MR Cholangiopancreatography : Atlas with Cross-Sectional Imaging Correlation.

MRCP Technique I Introduction: Basic Principles of Magnetic Resonance Imaging 1 1 Technique . . . . . . . . . . . 6 1.1 Magnetic Resonance Sequences 6 # 1 Overview of Imaging Protocol 6 # 2 Snapshot T2-Weighted MRI . . 10 #3 Snapshot T2-Weighted MRI: Double-Echo Technique . . . . 12 #4 Snapshot T2-Weighted MRI: Is Fat Suppression Required? 14 #5 “Projective” Cholangiography 16 #6 “Projective” Cholangiography: Limitations . . . . . . . . . . . 18 # 7 An Alternative Approach: Calculation of Maximum- Intensity Projection Images . . 20 #8 Other Techniques for Obtaining T2-Weighted Images . . . . . . 22 #9 T1-Weighted MRI: Non-fat-suppressed Magnetizationprepared Snapshot Gradient Echo . . . . . . . . . 24 # 10 T1-Weighted MRI: Use of Fat Suppression . . . . . . . . . . 26 1.2 Practical Setup of an MRCP Study # 11 Selection of Slice Location for Projective MRCP . . . . . . 27 # 12 Selection of Slice Thickness . . 28 # 13 Dynamic Evaluation of the Vaterian Sphincter Complex . . 30 1.3 Use of Contrast Media and Drugs . . . . . . . . . . . 32 # 14 Oral Contrast Media . . . . . . 32 # 15 Nonspecific Intravenous Contrast Media (1): Parenchymal Organs and Lymph Nodes . . . 34 # 16 Nonspecific Intravenous Contrast Media (2):Vascular „Roadmapping“ . . . . . . . . 36 # 17 Specific Intravenous Contrast Media (1): Hepatocyte-Directed Agents . . . . . . . . . . . . . 38 # 18 Specific Intravenous Contrast Media (2): Reticuloendothelial Agents . . . . . . . . . . . . . 40 # 19 Drugs Stimulating Excretory Function . . . . . . 42 #20 Spasmolytic Drugs (1): Buscopan . . . . . . . . . . . 44 #21 Spasmolytic Drugs (2): Glucagon . . . . . . . . . . . . 45 1.4 Comparison with Other Techniques . . . . 46 #22 MRCP Compared with ERCP (1): Limitations of ERCP . . . . . . 46 #23 MRCP Compared with ERCP (2): Limitations of MRCP . . . . . 48 #24 MRCP Compared with Ultrasonography . . . . . 50 #25 MRCP Compared Multislice Computed Tomography . . . . 52 Intrahepatic Bile Ducts 2 Intrahepatic Bile Ducts . . . . 56 2.1 Normal Anatomy and Variants 56 #26 Normal Anatomy . . . . . . . 56 #27 Variant Anatomy (1): Variable Junction of the Posterior Right Hepatic Duct 58 #28 Variant Anatomy (2): Other Variations . . . . . . . . 60 #29 Postoperative Anatomy: After Hepat(ic)ojejunostomy 62 XIII Contents 2.2 Benign Nontraumatic Abnormalities . . . . . . . . . 64 #30 Developmental Abnormalities (1): Caroli’s Disease . . . . . . . . 64 #31 Developmental Abnormalities (2): Hepatic Cysts . . . . . . . . . 66 #32 Morphologic Description of Biliary Abnormalities in Parenchymal Liver Disease 68 #33 Bile Duct Lithiasis . . . . . . . 70 #34 Acute Hepatitis . . . . . . . . 72 #35 Fatty Metamorphosis (Steatosis) . . . . . . . . . . . 74 #36 Cirrhosis, Ductal Changes . . . . . . . . 78 #37 Cirrhosis, Parenchymal Changes . . . . . 80 #38 Primary Biliary Cirrhosis . . . 82 #39 Vanishing Bile Duct Disease: Differential Diagnosis . . . . . 84 #40 Bacterial Cholangitis . . . . . 86 #41 Primary Sclerosing Cholangitis, General . . . . . . . . . . . . 88 #42 Primary Sclerosing Cholangitis, Early Disease (Type I) . . . . . 89 #43 Primary Sclerosing Cholangitis, Advanced Disease (Types II and III) . . . . . . . 90 #44 Atypical and Complicated Primary Sclerosing Cholangitis 92 #45 Secondary Sclerosing Cholangitis . . . . . . . . . . . 94 #46 Oriental Cholangitis . . . . . . 96 #47 Echinococcosis . . . . . . . . 98 2.3 Traumatic, Postoperative, and Iatrogenic Abnormalities 100 #48 Sequelae of Direct Liver Trauma . . . . . . . . . . . . . 