Two cases of thoracopancreatic fistula in alcoholic pancreatitis: clinical and CT findings

We report two patients who were long-time habitual consumers of alcohol and suffered from thoracopancreatic fistula. The first patient, a 52-year-old man with no symptoms, underwent chest CT scan for a medical check-up and was revealed to have left small pleural effusion. A month later, he suddenly experienced severe cough and back pain. The immediate CT scan showed massive pleural effusion and mediastinal pseudocyst, and the amylase level in the aspirated pleural effusion proved to be elevated. He was successfully treated with medication and drainage of the effusion. The second patient, a 39-year-old woman, underwent CT scan for a medical check-up, and it disclosed that she had a small pleural effusion in the left lower thorax. Follow-up CT two months later revealed the pleural effusion to be resolved, however, it demonstrated that a narrow tract derived from the pancreatic secretion located just posterior to the pancreatic tail extended to the mediastinum along the left hemidiaphragmatic crus. She experienced severe cough and sputum four months later. CT scan showed massive pleural effusion in the left thorax and revealed that the pancreaticopleural fistula was located in the same position as the small tract that had been detected by the previous CT scan. The patient received conservative treatment and eventually recovered from the severe chest complications. We consider that asymptomatic left small pleural effusion in these patients who were habitual drinkers is a potential precursor to symptomatic pancreatitis. The patients developed mediastinal pseudocyst and pancreaticopleural fistula in association with chronic pancreatitis within a few months, and therefore intensive follow-up should be undertaken to minimize or prevent chest complications in association with the subsequent symptomatic pancreatitis.     

Comparison of endoscopic retrograde cholangiopancreatography with MR cholangiopancreatography in patients with pancreatitis

PURPOSE: To assess the usefulness of magnetic resonance (MR) cholangiopancreatography (MRCP) in the evaluation of disease in patients with acute or chronic pancreatitis. MATERIALS AND METHODS: MR imaging was performed at 1.5 T in 39 patients with chronic (n = 30) or acute (n = 9) pancreatitis. The patients underwent a pancreas MR imaging protocol that included an MRCP sequence. Comparison was made with findings at endoscopic retrograde cholangiopancreatography (ERCP), performed within 30 days. Three blinded readers used a scoring system to evaluate nine segments of the pancreatic and biliary ducts as depicted on the ERCP and MRCP images. MRCP image quality was also evaluated. RESULTS: Of 196 segments analyzed, 17 were not seen at MRCP (sensitivity, 91%). Of the segments visualized at MRCP, 14 were incorrectly characterized (accuracy, 92%). At MRCP, segments not detected or mischaracterized were either normal, slightly dilated, or narrowed. At ERCP, 42 segments in 19 patients were not visualized. MRCP findings were considered useful in all those cases. MRCP image quality was not interpretable in two cases due to artifacts. CONCLUSION: Very good correlation between ERCP and MRCP findings was demonstrated. Both modalities failed to depict pathologic conditions depicted by the alternative method. MRCP may obviate ERCP, particularly in patients who cannot undergo ERCP or in whom ERCP has been unsuccessful.     

Autoimmune pancreatitis: imaging features

PURPOSE: To retrospectively determine imaging findings in patients with autoimmune pancreatitis. MATERIALS AND METHODS: Twenty-nine patients (25 male and four female; mean age, 56 years; range, 15-82 years) with histopathologic diagnosis of autoimmune pancreatitis were examined. Data were reviewed by two radiologists in consensus. Imaging findings for review included those from helical computed tomography (CT), 25 patients; magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP), four patients; endoscopic ultrasonography (US), 21 patients; endoscopic retrograde cholangiopancreatography (ERCP), 19 patients; and percutaneous transhepatic cholangiography, one patient. Images were analyzed for appearances of pancreas, biliary and pancreatic ducts, and other findings, such as peripancreatic inflammation, encasement of vessels, mass effect, pancreatic calcification, peripancreatic nodes, and peripancreatic fluid collection. Follow-up images were available in nine patients. Serologic markers such as serum immunoglobulin G (IgG) and antinuclear antibody levels were available in 12 patients. RESULTS: CT showed diffuse (n = 14) and focal (n = 7) enlargement of pancreas. Seven patients had minimal peripancreatic stranding, with lack of vascular encasement, calcification, or peripancreatic fluid collection. Nine patients had enlarged peripancreatic lymph nodes. MR imaging showed focal (n = 2) and diffuse (n = 2) enlargement with rimlike enhancement in one. MRCP revealed pancreatic duct strictures in two and sclerosing cholangitis-like appearance in one. Endoscopic US showed diffuse enlargement of pancreas with altered echotexture in 13 patients and focal mass in the head in six. ERCP showed stricture of distal common bile duct in 12 patients, irregular narrowing of intrahepatic ducts in six, diffuse irregular narrowing of pancreatic duct in nine, and focal stricture of proximal pancreatic duct in six. Serologic markers showed increased IgG and antinuclear antibody levels in seven of 12 patients. At follow-up, CT abnormalities and common bile duct strictures resolved after steroid therapy in three patients. CONCLUSION: Features that suggest autoimmune pancreatitis include focal or diffuse pancreatic enlargement, with minimal peripancreatic inflammation and absence of vascular encasement or calcification at CT and endoscopic US, and diffuse irregular narrowing of main pancreatic duct, with associated multiple biliary strictures at ERCP.     

