Magnetic Resonance cholangiopancreatography, MRCP, slideshare ppt, radiology protocol, Prajjwal upadhayaya

1. A PRESENTATION BY:
PRAJJWAL UPADHAYAYA
B.Sc.MIT ,11th BATCH
INSTITUTE OF MEDICINE(IOM)
Date: 077-12-

2. • Magnetic resonance cholangiopancreatography
(MRCP) is a special type of non-invasive radiological
examination that produces detailed images of the
hepatobiliary and pancreatic systems, including the
liver, gallbladder, bile ducts, pancreas and pancreatic
duct.

3.  MRCP is based on heavily T2 weighted pulse sequence in which
stationary fluid like bile and pancreatic secretions and fluid within
the bowel have high signal intensity , while solid organs have low
signal intensity and blood vessels have no measureable signal.
 It makes use of heavily T2 weighted pulse sequence, thus
exploiting the inherent differences in the T2 weighted contrast
between stationary fluid filled structures in the abdomen ( which
have a long T2 relaxation time ) and adjacent soft tissue ( which
has a much shorter T2 relaxation time ).

4. Static or slow moving fluids within the biliary tree and
pancreatic duct appears of high signal intensity on MRCP,
whereas surrounding tissue of reduced signal intensity.
 Since a large component of residual background signal in the
abdomen arises from fat, magnetic resonance techniques that
allow the selective suppression of fat can substantially reduce
the background signal.

5. Liver:
Largest gland.
Consists of both :
 i)Exocrine gland.
 ii)Endocrine gland.
Weight: 1500 gm.
Structural and functional unit :
Hepatic lobules.

6. BILIARY SYSTEM

15. • Biliary obstruction(choledocholithiasis, cholelithiasis, benign and
malignant strictures)
• Bile ducts, surgery or postsurgical biliary tract alternations
• Biliary cystadenoma and cystadenocarcinoma
• Congenital anomalies
• Pancreatic psuedocyst
• Chronic pancreatitis
• Acute cholecystitis
• Bile ducts calculi
• Pancreatic cancer
• Pancreas divisum

16. • Any electrically, magnetically or mechanically
activated impant( eg. Cardiac pacemaker, insulin
pump biostimulator, neurostimulator, cochlear implant
and hearing aids)
• Intracranial aneurysm clips(unless made of titanium)
• Ferromagnetic surgical clips or staples
• Metallic foreign body in the eye
• Metal shrapnel or bullet.

17. • A satisfactory written consent form must be taken from the patients
before entering the scanner room.
• Ask the patient to remove all metal objects including keys, coins, wallet,
any cards with magnetic strips, jewellery, hearing aid and hairpins.
• Ask the patient to undress and change into a hospital gown.
• Instruct the patient to hold their breath for the breath hold scans and
breathe gently for the gated scans( its advisable to coach the patient two
or three times before starting the scans)

18. • Claustrophobic patients may be accompanied into the
scanner room by relative or staff member with proper
safety screening.
• Patient should fast for 4-6 hours before the
exam.(not to eat & drink)
• Offer headphone for communicating with the patient
and ear protection.

19. • Patients are fasted for 4-6 hrs prior to the study in
order to reduce fluid secretions within the stomach
and duodenum, reduce bowel peristalsis and promote
gallbladder distension.

20. • Magnet system preferably high field system
• Phased array body coil of appropriate size and respiratory belt
for respiratory triggering technique

21. The next important step is to instruct the patient on the specific
breathing instructions and inform the patient that they will hear
the technologist’s voice through their headphone or speaker
prompting them when to suspend expiration.
 If the breath hold technique is not adequate, then the CBD and
the main pancreatic duct may not appear to unite or may appear
either stenotic or dilated.

22.  Breath holding can freeze the abdominal wall motion and enable
us to image them almost motion free.
Even though a routine breath-hold scan can be on the order of 20 s
, the breath-hold times for elderly and sick patients would be
considerably less.
 To maintain the quality of breath-hold scans, strongly recommend
practicing the breath holding on the MR table before the actual
scan, so that the patient can understand what is required.

23.  Breath holding in inspiration or expiration seems to be a
choice of each site depending on their experience.
 For longer breath holds, the patient can inhale oxygen if you
have the setup in the room. The oxygen supplement can
increase the breath holding ability of the patients.

24. Simple respiratory gating is a generally effective for reducing
artifacts provided the breathing pattern is reasonably regular.
 Chest expansion is detected with a belt or bellows and displayed
as a waveform on the operator's console.
Points are selected on this waveform that trigger data acquisition.
 Typically the acquisition window is chosen during end expiration
as this is the time when diaphragmatic motion is minimal.
Because data acquisition occurs during only part of the respiratory
cycle, simple respiratory gating may prolong imaging time by 50-
300%

28. • It can be options for patients unable to hold breath.
• Improve the image quality for T2 sequences due to
longer TR and ability to do longer acquisition times.
• Respiratory gating cannot be used with T1 weighted
acquisitions. Because the significant increase in TR
time with the respiratory gating can destroy the T1
contrast completely.

