This document provides an overview of magnetic resonance cholangiopancreatography (MRCP). It discusses patient preparation, techniques, advantages, limitations, and clinical applications of MRCP. Key points include: MRCP uses heavily T2-weighted sequences to noninvasively visualize the biliary and pancreatic ducts. Patient preparation involves fasting and administering oral contrast. Thin-slab MRCP images provide high resolution of the ductal systems. MRCP is useful for evaluating biliary diseases, pancreatic diseases, and postoperative complications without radiation exposure. Limitations include inability to detect small stones and artifacts from gas or metal.

1. MRCP
Presenter:Dr. Vidya T K
IIYR Resident
MD RADIO-DIAGNOSIS

2. Objectives
• Introduction
• Patient preparation
• Technique
• Advantages
• Limitations
• Clinical applications

3. Introduction
 Introduced in 1991.
 Magnetic resonance cholangiopancreatography
(MRCP) is performed with heavily T2-weighted fast
spin-echo sequences.
 Noninvasive, less costly, and sensitive alternative to
diagnostic ERCP

4. PATIENT PREPARATION
• It is very crucial to optimize imaging of the biliary
system with MRCP.
• The patient fasts for 4 hours to help reduce peristalsis
and gastroduodenal fluid before imaging.

5. PATIENT PREPARATION
• Oral contrast material that lowers the signal intensity
of intraluminal fluid in the bowel on T2-weighted
images.
• Superparamagnetic iron oxide particles, gadolinium-
meglumine compounds or pineapple juice
administered to suppress the signal from fluid in the
gastrointestinal tract.

6. PATIENT PREPARATION
• Patient removes all external metal items prior to
entering the magnet, and is given ear plugs.

7. PATIENT PREPARARTION
• Once in the scanning room, patient lie supine and
phased array torso-coil placed against the chest wall
& upper abdomen.
• The coil acts as antenna - improve the signal to noise
ratio of the images.
• Instructed to remain still and follow the breathing
instructions during the study.

8. MAGNET
• 1.5 Tesla -3Tesla magnet.
• Multiplanar thin-slice images -excellent spatial
resolution of the ducts.
• Stronger magnetic fields may provide better spatial
resolution.

9. TECHNIQUE
• 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.

10. TECHNIQUE
• MR cholangiopancreatography uses
heavily T2-weighted images to visualize
stationary or slow moving fluids in the
biliary system and pancreatic duct with
high signal intensity.

11. TECHNIQUE
• Earlier sequences such as GRE & FSE provided
MRCP images ,but these long sequences often
suffered from motion artifact & poor spatial
resolution.
• Images are now acquired in one of the following
sequences that use heavy T2 weighting .

12. TECHNIQUE
1) Single shot fast-spin echo (SSFSE)
2) Half Fourier single-shot turbo spin echo (HASTE)
3) Rapid acquisition relaxation enhanced (RARE).
These ultrafast techniques obtain images rapidly with
reduced artifacts.

13. TECHNIQUE
• Since large component of residual background
signal from abdomen arises from fat, selective fat
suppression techniques used to improve overall
quality of the image.

14. TECHNIQUE
• Other refinements include development of breathing
independent sequences that suppress artifacts
associated with surgical clips, stents, and bowel gas
and allow image acquisition at thickness of 2-5mm.

15. TECHNIQUE
• Respiratory triggering : in which the imaging
procedure is timed to coincide with the patients
breathing.
• Can be used in patients who are unable to suspend
respiration.

16. TECHNIQUE
• Parameters for MRCP
- TE : 900 to -1000
- TR : Infinite
- Matrix : 256 x 256
- FOV : small, but without signal wrap of the biliary
structures.
- T1 axial – for any pancreatic lesion causing biliary
obstruction.

17. TECHNIQUE
• In general, the first step in performing MRCP is to
localize the biliary tract and pancreatic duct.
• Accomplished by acquiring a scout image of 30-70
mm – thick slab or single-shot projection. Depicts
majority of the biliary tract & pancreatic duct on a
single image.

18. TECHNIQUE
• To depict finer details of the ducts, thin-slab
technique is employed.
• By using the thick-slab images as guides ,
multiple, thin-slab (2-5mm)images of the
pancreaticobiliary tract in the coronal plane and at
a variety of angles which depict the ductal
systems.