Pancreaticopleural fistula in children: Report of 2 cases

Pancreaticopleural fistula is an extremely rare complication of pancreatic duct injury. The reported treatments include conservative approaches, such as pleural drainage, and interventional approaches, such as sphincter stenting via endoscopic retrograde cholangiopancreatography and surgery. However, no specific consensus treatment has been defined. We present 2 cases of pediatric patients with pancreaticopleural fistulas due to pancreatic trauma and pancreatitis that were successfully treated surgically. The most prominent symptom in both cases was dyspnea caused by pleural effusion. Thoracoabdominal computed tomography scans showed large pleural effusions and visible fistulas from the pancreatic duct to the thoracic cavity through the esophageal hiatus and aortic hiatus. Following unsuccessful conservative treatment using pleural drainage, the 2 patients underwent surgical fistulo-jejunostomy and cystojejunostomy. Both patients were stable and were discharged on postoperative days 10 and 12. Conservative treatment for pancreaticopleural fistula often fails, and a surgical approach, such as fistulo-jejunostomy and cystojejunostomy, can serve as an efficacious management strategy when conservative treatment fails.     

Clinical impact of MR cholangiopancreatography in patients with biliary disease

PURPOSE: To evaluate the role of MR Cholangiopan-creatography (MRCP) as a first imaging modality in patients with suspected biliary tree pathology and indications to endoscopic retrograde cholangiopancreatography (ERCP). MATERIAL AND METHODS: Eighty-eight patients, with clinical signs of biliary tree pathology underwent MRCP, performed with a 1.5 T unit and a phased-array coil. Surgery, intraoperative cholangiography, percutaneous transhepatic cholangiography (PTC) or ERCP were regarded as the gold standard in patients with obstruction; the remaining patients underwent follow-up MRCP examinations at 6-9 months. The MR examination was performed with baseline T1w 2D FLASH and T2w TSE sequences, followed by the MRCP study (single-slab breath-hold RARE and multislice breath-hold HASTE sequences). The MR images were independently evaluated by two radiologists. RESULTS: MRCP showed normal findings in 20 patients; 68 patients had biliary duct dilatation. In 11 out of 68 patients MRCP did not identify any obstruction (9/11 were true negative cases). A diagnosis of benign obstruction was expressed in 36/59 patients (4 chronic pancreatitis, 29 choledocolithiasis, 4 inflammatory obstruction, 2 primary sclerosing cholangitis), with 1 false positive and 5 false negatives (sensitivity, specificity and diagnostic accuracy of 86%, 95% and 90%, respectively). MRCP identified 23 neoplastic stenoses (20/23 were true positives): the sensitivity, specificity and diagnostic accuracy values were 100%, 87% and 95%, respectively. MRCP correctly identified the level of obstruction in 100% of cases. CONCLUSIONS: MRCP may be considered as a first-step imaging method in patients with clinical signs of biliary disease. The workload of ERCP in the diagnostic stage could therefore be reduced and its use be reserved for therapeutic indications.     