100 #49 After Hepaticojejunostomy: Anastomotic Stricture . . . . . 102 #50 After Hepatic Transplantation (1): Ischemia . . . . . . . 104 #51 After Hepatic Transplantation (2): Other Complications 106 #52 After Cholecystectomy: Stricture/Transection of an Aberrant Bile Duct . . . . 108 #53 Biliary Complications of Percutaneous Procedures . . 110 2.4 Malignant Tumors . . . . . . . 112 #54 Intrahepatic (Peripheral) Cholangiocarcinoma (1): Ductal Changes . . . . . . . . 112 #55 Intrahepatic (Peripheral) Cholangiocarcinoma (2): Enhancement Pattern . . . . . 114 #56 Recurrent Tumor After Hepat(ic)ojejunostomy . . . . 116 #57 Recurrent Tumor: Diagnostic Problems Related to the Presence of Endoprostheses . . 118 #58 Hepatocellular Carcinoma, General . . . . . . . . . . . . 120 #59 Hepatocellular Carcinoma, Biliary Invasion . . . . . . . . 124 #60 Metastases . . . . . . . . . . . 126 Extrahepatic Bile Duct 3 Extrahepatic Bile Duct . . . . 130 3.1 Normal Anatomy and Variants 130 #61 Normal Anatomy, Terminology, and Size . . . . . . . . . . . . 130 #62 Variant Anatomy (1): Narrow Aspect of the Pancreatic Segment . . . . . . . . . . . . 132 #63 Variant Anatomy (2): Location of the Bifurcation . . 134 #64 Variant Anatomy (3): Impression by Blood Vessels . . 136 #65 Postoperative Anatomy: After Hepatic Transplantation 138 #66 Postoperative Anatomy: After the Whipple Procedure 140 #67 Aerobilia . . . . . . . . . . . . 142 XIV Contents 3.2 Benign Nontraumatic Abnormalities . . . . . . . . . 144 #68 Developmental Abnormalities (1): Choledochal Cyst . . . 144 #69 Developmental Abnormalities (2): Atresia . . . . . . . . . 146 # 70 Web . . . . . . . . . . . . . . 148 # 71 Mirizzi Syndrome . . . . . . . 150 # 72 Stones in the Common Bile Duct (CBD) . . . . . . . . 152 # 73 Stones in the Common Bile Duct (2): Pitfalls in Diagnosis with MRCP/ERCP . . . . . . . 154 # 74 Stones Complicated by Fistula 156 # 75 Bacterial Cholangitis . . . . . 157 # 76 Primary Sclerosing Cholangitis 158 #77 Common Bile Duct Stenosis in Acute Pancreatitis . . . . . . 160 #78 Common Bile Duct Stenosis in Chronic Pancreatitis . . . . 162 #79 Other Benign Causes of Bile Duct Narrowing . . . . 164 3.3 Traumatic, Postoperative, and Iatrogenic Abnormalities 168 #80 After Hepatic Transplantation (1): Anastomotic Stricture 168 #81 After Hepatic Transplantation (2): Ischemic Stricture . . 170 #82 After Cholecystectomy (1): Stricture of the Common Bile Duct . . . . . . . . . . . . . . 172 #83 After Cholecystectomy (2): Bile Leak . . . . . . . . . . . . 174 #84 Post-cholecystectomy Syndrome . . . . . . . . . . . 176 #85 Bile Duct Trauma Related to Nonbiliary Surgery . . . . . 177 #86 Choledochoduodenostomy with Sump Syndrome . . . . . 178 3.4 Malignant Tumors . . . . . . . 180 #87 Extrahepatic Cholangiocarcinoma (1): Klatskin Tumor 180 #88 Extrahepatic Cholangiocarcinoma (2): Distal Duct Type . . . . . . . . 184 #89 Bile Duct Involvement by Gallbladder Carcinoma . . . 186 #90 Bile Duct Involvement by Pancreatic Carcinoma . . . 188 #91 Bile Duct Involvement by Other Extrabiliary Neoplasms . . . . . . . . . . . 190 Gallbladder and Cystic Duct 4 Gallbladder and Cystic Duct 194 4.1 Normal Anatomy and Variants 194 #92 Gallbladder . . . . . . . . . . 194 #93 Cystic Duct . . . . . . . . . . 196 4.2 Benign Nontraumatic Abnormalities . . . . . . . . . 198 #94 Cholecystolithiasis, Classical Appearance . . . . . 198 #95 Cholecystolithiasis, Variant Appearance . . . . . . 200 #96 Acute Cholecystitis . . . . . . 202 #97 Acute Cholecystitis with Pericholecystitis . . . . . 