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When we started preparing the first edition of this book in 1998, MR cholangiopancreatography (MRCP) was a newly developed technique successful only on high-end MRI machines equipped with strong gradients. Now,in 2005,most MRI units are capable of providing high quality images of the upper abdomen, and the technique has found its way into clinical practice.

In comparison with the first edition of the book, the basic structure remains un-

changed. Many examples have been added and older images have been replaced by new ones. Some new concepts and references have been added where needed.

It only remains to express the hope that the current edition will prove of value to all involved with the interpretation of upper abdominal MRI and MRCP.

Since its clinical introduction, already many years ago now, the advance of MRI has not been stopped or slowed down by technical limitations. On the contrary, technical improvements have constantly triggered the further spread of MRI into new clinical domains.

Though initially introduced as a new “cross-sectional” imaging modality, it soon became obvious that MRI could also produce “continuity” images, comparable to conventional X-ray techniques. With MRI, continuity images can either be calculated from cross-sectional data or obtained directly by using volumetric projective acquisition schemes. MR angiography (MRA) is typically calculated from tomographic images using a maximum-inten- sity projection algorithm, whereas magnetic resonance cholangiopancreatography (MRCP) is often obtained with projective acquisition sequences. The two approaches each have various advantages, but they are also subject to specific limitations and artifacts.

Continuity information is extremely useful in the interpretation of the pathology of smaller tubular structures. Particularly if it can be obtained directly without the intermediate step of tomography, this information constitutes one of the advantages of MRI over ultrasonography and computed tomography (CT).

MRCP is often considered as a noninvasive alternative to diagnostic endoscopic

retrograde cholangiopancreatograhy (ERCP) because it does not necessitate contrast medium injection, irradiation, or endoscopic manipulation. However, MRCP is obtained under totally different conditions, showing images of the ducts in “physiologic” or “pathophysiologic” conditions, in contrast to ERCP, which is obtained under nonphysiologic conditions, i.e., positive injection pressure. These differences become particularly obvious in the presence of obstrucitve lesions. In addition, MR images differ not only in terms of spatial and time resolution, but also fundamentally in the physics involved in the imaging process. Diagnostic features such as calcification or air can therefore be missed on MRCP.

The authors of this textbook have aimed to provide the interested reader with a comprehensive overview of all the issues involved in the acquisition and interpretation of MRI of the biliary and pancreatic ducts,not only from the point of view of the radiologist but also from that of the endoscopist and gastroenterologist. The chapters and text are arranged accordingly, providing key facts in terms of disease and MRI.A large spectrum of diseases is illustrated, and relevant references have been included.

We hope that this volume will be a successful stimulant for an even greater spread of MRI in abdominal radiology.

Guy Marchal

It was our aim to place at the disposal of radiologists and clinicians an atlas of Magnetic Resonance Cholangio Pancreatography (MRCP). From more than 1200 patients studied with this technique, we tried to assemble representative images of a large variety of diseases.

There is no doubt that the availability of MR systems equipped with high-power gradients opens new perspectives in the evaluation of abdominal diseases. While the non-invasive nature of MRI remains a crucial advantage over other techniques, the introduction of “snapshot” sequences providing images free of motion artifact in all patients, including those unable to cooperate, has triggered a more widespread use of this modality. A unique characteristic of state-of-the art MRI is its unrivaled capability for integrated abdominal imaging. Classic T1and T2-weighted crosssectional imaging, projective cholangiography, dynamic evaluation of contrast enhancement patterns or muscular contractility, functional imaging by assessing the uptake and excretion of specific contrast media, MR angiography, …all these techniques can be used within one session if required. It is likely, therefore, that MRI/MRCP will become an effective and cost-effective “one-stop shopping” diagnostic modality in a number of patients with suspected pancreatobiliary disease.

This book has some characteristics that should be stressed. First of all, it has been conceived as an atlas – teaching file. The format was designed so that the interested reader can “walk through”a large spectrum

of pancreatobiliary abnormalities within a relatively short period of time. Besides diseases confined to the biliary or pancreatic ducts, other conditions that may cause secondary ductal abnormalities, that have the potential to mimic ductal disease clinically,or that may be discovered incidentally during an“MRCP”study are also discussed. Most of the 200 separate topics consist of a short description of the entity under consideration, a summary of MRI/MRCP features, and a few representative images. Unlike classical teaching files, the book has rigourously been structured. With the exception of the first chapter on technique, each of the five other chapters that cover the intraand extrahepatic bile ducts, gallbladder and cystic duct, Vaterian sphincter complex, and pancreatic ducts, has been subdivided in normal anatomy and variants, benign diseases, traumatic and postoperative conditions, and malignant disorders. Hopefully, this organization will be beneficial for those faced with specific problems or questions. In order to further enhance the practical usefulness of the work,important issues such as pitfalls, specific problems in differential dignosis, and clues to a specific diagnosis have been indicated by a special symbol ! .

We hope that the readers of this book will enjoy it like we did enjoy its preparation.

Lieven Van Hoe, Dirk Vanbeckevoort,

Werner Van Steenbergen

Leuven, 1998

MRCP Technique

IIntroduction: Basic Principles

#7 An Alternative Approach: Calculation of Maximum-

#15 Nonspecific Intravenous Contrast Media (1): Parenchymal

Organs and Lymph Nodes . . . 34

# 16 Nonspecific Intravenous Contrast Media (2): Vascular

„Roadmapping“ . . . . . . . . 36

#17 Specific Intravenous Contrast Media (1): Hepatocyte-Directed

Agents . . . . . . . . . . . . . 38

#18 Specific Intravenous Contrast Media (2): Reticuloendothelial

1.4Comparison

3.2

#68

#69

#70

#71

#72

#73

#74

#75

#76

#77

#78

#79

3.3

#80

#81

#82

#83

#84

#85

#86

3.4

#87

#88

#149 Postoperative Anatomy (2): After Pancreatic Transplan-

tation . . . . . . . . . . . . . . 302

6.2Benign Nontraumatic Abnormalities . . . . . . . . . 304

#153 Acute Pancreatitis with Peripancreatic Inflammation

(Grade C) . . . . . . . . . . . 308

#154 Acute Pancreatitis with

#157 Complications of Acute Pancreatitis (3): Vascular

Complications . . . . . . . . . 316

#158 Recurrent (Relapsing)

#162 Chronic Pancreatitis, Ductal Changes (2):

Early Disease . . . . . . . . . . 324

#163 Chronic Pancreatitis,

#166 Complications of Chronic Pancreatitis (2):

Other Complications . . . . . . 332

#167 Chronic Pancreatitis

with Focal Inflammatory Mass 334

#178 Schwannoma . . . . . . . . . . 362

#179 Granulomatous Disease

#182 Complications of Pancreatic Transplantation (1):

Pancreatitis . . . . . . . . . . 370

#183 Complications of Pancreatic Transplantation (2): Other Complications . . . . . . . . . 372

#184 Complications of Partial

Pancreatic Resection . . . . . . 374

6.4Malignant Tumors and Tumors

#189 Variant Morphology of Adenocarcinoma (2): Necrosis/Cystic

Degeneration . . . . . . . . . 384