Pancreatitis: computed tomography and magnetic resonance imaging

The value of CT in management of severe acute pancreatitis is well established. Some, but not all, experimental studies suggest a detrimental effect of intravenous iodinated contrast agents in acute pancreatitis, but although initial clinical data tends to support this, the positive advantages of enhanced CT outweigh the possible risks. Magnetic resonance imaging has been shown to be as effective as CT in demonstrating the presence and extent of pancreatic necrosis and fluid collections, and probably superior in indicating the suitability of such collections for percutaneous drainage. Image-guided intervention remains a key approach in the management of severely ill patients, and the indications, techniques and results of radiological intervention are reviewed herein. Both CT and MRI can be used to diagnose advanced chronic pancreatitis, with the recent addition of MRCP as a viable alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP). Both MRCP and CT/MR imaging of the pancreatic parenchyma still have limitations in the recognition of the earliest changes of chronic pancreatitis – for which ERCP and tests of pancreatic function remain more sensitive – but the clinical significance of these minor changes remains contentious. Received: 12 February 1998; Revision received: 17 June 1998; Accepted: 22 June 1998     

胰腺炎合并感染性假性囊肿经内镜十二指肠乳头引流的治疗(附18例报告)

目的探讨胰腺炎合并感染性假性囊肿经内镜十二指肠乳头引流治疗的临床效果。方法回顾性分析2004年1月-2006年6月经内镜十二指肠乳头引流治疗的18例胰腺炎合并感染性胰腺假性囊肿患者的临床资料,均经内镜下逆行胰胆管造影(ERCP)及CT诊断。常规性应用乳头括约肌切开术(EST)、胰管括约肌切开术(EPS)、鼻胰腺假性囊肿引流术(ENPPD),选择性应用胰管取石、探条及球囊导管狭窄扩张等手段进行治疗。治疗后复查ERCP、CT并行鼻胰引流管造影。结果治疗过程中应用胰管取石术6例,胰管狭窄扩张9例,胰管内支架置放8例。18例患者术后临床症状均明显缓解,引流出大量脓性胰液。感染症状于治疗48h后明显缓解,1周内得到控制。治疗后假性囊肿消失16例,明显缩小2例,胰腺功能均明显恢复。结论内镜在感染性胰腺假性囊肿的治疗中具有重要的临床价值,经十二指肠乳头内镜引流术安全、创伤小、费用低、疗效显著,是临床治疗的重要方法。     

Pancreaticobiliary diseases. Comparison of 2D single-shot turbo spin-echo MR cholangiopancreatography with endoscopic retrograde cholangiopancreatography

PURPOSE: To compare the diagnostic value of MR cholangiopancreatography (MRCP) to that of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of various obstructive and nonobstructive pancreaticobiliary diseases. MATERIAL AND METHODS: We retrospectively reviewed 153 patients who had undergone both MRCP and ERCP Breath-hold, heavily T2-weighted images using 2D single-shot turbo spin-echo technique were obtained. MRCP and ERCP results were correlated with the final clinical diagnoses. Accuracy of MRCP and ERCP in the diagnosis of pancreaticobiliary diseases, detecting the cause and site of biliary obstruction, if present, and distinguishing malignant from benign cause of obstruction were compared. RESULTS: Success rates of MRCP and ERCP were 98.7% and 89.5%, respectively. The accuracy of MRCP and ERCP in detecting the site of biliary obstruction was 89.7% and 96.2%, and in detecting the cause of biliary obstruction 69.2% and 71.8%, respectively. The sensitivity, specificity and likelihood ratios for positive and negative tests for MRCP and ERCP in distinguishing malignant biliary obstruction from benign causes were 86.4%, 82.4%, 4.9, 0.2 and 88.6%, 94.1%, 15.1, 0.1, respectively. Concordance between the two tests was 91% (kappa coefficient 0.82, standard error of kappa 0.113, p<0.001). In the group of nonobstructive biliary diseases, accuracy of MRCP and ERCP in detecting cholecystolithiasis were 100% and 73.7%, and in detecting pancreatitis 57% and 14%, respectively. CONCLUSION: 2D single-shot turbo spin-echo MRCP can be performed as a complement to ERCP and can replace ERCP in high-risk patients and in case of unsuccessful cannulation.     

