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‡ Introduction
‡ Technique
‡ Advantages
‡ Limitations
‡ Clinical applications
 


‡ Introduced in 1991
‡ Noninvasive, less costly, and sensitive alternative to
diagnostic ERCP
‡ Allows rapid evaluation of the intrahepatic and
extrahepatic bile ducts, gallbladder, and the
pancreatic duct
‡ Equivalent diagnostic accuracy to ERCP in the
evaluation of a broad spectrum of benign and
malignant pancreatic and biliary ductal diseases
± Including, choledocholithiasis, malignant obstruction,
anatomic variants, and chronic pancreatitis
  
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‡ Basic principle: body fluids (bile and pancreatic
secretions) have high signal intensity on heavily T2-
weighted MR sequences  therefore, appear white
± Background tissues generate little signal  appear
dark
‡ Stationary or slow-flowing fluid within the bile and
pancreatic ducts appears bright relative to low signal
intensity produced by adjacent solid tissues
 
‡ New MR advancements allow faster imaging in
which imaging is performed during single breath-
holding session to reduce motion artifact due to
respiration
‡ New variants such as rapid acquisition with relaxation
enhancement (RARE) and half-Fourier acquisition
single-shot turbo spin-echo (HASTE) can be
performed in a breath-hold period with a scan time of
<20 seconds provide superior images
  

‡ Does not require intravenous or oral contrast material
to be administered into the ductal system
‡ Avoids complications of ERCP such as pancreatitis
(3-5%), sepsis, perforation, hemorrhage, sedation
‡ Can be completed in 10 minutes, easily performed as
outpatient examination
  

‡ Passive procedure; displays the ducts in the
resting state and more accurately displays
native caliber of the duct than ERCP.
± In ERCP, segments may be overdistended because
of attempt to visualize the duct upstream from a
stricture, or segments may be underdistended
because of the operator's fear of inducing
cholangitis or pancreatitis.
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‡ Purely diagnostic, does not provide access for
therapeutic intervention (e.g. stone extraction,
stent insertion, or biopsy)
‡ Image artifact due to other structures in abdomen
with high fluid content
± stationary fluid within the adjacent duodenum,
duodenal diverticulae, and ascitic fluid
‡ Lack of patient compliance; claustrophobia,
inability to breath-hold
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‡ Dropout of signal can be caused by metallic
clips, crossing defects induced by the right
hepatic artery, or from severely narrowed
ducts, such as occurs with primary sclerosing
cholangitis
‡ Lower resolution than direct cholangiography
± Can miss small stones (<4 mm), small ampullary
lesions, primary sclerosing cholangitis, and
strictures of the ducts
    
 
   

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‡ Screening examination in patients with low or intermediate
probability of choledocholithiasis

‡ Cholangiocarcinoma
‡ Anatomic variants (low or medial duct insertion, aberrant
right hepatic duct)
‡ Failed or incomplete ERCP

‡ Post-operative anatomy or screening for biliary

complications

‡ Primary sclerosing cholangitis

‡ Cystic disease of bile duct (choledochal cyst,

choledochocele, Caroli¶s disease)

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‡ Anatomic variants (pancreas divisum)
‡ Chronic pancreatitis
‡ Pancreatic cancer
    
 

 
 
 


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‡ MRCP can visualize the normal or dilated common bile duct
in 96 to 100 percent of patients.
‡ Strictures typically appear as focal areas of ductal narrowing or
signal void with proximal dilatation.
‡ Cause of biliary strictures may be more difficult to determine
on the basis of MRCP alone.
± lacks specificity
± differentiation between benign and malignant causes is based on a combination
of clinical, radiographic, and pathological data
‡ Obstruction 2° to calculi, pancreatic adenocarcinoma, or
pancreatitis is usually obvious with MRCP, and with aid of
conventional MRI or CT

 


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The biliary-duct obstruction is indicated
by the curved arrow, and the pancreatic-
duct obstruction by the straight arrow. The
mass was identified on axial, contrast-
enhanced, T1-weighted images (not
shown) obtained by routine MRI during
the same examination. Arrowheads
indicate the pancreatic duct.

 

‡ ERCP is more beneficial in pts with dilatation of the common
bile duct who have obstruction at the ampulla, since it permits
direct visualization of the ampulla, biopsy of lesions,
manometry, or endoscopic sonography.
‡ MRCP Study of 79 cases of biliary obstruction found 14 due
to malignant cause; 6 cases due to ampullary carcinoma.
± 2 of 6 cases were misdiagnosed as benign obstructions, and 2 cases of
benign obstruction were thought to be ampullary cancers. (This study used an
early form of the technique, and results may be more accurate with the currently available technology.)

‡ MRCP performed after pharmacologic stimulation with

secretin has been shown to be helpful in evaluating ampullary
obstruction
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‡ Visualization of the pancreatic duct can be
improved with imaging after administration of
IV secretin
‡ Secretin frequently used when pancreatic duct
is not apparent on MRCP
‡ Reduces the incidence of false positive
findings of strictures
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(ERCP was not attempted because the patient
had a pancreaticoenteric anastomosis.)
In Panel A, the pancreatic duct (arrowheads) is
incompletely visualized on MRCP before the
administration of secretin.
In Panel B, an MRCP obtained 15 minutes after
the administration of secretin shows prominent
and prolonged dilatation of the pancreatic duct
upstream of a stricture (arrow) at the
pancreaticoenteric anastomosis.
Je denotes jejunum.
 