19. TECHNIQUE
• The entire ductal systems are usually not located on a
single image.
• Although most diagnostic decisions are made on the
basis of 2D thin-slab images, the thin-slab images
may be manipulated with MIP algorithms MPR
techniques to generate 3D images of the ductal
systems.

20. TECHNIQUE
• Additional information may be obtained when
conventional MR is performed in conjunction with
MRCP.
• In suspected malignancy of the pancreaticobiliary
tract, MRA may also yield information important in
determining the resectability of neoplasms.
• The entire procedure takes about 10-30 minutes.

21. TECHNIQUE
• ROLE OF IV SECRETIN : IV injection of secretin,
at dose of 1ml/kg stimulates secretion by pancreas
thus allowing better distension of the pancreatic duct.
• The effect is rapid & resolves quickly.

22. TECHNIQUE
• Repeated imaging with thick-slab, every 15-30
seconds for 10-15 minutes is performed.
• This allows dynamic evaluation of the pancreatic duct
& ampullary regions.
• Secretin stimulation allows improved visualization of
the pancreatic duct compared with standard MRCP.
• This technique improves the detection of pancreas
divisum.

24. INTERPRETATION
• The interpretation of images obtained with MRCP
follows the same principles used for interpreting
ERCP images.

25. APPLICATIONS
• BILIARY DISEASE
- Cystic disease of bile ducts (choledochal cyst,
choledochocele, caroli’s disease)
- Congenital variants (aberrant right hepatic artery, low
or medial duct insertion).
- Choledocholithiasis
- Primary sclerosing cholangitis
- Post surgical biliary complications
- Cholangiocarcinoma

26. APPLICATIONS
• PANCREATIC DISEASE
- Pancreatic divisum
- Chronic pancreatitis
- Ca pancreas

27. APPLICATIONS
• In choledochal cysts :
- MRCP is equivalent to ERCP.
- detects the presence of anomalous union of
pancreatic & bile ducts.
- the length of extrahepatic bile duct involved by the
cyst is known – an important consideration in
planning surgery.
- well suited for pediatric patients.

30. APPLICATIONS
• In anatomic variants of the bile ducts :
- Variations in the branching pattern of the IHBD occur
in 37% - detected well on MRCP.
- MC being accessory right & left hepatic ducts that
enter the bile duct caudal to the confluence.
- cystic duct anomalies.
- although these may be incidental findings they can
complicate surgery

32. APPLICATIONS
• In Choledocholithiasis :
- USG & CT are often used in the initial evaluation in
suspected choledocholithiasis.
- On MRCP stones appear as signal void in the
background of high signal intensity bile.
- number, size & location are determined.
- stones as small as 2mm can be identified with current
techniques.

37. APPLICATIONS
• In Primary Sclerosing Cholangitis :
- MRCP depicts the subtle ductal abnormalities that
characterize PSC – mural irregularities, strictures
& diverticular outpouchings.
- Conventional abdominal MR + MRCP provides
useful information regarding the presence of cirrhosis
& portal hypertension in PSC patients.

39. APPLICATIONS
• In post surgical complications:
- The utility of MRCP has been demonstrated in the
evaluation of the surgically altered pancreatobiliary
tract.
- These alterations include
1) biliary – enteric anastomoses
2) pancreaticoenteric anastomoses
3) duct-to-duct anastomoses

40. • MRCP demonstrates the anastomoses & also the
complications such as – strictures, intraductal stone
formation, & anastomotic leak.

41. APPLICATIONS
• In Cholangiocarcinoma :
- MRCP is very accurate in identifying the presence &
level of neoplastic obstruction of pancreatobiliary
tract.
- In conjunction with conventional MR + MRCP and ,
when necessary MRA permits not only diagnosis but
also staging of malignant tumors of pancreatobiliary
tract.

42. • In hilar cholangiocarcinoma, it depicts the length of
extra-hepatic bile duct involved by the disease as well
as the proximal extent of the disease – an important
factor in determining the resectability.