29. • Pineapple Juice/Blueberry Juice : 200-300 ml
• 15 min prior to examination.
• Acts a negative oral contrast in T2 weighted
images.

30. • However, even in fasting patients, overlap between high signals from the
pancreaticobiliary system and from the gastrointestinal tract (GIT) (stomach,
duodenum and proximal intestine), is a recognized limitation of MRCP and this
may mimic pathology.
• To avoid this problem in advance, a reduction or better yet, an elimination of
fluid signal from the upper GI tract is desirable.
• Apart from fasting prior to examination, orally administered negative contrast
agents with a strong T2 relaxation time shortening effect allows a suppression
of high intensity fluid signal in T2 weighted images and improve image quality ,
provide good visualization of the bile and pancreatic ducts.

31. The negative contrast effect of Pineapple Juice/Blueberry Juice
is due to shortening of the T2 relaxation time resulting in
reduced signal intensity from fluid in the GIT on heavily T2
weighted imaging.
This effect is likely to be due to the paramagnetic effect of the
relatively high concentration of manganese in Pineapple
Juice

33. • Position the patient in supine position with head pointing towards
the magnet.( Head first supine)
• Position the patient over the spine coil and place the body coil over
the upper abdomen(nipple down to iliac crest) and then secure the
respiratory bellows tightly around the abdomen.
• Securely tighten the body coil using straps to prevent respiratory
artifacts.

34. • Give a pillow under the head and cushions under the
legs for extra comfort.
• Check the respiratory waveform signal on the
computer console screen.
• If it’s clear and visible, we may proceed with
alignment and landmarking
• Centre the laser beam localiser over xiphoid process
of sternum.

36. Heavily T2-weighted images were originally achieved using a
gradient-echo (GRE) balanced steady-state free precession
technique.
 However, a fast spin-echo (FSE) pulse sequence with a long
echo time (TE) was then introduced shortly after with the
advantages of a higher signal-to noise ratio and contrast- to-
noise ratio, and a lower sensitivity to motion and susceptibility
artefacts.

37. • Rapid Acquisition with rapid enhancement ( RARE )
• Half-Fourier Acquisition single shot turbo spin echo ( HASTE)
• Fast recovery fast spin echo (FRFSE)

38. Balanced SSFP ( true FISP/FIESTA ):
This can be helpful in defining anatomic relationships.
It can also help eliminate pulsatility artifacts in the bile ducts
sometimes seen with SSFSE sequences.
The sequences is SNR efficient and thus high spatial resolution
images can be obtained that appear sharp.

39. DWI:
Diffusion weighted imaging can be valuable in detecting mural
pathology in the duct wall as well as pancreatic inflammation
or tumor.
B values of 50s/mm2 or higher will results in elimination of
signal from portal vessels which helps in assessment of
periportal pathology near duct walls such as periductal
inflammation or tumor.

40. 3D T1 (VIBE , THRIVE) with fat saturation
 Intraductal stones may be of high signal on T1 weighted images.
In addition intraductal air is very dark as compared to stones and
these sequences can help distinguish intraductal air from stones.
 Pancreatic pathology often is dark against the normal bright T1 of
the pancreatic parenchyma.
 For this reason a T1 weighted image through the liver and pancreas
is an important part of the MRCP exam even if contrast is not being
administered.

41. 1. T2_HASTE_FAT_SAT_CORONAL
2. T2_TRUFI_AXIAL
3. T2_HASTE_FATSAT_AXIAL
4. T2_HASTE_40MM_CORONAL OBL
5. T2_HASTE_40MM_CORONAL OBL
6. T2_SPACE 3D_CORONAL GATED

42. Localiser
 A three plane TrueFISP localizer must be taken initially to
localise and plan the sequences.
These are fast single shot localisers with under 25sec
acquisition time which are excellent for localising abdominal
structures.

43. Plan the coronal slices on the axial localizer such that
the position block is across the liver as shown in
figure. Check the other two planes.
Slices must be sufficient to cover the whole liver from
the anterior abdominal wall to the posterior abdominal
wall in saggital plane.
Phase direction must be right to left to avoid the
artifacts from the heart .

45. • Phase oversampling must be used to avoid wrap around
artifacts.
• Instruct the patient to hold their breathe during image
acquisition.

46. • Plan the axial slices on the coronal TRUFI image such
that position block is across the liver as shown in
figure.
• Slices must cover the whole biliary system from the
diaphragm down to the C loop of duodenum.
• Instruct the patient to hold their breathe during image
acquisition.

48. • Plan the coronal oblique(right anterior
oblique) thick slab on the axial TRUFI(or
HASTE) image.