Quantitative secretin MRCP (MRCPQ): results in 215 patients with known or suspected pancreatic pathology

Secretin magnetic resonance cholangiopancreatography quantification (MRCPQ) of pancreatic exocrine function correlates well with steatorrhoea and conventional, non-invasive function tests. We report MRCPQ results in a variety of pancreatic conditions. A total of 215 patients [107 male, mean age 46 years (14-78)] were studied. A multi-slice MRCP sequence was performed before and at 2-min intervals after 0.1 ml/kg IV secretin. Change in small intestinal water volume was plotted against time and the flow rate derived from the gradient. Patients were classified using clinical history, MRCP, MR imaging, computed tomography (CT) [150/215 (70%)] and endoscopic retrograde cholangiopancreatography (ERCP) [56/215 (26%)] findings but not MRCPQ results. Mean, standard deviation and 95% confidence intervals were calculated. The one way ANOVA and Student's t-test were used for statistical analysis. Seventy-six patients had chronic pancreatitis, 26 were post-surgical, 34 post-acute pancreatitis, six atrophic pancreatopathy, eight with obstruction, 15 divisum, ten sphincter of Oddi dysfunction, 26 normal and 14 miscellaneous. Significant differences were observed between normals (mean+/-SD; 7.4 +/- 2.9 ml/min) and severe chronic pancreatitis (5.3 +/- 2.4) (P = 0.018), pancreatic atrophy (3.8 +/- 3.1) (P = 0.013) or duct obstruction (5.3 +/- 2.4) (P = 0.047)) and between moderate (7.0 +/- 3.0) (P = 0.03) and severe chronic pancreatitis. MRCPQ can be used to quantify function across the spectrum of pancreatic disease and showed significant differences between several different pathologies.     

Comparison of ERCP and MRCP: invasiveness and cost

The purpose of this study was to compare ERCP and MRCP in terms of invasiveness and cost. A questionnaire regarding patient satisfaction was distributed to 23 ERCP patients and 63 MRCP patients. The practical cost of each examination and total yearly cost for 2002, including medication costs for post-ERCP pancreatitis, were calculated. On a trial basis, the total yearly cost for 2002 was also calculated as a percentage of the cost in 1996. Results of the questionnaire showed that patients tended to favor MRCP over ERCP. In our hospital, the practical costs of MRCP and ERCP were 2063 points and 3964 points, respectively. Medication costs for pancreatitis corresponded to about 3% of the total yearly cost for ERCP. The total yearly costs for both examinations and the medication costs for pancreatitis were about 1,360,000 points. The result of trial calculation with the examination percentage of 1996 was about 1,950,000 points. The results of our study demonstrated that MRCP is a noninvasive examination for patients and that its popularization contributed to a reduction in medical costs. For further popularization of equipment and advanced imaging methods, careful assessment of examination costs is important.     

Diffuse pancreatic ductal adenocarcinoma: characteristic imaging features

PURPOSE: To evaluate imaging findings of diffuse pancreatic ductal adenocarcinoma. MATERIALS AND METHODS: We included 14 patients (4 men and 10 women; mean age, 64.5 years) with diffuse pancreatic ductal adenocarcinoma on the basis of retrospective radiological review. Two radiologists retrospectively reviewed 14 CT scans in consensus with respect to the following: tumor site, peripheral capsule-like structure, dilatation of intratumoral pancreatic duct, parenchymal atrophy, and ancillary findings. Eight magnetic resonance (MR) examinations with MR cholangiopancreatography (MRCP) and seven endoscopic retrograde cholangiopancreatography (ERCP) were also reviewed, focusing on peripheral capsule-like structure and dilatation of intratumoral pancreatic duct. RESULTS: CT revealed tumor localization to the body and tail in 11 (79%) patients and peripheral capsule-like structure in 13 (93%). The intratumoral pancreatic duct was not visible in 13 (93%). Pancreatic parenchymal atrophy was not present in all 14 patients. Tumor invasion of vessels was observed in all 14 patients and of neighbor organs in 8 (57%). On contrast-enhanced T1-weighted MR images, peripheral capsule-like structure showed higher signal intensity in five patients (71%). In all 11 patients with MRCP and/or ERCP, the intratumoral pancreatic duct was not dilated. CONCLUSION: Diffuse pancreatic ductal adenocarcinoma has characteristic imaging findings, including peripheral capsule-like structure, local invasiveness, and absence of both dilatation of intratumoral pancreatic duct and parenchymal atrophy.     

Is magnetic resonance cholangiopancreatography the new gold standard in biliary imaging?

