MR cholangiopancreatography in patients with primary sclerosing cholangitis: interobserver variability and comparison with endoscopic retrograde cholangiopancreatography.

OBJECTIVE: The purpose of our study was to determine the degree of interobserver variability and correlation between MR cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) for the presence of bile duct strictures in patients with primary sclerosing cholangitis. MATERIALS AND METHODS: For this retrospective study involving 26 patients with primary sclerosing cholangitis, 31 MR cholangiopancreatograms were compared with 30 endoscopic retrograde cholangiopancreatograms. The MR cholangiopancreatograms were independently interpreted by two abdominal radiologists in a blinded, randomized manner for overall image quality, extent of ductal visualization, and the presence and location of bile duct strictures. Unweighted multirater kappa coefficient values were estimated for each comparison. RESULTS: Visualization of more than 50% of the expected ductal length was possible in the extrahepatic, central intrahepatic, and peripheral intrahepatic bile ducts in 99%, 88%, and 69% of the MR cholangiopancreatograms and 100%, 86%, and 52% of the endoscopic retrograde cholangiopancreatograms, respectively. Strictures were detected in the extrahepatic, central, and peripheral ducts in 53%, 68%, and 87% of the MR cholangiopancreatograms and 73%, 67%, and 63% of the endoscopic retrograde cholangiopancreatograms, respectively. The interobserver agreement for stricture detection was 61% for MR cholangiopancreatography and 76% for ERCP. MR cholangiopancreatographic findings were consistent with ERCP findings for the presence of strictures in 69% of the cases. CONCLUSION: In patients with primary sclerosing cholangitis, MR cholangiopancreatography better shows the bile ducts and can depict more strictures, especially of the peripheral intrahepatic ducts, than ERCP. MR cholangiopancreatography can be used to noninvasively diagnose and follow up patients with primary sclerosing cholangitis.

Magnetic resonance cholangiopancreatography (MRCP) of intraductal papillary-mucinous neoplasm (IPMN) of the pancreas: case report.

The intraductal papillary-mucinous neoplasm (IPMN) is the rarest of the cystic pancreatic tumors. Endoscopic retrograde cholangiopancreatography (ERCP) is currently the gold standard for evaluating IPMN's and can demonstrate dilatation of the main duct or side branches, mural nodules, filling defects, and communication between the tumor and the main pancreatic duct. Recent literature has shown that MRCP may be more sensitive and specific in the diagnosis of IPMN In this case report, we present a patient with IPMN of the pancreas where MRCP was superior to ERCP in characterizing the tumor.

Canine abdominal MRI at 8 Tesla: initial experience with conventional gradient-recalled echo and rapid acquisition with relaxation enhancement (RARE) techniques.

PURPOSE: In this manuscript, we present our initial experience with MRI of the abdomen at 8 T of canine subjects both alive and dead. Our hypothesis is that abdominal imaging at 8 T should be possible and should demonstrate unique information. To our knowledge, this is the first description of imaging characteristics of the abdomen at such field strengths using a human MR scanner. METHOD: An 8 T, 80 cm magnet housed in our department since 1998 was used for our study. GRE and rapid acquisition by relaxation enhancement (RARE) pulse sequences were selected to give reasonable slice profiles with relatively low power. Three dogs were imaged alive and after being killed. RESULTS: Our initial results show excellent signal-to-noise ratio and good RF penetration. Structures in the center of the abdomen were well visualized. Homogeneous signal was noted throughout each image without dielectric resonance artifact. Magnetic susceptibility artifacts were most severe on the GRE sequences. On the GRE sequences, the images appeared relatively T2 weighted. Signal voids were seen due to gas in the lung and bowel and susceptibility artifact at subcutaneous fat-muscle boundaries. The liver and spleen showed similar signal intensity, hypointense to subcutaneous muscle at low TE values. There was little internal anatomy of the liver or spleen visible except for the vessels. The kidney, in contrast, demonstrated very good internal structure with visualization of the cortex and medulla. Linear signal voids were depicted in the expected location of normal renal vascular anatomy on the GRE sequences. On the RARE sequences, the images also appeared T2 weighted. Magnetic susceptibility artifacts at subcutaneous fat-muscle boundaries were absent. Signal voids were noted in vessels with blood flow and gas. The liver and spleen were of similar signal intensity and slightly hypointense to muscle. The kidney and pancreas were of higher signal intensity than liver and subcutaneous muscle. The gallbladder wall demonstrated a striated pattern of two layers, with an inner hypointense and an outer hyperintense layer on the RARE sequence. The gastric wall demonstrated a striated pattern of five layers on the RARE sequence. CONCLUSION: Images of the dog abdomen with the world's first ultra high field 8 T magnet show robust image quality and excellent spatial resolution. Image contrast is greatest on the RARE sequence, and susceptibility artifact is strongest on the GRE sequence.