49. • Position the block across the common bile duct and rotate the
block 20-30 degree anticlockwise to include common bile duct
and pancreatic duct
 Slices must be sufficient to cover the whole common bile duct and pancreatic duct.

50. • Plan the coronal oblique(left anterior oblique) thick
slab on the axial TRUFI(or HASTE) image.

51.  Position the block across the common bile duct and rotate the
block 20-30 degree clockwise to include common bile duct and
gall bladder.
 Slices must be sufficient to cover the whole common bile duct and pancreatic duct.

52. • Plan the coronal 3D on the axial TRUFI(or HASTE) such that
the position block is across the common bile duct.
• Slices must be sufficient to cover the whole common bile duct,
pancreatic duct and gall bladder.
• Phase oversampling must be used to avoid wrap around
artifacts.

53. For respiratory gated scans, it is important to place the
respiratory navigator box correctly i.e. in the middle of the
right dome of diaphragm with half the box over the right lobe
of the liver(segment 8) and the other half over the lungs.

54. T2 HASTE CORONAL TRIGGER
T2 HASTE AXIAL TRIGGER
T2 BLADEFat_Sat AXIAL TRIGGER
T2 HASTE Fat_Sat CORONALTHICK_ BH
T2 SPACE CORNAL TRIGGER

55.  Secretin is an endogenous hormone normally produced by the
duodenum, which stimulates exocrine secretion of the pancreas.
It is used to examine the pancreatic ductal anatomy in order to
detect any pancreatic ductal pathologies.
When given as a synthetic agent intravenously (1 ml/10 kg body
weight), it improves the visualisation of the pancreatic duct by
increasing its calibre.
 Pancreatic juice flows out of the major duodenal papilla to
progressively fill the duodenum.
Perform a thick slab MRCP in the coronal oblique plane at baseline
and then at 1, 3, 5, 7 and 9 min following injection.

56. A progressive dilatation of the pancreatic duct can be
obtained within 2 to 9 minutes of secretin injection.
The peak dilatation is normally obtained at 2 to 3
minutes after injection.
Subsequently, the main pancreatic duct returns to its
normal calibre as pancreatic juice flows out through
the papilla and fills the duodenum.
Filling of the duodenal lumen is best visualized at 6 to
9 minutes after secretin injection.

58. It involves the use of MR lipophilic paramagnetic contrast agents,
which when given intravenously, show hepatobiliary excretion.
 Contrast agents includes :
• gadobenate dimeglumine (Gd-BOPTA)
• gadolinium ethoxybenzyldiethylenetriamine penta- acetic acid
(Gd-EOB-DTPA)
• historically, mangafodopir trisodium

59. • Delayed imaging in the axial and coronal plane, performed
between 10-120 min following intravenous administration,
normally results in hyper-intense bile on 3D T1-weighted fat-
saturated GRE images.
• The signal to- noise ratio is higher than conventional T2-
weighted MRCP, allowing better delineation of the bile ducts.
• It is more expensive than conventional T2-weighted MRCP and
only the biliary tree is seen. For these reasons, most centres
continue to use conventional T2-weighted MRCP

60. For many years, ERCP has been considered the Gold Standard
of reference for imaging of the biliary tract and pancreatic duct
because of its ability to render high-quality images of the ducts.
However ERCP is an invasive examination associated with
complications that occur in up to 5% of all attempts and that
range from subclinical to life threatening.
Those complications include pancreatitis, hemorrhage,
cholangitis and GI tract perforation.

61. The relatively rapid acceptance of MRCP in large part is due to
its ability to provide images of the ducts similar to those of
ERCP without the associated complications of ERCP while
offering comparable sensitivity, specificity and accuracy.
In addition, MRCP is readily performed in the outpatient
setting and does not expose patient to ionizing radiation.
In most instances, performance of MRCP does not require
administration of sedation.

62. Although ERCP yields exquisite images of the ductal systems, it
provides no direct information about the solid organs and vessels
of the abdomen.
However when MRCP is performed in conjunction with
conventional MRI and when necessary MRA too, a comprehensive
examination is achieved.
However, ERCP include direct therapeutic interventional
procedures that may be performed concurrent with diagnostic
imaging which is not possible with MRCP.

63. MRCP ERCP
No ionizing radiation Ionizing radiation
Non-invasive Invasive
Generally, no positive contrast is used Iodinated contrast is used
Only diagnostic Both diagnostic and therapeutic
3D imaging and image reformatting is
possible
Not possible
Extra ductal pathologies can also be
assessed simultaneously.
Not possible
Possible to perform in post surgical
cases
May not be possible to perform in post
surgical cases

67. Choledocholithiasis

71. Normal MRCP Pancreatic Divisum

72. Since the first clinical application of MRCP in the early 1990s,
MRCP has evolved from a technique with questionable
potential for imaging that is now recognized as pivotal tool for
diagnosis of pancreaticobiliary diseases.

73.  PREVIOUS PRESENTATIONS

74. END OF PRESENTATION !!!