The timing and technique of perioperative biliary imaging in relation to laparoscopic surgery remains controversial. This study assessed the predictive value of magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of biliary pathology. Clinical, laboratory and investigational data were evaluated from 374 patients undergoing MRCP at two hospital sites over a 5-year period. MRCP findings were compared with endoscopic retrograde cholangiopancreatography (ERCP) or operative findings and appropriate clinical endpoints. Complete data were available for 351 of the 374 patients (94%), of whom 232 (66%) were female. Median age was 64 years. The predominant presentation was abdominal pain (n = 190). Features of pancreatitis were present in 59, cholangitis in 26 and jaundice in 109 patients. Ultrasound was the initial investigation in 312 (89%) (176-gallstone positive). Common duct dilatation was evident in 114 patients and ductal calculi in 31. ERCP was successful in 212/283 (75%) patients. Significant ERCP induced pancreatitis occurred in 12 (5.6%). Comparison between MRCP and ERCP was not possible in 85 due to failure of either technique. Nine patients underwent other investigations including intraoperative cholangiogram (IOC), percutaneous transhepatic cholangiogram (PTC) and were included. Of the 221 patients with full comparative data available the MRCP showed a sensitivity of 97.98% and specificity of 84.4%. MRCP is highly sensitive and specific for choledocholithiasis and avoids the need for invasive imaging in most patients with suspected choledocholithiasis.     

MRCP诊断梗阻性黄疸及其影像学对比研究

目的 探讨MRCP在梗阻性黄疸中的诊断价值。方法 对75例梗阻性黄疸患行MRCP检查，原始图像作三维重建，然后分析其影像表现及诊断结果，并与US、CT和直接胰胆管造影进行比较，对照手术病理结果进行分析结果本组75例中MRCP确诊71例，误诊4例，确诊率95％，与直接胰胆管造影(92％）相近，明显高于US(74％)和CT(75％)。MRCP对梗阻性黄疸定位诊断准确率为100％。结论 MRCP作为无创性检查技术，完整清晰地显示胰胆管系统结构，提高了，梗阻性黄疸的定位和定性诊断率，为临床保守或手术治疗提供可靠依据，可作为梗阻性黄疸患的首选影像学检查方法。     

Pankreas — Teil I

The pancreas develops from ventral and the dorsal buds, which undergo fusion. Failure to fuse results in pancreas divisum, which is defined by separate pancreatic ductal systems draining into the duodenum. Risk of developing pancreatitis is increased in pancreas divisum because of insufficient drainage. MR cholangiopancreatography (MRCP) is the technique of choice for detecting pancreas divisum non-invasively. Annular pancreas is the result of incomplete rotation of the pancreatic bud around the duodenum with the persistence of parenchyma or a fibrous band encircling (and sometimes stenosing) the duodenum. Acute pancreatitis is usually caused by bile duct stones or alcohol abuse. The Atlanta classification differentiates between mild acute and severe acute pancreatitis associated with organ failure and/or local complications such as necrosis, abscess or pseudocyst. Contrast-enhanced multi-detector row CT is the method of choice to assess the extent of disease. Balthazar et al.’s CT severity index assesses the risk of mortality and morbidity. In acute pancreatitis, the role of MRCP is mainly limited to finding bile duct stones in patients with suspected biliary pancreatitis. Chronic pancreatitis results in relentless and irreversible loss of exocrine (and sometimes endocrine) function of the pancreas. MDCT even shows subtle calcifications. MRCP is the method of choice for non-invasive assessment of the duct. Inflammatory pseudotumor in chronic pancreatitis and groove pancreatitis are difficult to differentiate from pancreatic cancer. In these cases, multiple imaging methods such as MDCT, MRI and endosonography including biopsy may be used to make a diagnosis.     