Detection of bile duct leaks using MR cholangiography with mangfodipir trisodium (Teslascan).

Mangafodipir trisodium (Teslascan), a hepatobiliary contrast agent, has the potential of providing functional biliary imaging similar to hepatobiliary scintigraphy. To our knowledge. the potential role of this biliary contrast agent in the detection of bile duct leaks has not been reported. In this case report, we report the first case of a bile duct leak diagnosed with enhanced MRI with mangafodipir trisodium in a patient following laparoscopic cholecystectomy. Our case illustrates that functional MR cholangiography images can be successfully acquired by using a post-mangafodipir fat-suppressed GRE technique and that bile duct leaks can be detected.

Biliary cystadenocarcinoma: seven year follow-up and the role of MRI and MRCP.

Biliary cystadenomas and their malignant counterparts, biliary cystadenocarcinomas, are rare cystic tumors that arise from hepatobiliary epithelium. Ultrasound (US) and computed tomography (CT) are the initial imaging modalities used for the evaluation of biliary cystic tumors, but are not specific. MRI and MRCP, because of increased contrast and spatial resolution, may be a more specific imaging modality in the detection of biliary cystic neoplasms. We present a case of biliary cystadenocarcinoma imaged by MRI and MRCP in a 65 year-old man managed conservatively for 7 years.

Cirrhosis: spectrum of findings on unenhanced and dynamic gadolinium-enhanced MR imaging.

The appearance of the cirrhotic liver on computed tomography can be difficult to evaluate and can frustrate the radiologist distinguishing benign from malignant lesions. Hepatic edema, fibrosis, atrophy, and vascular abnormalities are common in the cirrhotic liver and produce derangements in morphology, attenuation, and perfusion, limiting the accurate characterization of hepatic masses. With the development of fast magnetic resonance (MR) sequences and dynamic postgadolinium-enhanced imaging, most hepatic lesions with uncertain etiology on computed tomography can be accurately characterized on MR imaging. We describe MR imaging techniques useful for imaging cirrhosis and its complications. We also illustrate the spectrum of findings in the cirrhotic liver on dynamic gadolinium-enhanced MR imaging, including reticular and confluent fibrosis, fatty infiltration, hemochromatosis, regenerating nodules, dysplastic nodules, hepatocellular carcinoma, and sequela of portal hypertension.

MR cholangiopancreatography of bile and pancreatic duct abnormalities with emphasis on the single-shot fast spin-echo technique.

Magnetic resonance cholangiopancreatography (MRCP) is used for noninvasive work-up of patients with pancreaticobiliary disease. MRCP is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis of extrahepatic bile duct abnormalities. In patients with choledocholithiasis, calculi appear as dark filling defects within the high-signal-intensity fluid at MRCP. Benign strictures due to sclerosing cholangitis are multifocal and alternate with slight dilatation or normal-caliber bile ducts, producing a beaded appearance. Dilatation of both the pancreatic and bile ducts at MRCP is highly suggestive of a pancreatic head malignancy. Side-branch ectasia is the most prominent and specific feature of chronic pancreatitis. MRCP is more sensitive than ERCP in detection of pancreatic pseudocysts because less than 50% of pseudocysts fill with contrast material. Because the mucin secreted by biliary cystadenomas and cystadenocarcinomas causes filling defects and partial obstruction of contrast material at ERCP, MRCP is potentially more accurate in demonstrating the extent of these tumors. In patients with biliary-enteric anastomoses, MRCP is the imaging modality of choice for the work-up of suspected pancreaticobiliary disease. A potential use of MRCP is the demonstration of aberrant bile duct anatomy before cholecystectomy. MRCP is also accurate in detection of pancreas divisum.

Radiologic manifestations of sclerosing cholangitis with emphasis on MR cholangiopancreatography.