204 #98 Complications of Acute Cholecystitis (1): Intramural Abscess . . . . . . . . . . . . 206 #99 Complications of Acute Cholecystitis (2): Gangrene . . 208 # 100 Complications of Acute Cholecystitis (3): Perforation 209 # 101 Acute Emphysematous Cholecystitis . . . . . . . . . . 210 # 102 Peridiverticulitis of the Gallbladder . . . . . . . 211 # 103 Cholecystoenteric Fistula . . . 212 # 104 Chronic Cholecystitis . . . . . 214 # 105 Xanthogranulomatous Cholecystitis . . . . . . . . . . 216 # 106 Cholesterolosis . . . . . . . . . 218 # 107 Cholesterol Polyp . . . . . . . 220 # 108 Diffuse Adenomyomatosis . . . 222 # 109 Focal Adenomyomatosis . . . . 224 # 110 Porcelain Gallbladder . . . . . 226 # 111 Reactive Thickening of the Gallbladder Wall . . . . 228 # 112 Varices in the Gallbladder Wall 230 Contents XV 4.3 Traumatic, Postoperative, and Iatrogenic Abnormalities 232 # 113 Blunt Gallbladder Trauma . . . 232 # 114 After Cholecystectomy: Complications with Cystic Duct Remnant . . . 234 4.4 Malignant Tumors . . . . . . . 236 # 115 Gallbladder Carcinoma, General . . . . . . . . . . . . 237 # 116 Spread of Gallbladder Carcinoma (1): Direct Invasion of Liver Parenchyma and/or Biliary Tree 238 # 117 Spread of Gallbladder Carcinoma (2): Lymph Node Metastases . . . . . . . . . . . 240 # 118 Spread of Gallbladder Carcinoma (3): Other Metastases . . 242 Vaterian Sphincter Complex 5 Vaterian Sphincter Complex 246 5.1 Normal Anatomy and Variants 246 # 119 Normal Anatomy . . . . . . . 246 # 120 Normal Contractile Activity . . 248 # 121 Variant Anatomy (1): Type of Junction . . . . . . . . 250 # 122 Variant Anatomy (2): “Pseudocalculus” Sign . . . . . 252 # 123 Variant Anatomy (3): Length of Common Channel . . . . . 254 # 124 Variant Anatomy (4): Papilla in or Adjacent to a Duodenal Diverticulum . . . . . . . . . . 256 5.2 Benign Nontraumatic Abnormalities . . . . . . . . . 258 # 125 Impacted Stone . . . . . . . . 258 # 126 Choledochocele . . . . . . . . 260 # 127 Sphincter Dysfunction, General 261 # 128 Sphincter Dysfunction, Features on Dynamic MRCP . . 262 # 129 Sphincter Dysfunction, False-Negative Diagnosis on Dynamic MRCP . . . . . . 266 # 130 Benign Tumors . . . . . . . . 268 5.3 Traumatic, Postoperative, and Iatrogenic Abnormalities 270 # 131 Sequelae/Complications of ERCP . . . . . . . . . . . . 270 5.4 Malignant Tumors . . . . . . . 272 # 132 (Peri-)Ampullary Carcinoma 272 # 133 Carcinoma of the Pancreatic Head Invading the Vaterian Sphincter Complex . . . . . . 274 Pancreatic Ducts 6 Pancreatic Ducts . . . . . . . . 276 6.1 Normal Anatomy and Variants 276 # 134 Normal Pancreas: Location and Signal Intensity . . . . . . 276 # 135 Classical Ductal Anatomy . . . 278 # 136 Classical Ductal Anatomy in Pancreatic Head . . . . . . . 280 # 137 Variant Anatomy (1): “Bifid” Configuration with a Prominent Duct of Santorini . . . . . . . 282 # 138 Variant Anatomy (2): Ansa Pancreatica and Ductal Loops 284 # 139 Variant Anatomy (3): Focal Narrowing at the Junction 285 # 140 VariantAnatomy (4): Pancreas Divisum . . . . . . . 286 # 141 Variant Anatomy (5): Uneven Lipomatosis . . . . . . 290 # 142 Variant Anatomy (6): Lobulations of the Pancreatic Head . . . . . . . . . . . . . . 292 # 143 Developmental Abnormalities (1): Agenesis of the Dorsal Pancreas . . . . . 293 # 144 Developmental Abnormalities (2): Annular Pancreas . . . 294 # 145 Developmental Abnormalities (3): Ectopic Pancreas . . . 296 # 146 Developmental Abnormalities (4): Partial Duplication . . 298 # 147 The Elderly Pancreas . . . . . 299 # 148 Postoperative Anatomy (1): After Partial Resection . . . . . 