Diagnosis of intrahepatic stones: superiority of MR cholangiopancreatography over endoscopic retrograde cholangiopancreatography

OBJECTIVE: The purpose of this study was to compare the efficacy of MR cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of intrahepatic stones. MATERIALS AND METHODS: Of the 318 patients who underwent MRCP examinations at our institution during an 18-month period, we identified 49 patients who subsequently underwent surgery or cholangioscopic stone removal with proof of intrahepatic stones. Thirty-four of these patients also underwent ERCP; they made up our study population. All images were interpreted for the presence of bile duct stones: MRCP images were interpreted independently by two reviewers, and ERCP studies were interpreted by one reviewer who was unaware of the MRCP findings. RESULTS: The sensitivity and specificity of MRCP for detecting intrahepatic stones were 97% and 93%, respectively, whereas those of ERCP were 59% and 97%, respectively. MRCP showed a significantly higher sensitivity than ERCP in the diagnosis of intrahepatic stones (p < 0.001). We found no significant difference between MRCP and ERCP in sensitivity or specificity for detecting calculi in the common duct or gallbladder. CONCLUSION: MRCP is a more effective diagnostic method than ERCP for the evaluation of intrahepatic stones.     

Pancreas. Part I: congenital changes, acute and chronic pancreatitis

The pancreas develops from ventral and the dorsal buds, which undergo fusion. Failure to fuse results in pancreas divisum, which is defined by separate pancreatic ductal systems draining into the duodenum. Risk of developing pancreatitis is increased in pancreas divisum because of insufficient drainage. MR cholangiopancreatography (MRCP) is the technique of choice for detecting pancreas divisum non-invasively. Annular pancreas is the result of incomplete rotation of the pancreatic bud around the duodenum with the persistence of parenchyma or a fibrous band encircling (and sometimes stenosing) the duodenum. Acute pancreatitis is usually caused by bile duct stones or alcohol abuse. The Atlanta classification differentiates between mild acute and severe acute pancreatitis associated with organ failure and/or local complications such as necrosis, abscess or pseudocyst. Contrast-enhanced multi-detector row CT is the method of choice to assess the extent of disease. Balthazar et al.'s CT severity index assesses the risk of mortality and morbidity. In acute pancreatitis, the role of MRCP is mainly limited to finding bile duct stones in patients with suspected biliary pancreatitis. Chronic pancreatitis results in relentless and irreversible loss of exocrine (and sometimes endocrine) function of the pancreas. MDCT even shows subtle calcifications. MRCP is the method of choice for non-invasive assessment of the duct. Inflammatory pseudotumor in chronic pancreatitis and groove pancreatitis are difficult to differentiate from pancreatic cancer. In these cases, multiple imaging methods such as MDCT, MRI and endosonography including biopsy may be used to make a diagnosis.     

HASTE MR cholangiopancreatography in the evaluation of intraductal papillary-mucinous tumors of the pancreas

PURPOSE: The aim of this study was to determine the usefulness of MR cholangiopancreatography (MRCP) of intraductal papillary-mucinous tumors. METHOD: Thirteen patients with intraductal papillary-mucinous tumors were examined by breath-hold MRCP using a half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence with a body phased-array coil. RESULTS: Endoscopic retrograde cholangiopancreatography (ERCP) and MRCP completely imaged the entire main pancreatic duct in 12 and in all 13 patients, respectively. ERCP demonstrated the whole opacification of the cystic lesion in only one patient. MRCP depicted the whole of the cystic lesion in all 11 patients who had cystic lesions. ERCP and MRCP source images depicted a communicating duct between the main pancreatic duct and the cystic lesion in 8 and in all 11 patients, respectively. ERCP depicted papillary projections in the main pancreatic ducts in two patients. MRCP source images depicted papillary projections in the main pancreatic ducts or cystic lesions in five patients. CONCLUSION: MRCP may be more useful to reveal the main pancreatic duct, cystic lesion, communicating duct between the main pancreatic duct and cystic lesion, and papillary projections than ERCP in patients with intraductal papillary-mucinous tumors of the pancreas.     

MR cholangiopancreatography: prospective comparison of a breath-hold 2D projection technique with diagnostic ERCP