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‡ Displayed by MRCP as a signal void within bright
signal arising from bile
‡ MRCP is a useful means of determining presence or
absence of CBD stones, as well as number, size, and
location
‡ MRCP is as accurate as ERCP for detecting
choledocholithiasis
± Sensitivity = 95-100%
± Specificity = 85-100%
‡ Increased sensitivity in pts with suspected gallstone
pancreatitis, and pts with non-specific abdominal pain
and normal LFTs
 
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‡ Stones larger than 4 mm are readily seen but difficult
to differentiate from filling defects such as blood
clots, tumor, sludge, or parasites
± Other mimickers include flow artifacts, biliary air, and a
pseudostone at the ampulla
‡ In the presence of a dilated CBD, MRCP has a 90 to
95 percent concordance with ERCP in diagnosing
CBD stones over 4 mm in diameter
‡ ERCP is preferred in pts with cholangitis because it
allows therapeutic drainage

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‡ Role of MRCP in the diagnosis and management of bile
duct malignancy is not yet defined
‡ Useful noninvasive adjunct
‡ Capability to evaluate the bile ducts both above and below
a stricture while also identifying any intrahepatic mass
lesions
‡ Study of 126 patients with suspected bile duct obstruction
showed that MRCP alone has limited specificity in the
diagnosis of malignant strictures
± Malignant obstruction dx by MRCP in 12 out of 14 pts
± Positive predictive value = 86%
± Negative predictive value = 98%

 

 
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‡ Acute pancreatitis
± MRCP is useful for evaluating bile ducts and cystic duct remnants for
stones, for evaluating the pancreatic ducts, and for documenting the
presence of cysts in or around the pancreas.
± ERCP is often preferred in patients with gallstone pancreatitis since
endoscopic papillotomy can be performed in pts with obstructive
jaundice or biliary sepsis.
‡ Chronic pancreatitis
± MRCP is useful in demonstrating complications such as, ductal
dilatation, strictures, intraductal calculi, fistulas, and pseudocysts
± Defines ductal anatomy and extent of ductal disease prior to surgical
drainage
   
‡ MRCP is as accurate as ERCP for distinguishing pancreatic
cancer from chronic pancreatitis.
± In study of 124 patients who were suspected of having pancreatic
cancer, pts underwent a number of diagnostic studies, including ERCP
and MRCP. The correct diagnosis was confirmed histologically and
clinically. 37 patients (30 percent) dx with pancreatic cancer; others
had chronic pancreatitis (46 percent) or other causes.
± MRCP sensitivity (84%) and specificity (97%) for diagnosis of
pancreatic cancer
± ERCP sensitivity (70%) and specificity (94%)
‡ Secretin-enhanced MRCP is being increasingly studied for
evaluation of pancreatic exocrine function and in the early
diagnosis of chronic pancreatitis
      
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‡ MRCP is also useful in demonstrating variant
anatomy and congenital anomalies of the biliary tract
and pancreatic duct
± Pancreas divisum
± Choledochal cyst
± Annular pancreas
± Abnormal pancreaticobiliary junctions
± Aberrant bile ducts
‡ And in evaluation of pts prior to laparoscopic
cholecystectomy
      
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Magnetic resonance cholangio-
pancreatography is an accurate method of
diagnosing pancreas divisum because it
shows the dominant dorsal pancreatic duct
(arrowheads) continuously from the tail to
the head of the pancreas, crossing the
common bile duct (curved arrows) and
draining at the minor papilla (straight
arrow) superiorly and separately from the
common bile duct.
GB denotes gallbladder.
  

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‡ ERCP is technically challenging
± Associated with 10-20% failed cannulation rate
± Anatomic variants can contribute to failed ERCP attempts
‡ MRCP is useful in demonstrating variant anatomy
± MRCP may have advantages compared to ERCP in specific settings
such as pts who have gastric outlet or duodenal stenosis or who have
had surgical rearrangement (eg, Billroth II) or ductal disruption,
resulting in ducts that can¶t be assessed by ERCP
‡ MRCP also allows evaluation of ducts in pts with
contraindications for ERCP:
± Cervical spine fractures, head and neck tumors, sleep apnea, other
diseases/ injuries that preclude placement of endoscope or positioning

 
   
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Imaging was performed in two seconds
with the thick, single-slice technique.
The normal common bile duct (arrow)
and pancreatic duct (arrowheads) are
clearly visible.
Du denotes duodenal bulb.
 
‡ Barish M. A., Yucel E. K., Ferrucci J. T. Current Concepts: Magnetic Resonance
Cholangiopancreatography. ?
   22-JUL-1999; 341:258-264.

‡ Fayad L.M. MR cholangiopancreatography: evaluation of common pancreatic diseases.

  ?  01-JAN-2003; 41(1): 97-114

‡ Fulcher A.S. MR cholangiopancreatography.

  ?  01-DEC-2002; 40(6):
1363-76

‡ Fulcher A.S. MRCP and ERCP in the diagnosis of common bile duct stones.


 01-DEC-2002; 56(6 Suppl): S178-82

‡ Karnam U., et al. Magnetic resonance cholangiopancreatography. www.uptodate.com

‡ Motohara T. MR cholangiopancreatography.
  ?  01-JAN-2003; 41(1): 89-
96

‡ Romagnuolo J. Noninvasive vs. selective invasive biliary imaging for acute biliary
pancreatitis: an economic evaluation by using decision tree analysis. 

 01-
JAN-2005; 61(1): 86-97

‡ Taylor A.C. Prospective assessment of magnetic resonance cholangiopancreatography for

noninvasive imaging of the biliary tree. 

 01-JAN-2002; 55(1): 17-22