Magnetic resonance cholangiopancreatography (MRCP) is a relatively new, noninvasive cholangiographic technique that is comparable with invasive endoscopic retrograde cholangiopancreatography (ERCP) in the detection and characterization of extrahepatic bile duct abnormalities. The role of MRCP in evaluation of the intrahepatic bile ducts, especially in patients with primary or secondary sclerosing cholangitis, is under investigation. The key cholangiographic features of primary sclerosing cholangitis are randomly distributed annular strictures out of proportion to upstream dilatation. As the fibrosing process worsens, strictures increase and the ducts become obliterated, and the peripheral ducts cannot be visualized to the periphery of the liver at ERCP. In addition, the acute angles formed with the central ducts become more obtuse. With further progression, strictures of the central ducts prevent peripheral ductal opacification at ERCP. Cholangiocarcinoma occurs in 10%-15% of patients with primary sclerosing cholangitis; cholangiographic features that suggest cholangiocarcinoma include irregular high-grade ductal narrowing with shouldered margins, rapid progression of strictures, marked ductal dilatation proximal to strictures, and polypoid lesions. Secondary sclerosing and nonsclerosing processes can mimic primary sclerosing cholangitis at cholangiography. These processes include ascending cholangitis, oriental cholangiohepatitis, acquired immunodeficiency syndrome-related cholangitis, chemotherapy-induced cholangitis, ischemic cholangitis after liver transplantation, eosinophilic cholangitis, and metastases.

Pancreatitis complicated by gland necrosis: evolution of findings on contrast-enhanced CT.

PURPOSE: The purpose of this work was to investigate the natural history of pancreatic necrosis on contrast-enhanced CT in patients managed nonoperatively. METHOD: A computer-based radiology information search revealed 32 patients with pancreatic necrosis who had had serial contrast-enhanced CT scans and were managed nonoperatively. There were 23 men and 9 women with a mean age of 51 years. One hundred forty-five contrast-enhanced CT scans were retrospectively reviewed for the location and extent of necrosis. The medical records of all patients were reviewed. RESULTS: The 32 patients had a mean Ranson clinical grade of 5.8 (range 3-8). Eighteen of these 32 patients were managed nonoperatively, and 14 patients required a necrosectomy after initial nonoperative management. In the 32 patients, the location of necrosis was in the head (3), body (6), tail (2), head/body (2), head/body/tail (9), body/tail (9), and head/tail (1). Extent of necrosis was 0-25% (9), 26-50% (6), 51-75% (6), and 76-100% (11). The extent of necrosis remained stable during follow-up in 22 (69%) patients and increased during follow-up in 10 (31%). Necrosectomy was performed in six (60%) patients in whom there was an increase in necrosis and eight (36%) patients in whom necrosis was stable. No patient had restoration of normal enhancement in an area that was previously necrotic. There were five patients who were managed nonoperatively (mean follow-up 318 days) in whom the necrosis eventually resorbed, forming a focal parenchymal cleft reminiscent of a scar. Five of the 32 patients died. CONCLUSION: Pancreatic necrosis as demonstrated by CT tends to remain stable in most patients treated nonoperatively. If the extent of necrosis increases, patients are more likely to require a necrosectomy. In some patients managed nonoperatively, the pancreatic necrosis will resorb, resulting in a fat-replaced cleft reminiscent of a scar.

Fine-needle aspiration with flow cytometric immunophenotyping for primary diagnosis of intra-abdominal lymphomas.

Cytomorphology in conjunction with immunophenotypic characterization is becoming increasingly used for the primary diagnosis of non-Hodgkin's lymphomas (NHL). This combination is especially advantageous for the diagnosis of intra-abdominal and intrathoracic lymphomas, since unlike superficial lesions, open biopsy of deep-seated tissues is more invasive and more costly, and is associated with a higher risk. We report the cytologic and immunophenotypic features of intra-abdominal NHL obtained by fine-needle aspiration (FNA). Twenty-two cases of intra-abdominal lesions obtained by image-guided FNA where flow cytometry was also performed were reviewed. Of the 22 studied cases, 7 were classified as large-cell lymphoma, 5 as follicular center-cell lymphoma, 2 as small noncleaved-cell lymphoma, 2 as lymphoplasmacytoid lymphoma, one as small lymphocytic lymphoma, and one as marginal-zone lymphoma. In the remaining 4 cases where the immunophenotypic pattern was not definitive, the cytomorphologic features were of small cleaved cells in 3 cases and of mixed small cleaved and large cells in one case. We successfully classified 9 of the 10 patients on whom histologic confirmation was obtained. The successful primary classification of most intra-abdominal non-Hodgkin's lymphomas can be done with a combination of cytology and flow cytometry, and this can be the initial approach in patients with deep-seated lesions. Diagn. Cytopathol. 1999;21:98-104.

Castleman disease mimicking a hepatic neoplasm.

Castleman disease, or angiofollicullar hyperplasia, is a rare cause of lymph node enlargement. This most commonly occurs within the thorax, although rare extrathoracic presentations have been described. Only two cases with hepatic localization have been reported. We present a case of Castleman disease within the porta hepatis masquerading as a hepatic neoplasm.