KI et al, Eur J Radiol 2010
31 year-old-man, 13 min post Gd-EOB-DTPA Ringe KI et al, Eur J Radiol 2010
Take Home Points Best results are achieved if the patient is NPO for at least 4 hours The majority of patients demonstrate reflux of Gd-EOB-DTPA into gallbladder within 20 min following contrast injection Delayed reflux or absence of gallbladder reflux may indicate gallbladder pathology
MRC Normal Anatomy
Any help from T1w MRC?
Normal Variants Type 1-4: aberrant segmental branch
Normal Variants Type 5-6: aberrant cystic duct
46 YOF w incomplete divisum Accessory right segmental branch
46 YOF w incomplete divisum T2w 3D MRCP T1w 3D MRC
18 YOM, S/P lap cholecystectomy Patient develops bile leak Initial post-surgical ERCP shows no abnormality
18 YOM, S/P lap cholecystectomy Patient develops bile leak Initial post-surgical ERCP shows no abnormality Initial T2w MRCP read as normal
18 YOM, S/P lap cholecystectomy patent stent 15 min P.I. 120 min P.I.
18 YOM, S/P lap cholecystectomy
Choledochal Cysts Todani classification: five types Pathophysiology: uncertain Anomalous junction between the CBD and pancreatic duct? Frequency in the US range from 1 per 100,000-150,000 to 1 per 2,000,000 live births.
Choledochal Cyst Type 4 IVA: multiple dilatations (intra + extra) IVB: multiple dilatations (extra only)
Choledochal Cyst Type 4 IVA: multiple dilatations (intra + extra) IVB: multiple dilatations (extra only)
Simple Cyst or Choledochal Cyst
Simple Cyst or Choledochal Cyst
Simple Cyst or Choledochal Cyst
Choledocholithiasis
Complications of Cholelithiasis Acute cholecystitis Obstruction, cholangitis, secondary biliary cirrhosis Biliary-enteric fistula Gallstone ileus
Complications of Cholelithiasis Acute cholecystitis Obstruction, cholangitis, secondary biliary cirrhosis Biliary-enteric fistula Gallstone ileus
Acute Cholecystitis?
Acute Cholecystitis
Primary Sclerosing Cholangitis Male preference, < 45 yo Associated w IBD (50%!) Complications Cirrhosis Recurrent bacterial cholangitis Cholangiocarcinoma
Primary Sclerosing Cholangitis MRCP vs ERCP Sensitivity of MRCP: 88 % Specificity of MRCP: 99 %
Primary Sclerosing Cholangitis Stenoses, beaded ducts, irregular ducts
MRC Remaining Problems Functionally relevant stenoses? 24 min post Gd-EOB-DTPA
MRC in Patients with Biliary Stents 46 yr-old woman with breast and gastric cancer
MRC in Patients with Biliary Stents 61 yr-old man with gastric cancer
MRC in Patients with Biliary Stents 65 yr-old man with pancreatic cancer
MRC in Patients with Biliary Stents
S/P OLT, bilio-biliary anastomosis 15 min post Gd-EOB-DTPA
Chronic P itis, bilioduodenal anastomosis 20 min post Gd-EOB-DTPA
18 YOF, S/P OLT T2W image reveals a fluid collection in ant abdomen post percutaneous biopsy
18 YOF, S/P OLT
Summary MR Cholangiography Is the primary imaging modality to evaluate the biliary ductal system non-invasively It should be performed if an interventional procedure is unlikely Gd-EOB-DTPA adds a functional flavor to biliary MRI