44. APPLICATIONS
• In pancreatic divisum :
- occurs in 5.5 – 7.5% individuals
- MC variant of pancreatic duct, where the dorsal &
ventral anlage of the pancreas fail to fuse – resulting
in two separate drainage routes for pancreatic
secretions.

46. APPLICATIONS
• In pancreatitis :
- especially when ERCP is contraindicated in ongoing
acute pancreatitis.
- in detecting common ductal manifestations of chronic
pancreatitis such as dilatation, strictures, stones &
thoracopancreatic fistulas.

50. APPLICATIONS
• MRCP following the administration of secretin
shows improved depiction of pancreatic duct &
estimation of exocrine function as determined by the
amount of fluid filling the duodenum.

51. APPLICATIONS
• In pancreatic carcinoma :
- depicts the ducts obstructed by the pancreatic
mass & localizes the obstruction to pancreas.
- “double duct sign” is observed in case of
pancreatic head mass. ( non- specific as it may
seen in chronic pancreatitis)
- MRA done in conjunction – assesses the
resectability..

54. APPLICATIONS
• In failed / incomplete ERCP:
- most often technical in nature
- may be related to anatomic abnormalities such as
periampullary diverticula, duodenal stenosis, or
obstructing gastric neoplasms

55. APPLICATIONS
• In gall bladder :
- visualized as a high signal intensity structure owing to
its fluid content.
- fluid in the lumen allows the detection of stones that
are seen as low signal intensity foci.
- polyps, carcinoma and adenomyomatosis are also
detected.

57. LIMITATONS OF MRCP
• Only diagnostic
• Small / impacted calculi may be missed.
• Air / metal artifacts limit visualization of entire duct.
• Volume averaging can mask small calculi in thick-
slab HASTE images.
• Artifacts due to – gas, clot, metallic clips, motion /
pulsation.
• Respiratory motion may simulate ductal stones or
strictures.

59. LIMITATONS OF MRCP
• Pulsitality from the hepatic artery may simulate as
stricture in common duct.
• Overestimation of severity of biliary stenosis on MIP
images – thick slab HASTE images can overcome
this.
• Cannot be used in patients with aneurysms clips,
pacemakers etc.
• Can cause claustrophobia.

61. LIMITATIONS OF MRCP
• Inappropriate selection of the region
• If negative contrast is not used, fluid in the duodenum
may obscure the common duct.
• Ampullary region shows poor visualization thus
hinders interpretation.

62. MRCP
• Non – invasive
• Only diagnostic
• Multiplanar
projection
• No risk of ionizing
radiation
• No post procedure
complications
ERCP
• Invasive
• Diagnostic &
therapeutic
• Less
maneuverability
• Risk of radiation
• Complications –
pancreatitis,
hemorrhage, GI
perforation

63. Advantages of 3.0 T over 1.5 T
• Improved image quality ( SNR at 3.0 T is twice that at 1.5 T).
• Distal arborization and intrahepatic bile duct variation more
easily detected.
• Relation of pancreatic parenchyma to the ductal system
better visualized on nonpostprocessed images obtained at 3.0
T than in those obtained at 1.5 T.
• Delineation of pancreatic duct, particularly side branches,
improved at 3.0 T.
• When oral contrast is used, the fluid signal in the
gastrointestinal tract more effectively suppressed at 3.0T.
• Thin sections of 3–4 mm can be acquired in less time at 3.0 T
than at 1.5 T, helping reduce motion artifacts.

64. SUMMARY
• Over the past decade, MRCP has evolved not only as
a feasible means of non-invasively evaluating the
pancreatobiliary tract but also as a technique with
documented clinical utility.
• In fact, at some institutions MRCP has replaced
diagnostic ERCP such that ERCP is preserved for
only therapeutic interventions.
• MRCP + abd MR + MRA – evaluates solid organs &
vessels of abd & ductal systems

65. REFERENCES
• Hemant T. Patel, Ankur J. Shah, Shikha R.
Khandelwal, Hiren F. Patel, Megha D. Patel:
MR Cholangiopancreatography at 3.0 T.
RadioGraphics 2009; 29:1689–1706 .
• Computed body tomography with MRI
correlation-Lee & Sagel.

66. THANK YOU