The aim of this study was to compare prospectively a breath-hold projection magnetic resonance cholangiopancreatography (MRCP) technique with diagnostic endoscopic retrograde cholangiopancreatography (ERCP). Seventy-six patients with suspected strictures or choledocholithiasis were referred for MRCP and subsequent ERCP examination, which were performed within 4 h of each other. The MRCP technique was performed using fat-suppressed rapid acquisition with relaxation enhancement (RARE) projection images obtained in standardised planes with additional targeted projections as required by the supervising radiologist. Two radiologists (in consensus) assessed the MRCP results prospectively and independently for the presence of bile duct calculi, strictures, non-specific biliary dilatation and pancreatic duct dilatation, and recorded a single primary diagnosis. The ERCP was assessed prospectively and independently by a single endoscopist and used as a gold standard for comparison with MRCP. Diagnostic agreement was assessed by the Kappa statistic. The MRCP technique failed in two patients and ERCP in five. In the remaining 69 referrals ERCP demonstrated normal findings in 23 cases, strictures in 19 cases, choledocholithiasis in 9 cases, non-specific biliary dilatation in 14 cases and chronic pancreatitis in 4 cases. The MRCP technique correctly demonstrated 22 of 23 normal cases, 19 strictures with one false positive (sensitivity 100 %, specificity 98 %), all 9 cases of choledocholithiasis with two false positives (sensitivity 100 %, specificity 97 %), 12 of 14 cases of non-specific biliary dilatation and only 1 of 4 cases of chronic pancreatitis. There was overall good agreement for diagnosis based on a kappa value of 0.88. Breath-hold projection MRCP can provide non-invasively comparable diagnostic information to diagnostic ERCP for suspected choledocholithiasis and biliary strictures and may allow more selective use of therapeutic ERCP. Received: 20 May 1998; Revision received: 26 November 1998; Accepted: 7 January 1999     

MR cholangiopancreatography (MRCP) at 0.5 T: technique optimisation and preliminary results

The aim of our study was to evaluate the feasibility of MR cholangiopancreatography (MRCP) at 0.5 T. To our knowledge no previous studies of MRCP have been performed at mid-field strength. Thirty-one patients with dilated biliary systems were examined with three-dimensional MRCP. All patients were studied with a 0.5 T superconducting magnet. A three-dimensional turbo spin-echo (TSE) sequence was acquired (TR = 3000 ms, TE = 700 ms, echo train length = 45; acquisition time = 14 min 10 s). Coronal images were post-processed with the MIP algorithm. Recently, the parameters have been optimised (TR = 3000 ms, TE = 700 ms, echo train length =128), reducing the acquisition time to 3 min. Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 26 cases; 5 patients underwent percutaneous transhepatic cholangiography PTC. MRCP and ERCP images were evaluated by an experienced radiologist and an endoscopist. MRCP of diagnostic quality was acquired in all patients. Choledocholithiasis was correctly evaluated by MRCP in 12 of 12 patients, compared with 11 correct diagnoses by ERCP. The presence and the level of the stricture were accurately shown in 16 of 16 patients with MRCP and in 13 of 16 patients with ERCP. The peripheral biliary tree above the obstruction and pancreatic duct were better evaluated by MRCP in all cases. In 3 of 3 patients who had undergone bilio-enteric surgery, a correct evaluation of the site of the anastomosis was possible with MRCP. It is concluded that MRCP performed at mid-field strength allows good visualisation of the dilated biliary system. Excellent results have been obtained on comparison with ERCP. MRCP performed at mid-field strength could have the same clinical value as high field strength MRCP. Correspondence to: P. Pavone     

Intraductal papillary mucinous tumors of the pancreas. Comparison of helical CT and MR imaging

PURPOSE: To compare the effectiveness of thin-section helical CT and MR imaging with gadolinium-enhanced dynamic technique and MR cholangiopancreatography (MRCP) in the examination of patients with intraductal papillary mucinous tumors. MATERIAL AND METHODS: Helical CT, dynamic MR imaging, and MRCP of 25 intraductal papillary mucinous tumors were compared with ERCP and surgical findings. RESULTS: The duodenal papilla was identified by helical CT and dynamic MR imaging in 11 (44%) and 20 (80%) of the 25 patients, respectively (p<0.05). The main pancreatic duct was visualized on helical CT, dynamic MR imaging, and MRCP in all patients (100%): 25 (96.2%), 24 (92.3%), and 26 (100%) cystic lesions were depicted, respectively. A communicating duct between the main pancreatic duct and the cystic lesion was visualized on helical CT, dynamic MR imaging, and MRCP in 14 (53.8%), 11 (42.3%), and 15 (55.7%) lesions, respectively. The papillary projections corresponding to 3 mm or larger papillary neoplasms were depicted on helical CT and MR imaging in 7 patients (25%). CONCLUSION: MR imaging was equal or slightly superior to thin-section helical CT in the evaluation of intraductal papillary mucinous tumors.