300 XVI Contents # 149 Postoperative Anatomy (2): After Pancreatic Transplantation . . . . . . . . . . . . . . 302 6.2 Benign Nontraumatic Abnormalities . . . . . . . . . 304 # 150 Santorinicele and Wirsungocele 304 # 151 Acute Pancreatitis, General . . 306 # 152 Edematous Pancreatitis (Grades A and B) . . . . . . . 307 # 153 Acute Pancreatitis with Peripancreatic Inflammation (Grade C) . . . . . . . . . . . 308 # 154 Acute Pancreatitis with III-Defined Fluid Collection/ Phlegmon (Grades D and E) . . 310 # 155 Complications of Acute Pancreatitis (1): Necrosis . . . . 312 # 156 Complications of Acute Pancreatitis (2): Pseudocyst . . 314 # 157 Complications of Acute Pancreatitis (3):Vascular Complications . . . . . . . . . 316 # 158 Recurrent (Relapsing) Pancreatitis . . . . . . . . . . 318 # 159 Chronic Pancreatitis, General 320 # 160 Chronic Pancreatitis, Signal Intensity Changes and Enhancement Pattern . . . 321 # 161 Chronic Pancreatitis, Ductal Changes (1): ERCP Classification . . . . . . 322 # 162 Chronic Pancreatitis, Ductal Changes (2): Early Disease . . . . . . . . . . 324 # 163 Chronic Pancreatitis, Ductal Changes (3): Advanced Disease . . . . . . . 326 # 164 Atypical Ductal Changes in Chronic Pancreatitis . . . . 328 # 165 Complications of Chronic Pancreatitis (1): Pseudocyst . . 330 # 166 Complications of Chronic Pancreatitis (2): Other Complications . . . . . . 332 # 167 Chronic Pancreatitis with Focal Inflammatory Mass 334 # 168 Chronic Obstructive Pancreatitis . . . . . . . . . . 338 # 169 Nonalcoholic Duct-Destructive Chronic Pancreatitis . . . . . . 340 # 170 Hereditary Pancreatitis . . . . 344 # 171 Simple True Cyst . . . . . . . . 346 # 172 Cysts in Von Hippel-Lindau Disease . . . . . . . . . . . . . 348 # 173 Lymphangioma . . . . . . . . 350 # 174 Cystic Fibrosis . . . . . . . . . 352 # 175 Microcystic Serous Cystadenoma . . . . . . . . . 354 # 176 Macrocystic Serous Cystadenoma . . . . . . . . . 356 # 177 Benign Neuroendocrine Tumors . . . . . . . . . . . . . 358 # 178 Schwannoma . . . . . . . . . . 362 # 179 Granulomatous Disease of the Pancreas . . . . . . . . . 364 # 180 Hemochromatosis . . . . . . . 366 6.3 Traumatic, Postoperative and Iatrogenic Abnormalities 368 # 181 Pancreatic Duct Injury . . . . . 368 # 182 Complications of Pancreatic Transplantation (1): Pancreatitis . . . . . . . . . . 370 # 183 Complications of Pancreatic Transplantation (2): Other Complications . . . . . . . . . 372 # 184 Complications of Partial Pancreatic Resection . . . . . . 374 6.4 Malignant Tumors and Tumors with Malignant Potential . . . 375 # 185 Adenocarcinoma, General . . . 375 # 186 Adenocarcinoma, Signal Intensity . . . . . . . . 376 # 187 Adenocarcinoma, Ductal Changes . . . . . . . . 378 # 188 Variant Morphology of Adenocarcinoma (1): Degree Obstruction . . . . . . 382 # 189 Variant Morphology of Adenocarcinoma (2): Necrosis/Cystic Degeneration . . . . . . . . . 384 Contents XVII # 190 Adenocarcinoma in Pancreas Divisum . . . . . . 386 # 191 Spread of Adenocarcinoma (1): Vascular Invasion . . . . . . . 388 # 192 Spread of Adenocarcinoma (2): Lymph Nodes . . . . . . . . . 390 # 193 Spread of Adenocarcinoma (3): Distant Metastases . . . . . . . 392 # 194 Adenocarcinoma with Retro-obstructive Pancreatitis 394 # 195 Recurrent Adenocarcinoma . . 396 # 196 Secondary Pancreatic Tumors 398 # 197 Malignant Neuroendocrine Tumors . . . . . . . . . . . . . 400 # 198 Mucinous Pancreatic Neoplasm (Peripheral Type) . . 404 # 199 Intraductal Mucinous Neoplasm . . . . . . . . . . . 406 Subject Index . . . . . . . . . . . . 411 XVIII Contents