acute pancreatitis ? acute and chronic pancreatitis · paraduodenal pancreatitis = groove...
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Acute and Chronic pancreatitis
why MRI ?
Why should we consider the use of MRI in acute pancreatitis ?
• Specific ductal evaluation (MPD and CBD) – Mechanical obstruction, necrosis, pancreatic leak
• Better contrast resolution (hemorrhage, fluid collections)
• Repeated imaging is often required in complicated pancreatitis
Lecesne et al. Radiology 1999
Martin DR, et al. JMRI 2003
Arvanitakis et al. Gastroenterology 2004
Gillams AR, et al. AJR 2006
MRI in acute pancreatitis
• Recurrent attacks of pancreatic pain associated with abnormal amylase and lipase in the setting of a normal morpho-functional gland
• Staging when the diagnosis is established
Recurrent attacks of pancreatitis • Rule out a mechanical factor
that may induce a transient outflow obstruction
• sphincter dysfunction / obstruction – major / minor ampullary orifice
• stricture w/o a visible mass
• IPMN
Matos et al. Radiology 1997 Matos et al. Radiographics 2002
Matos et al. Radiology 1997 Manfredi et al. Radiology 2000 Capelliez et al. Radiology 2000 Matos et al. Gastrointest Endosc 2001 Matos et al. Radiographics 2002 Hellerhoff et al. AJR 2002 Fukukura et al. Radiology 2002
Normal response to secretin stimulation
Mean caliber variation of the MPD
Diameter (mm) Time to peak Subjects Baseline Maximum Final Controls (n=10) 2.3 ± 0.5 3.1 ± 0.7 2.2 ± 0.5 < 150 s
Papillary stenosis (n=5) 3.6 ± 0.7 5.5 ± 1.8 5.2 ± 1.2* 30 s No p stenosis (n=8) 2.6 ± 0.6 3.4 ± 1.0 2.3 ± 0.4 60-240 s * p = 0.002
Matos et al. Radiology 1997
MRCP and sphincter obstruction
• Decreased pancreatic duct compliance (pdc)
• Parenchymogram (acute pancreatitis)
Abnormal flow dynamics : persistent dilatation
Matos, C. et al. Radiographics 2002
� Parenchymogram
Progressive enhancement of the pancreatic parenchyma after stimulation with secretin
Reduced duodenal filling
Matos et al. AJR 1998 Gosset et al. JOP 2004
Parenchymogram
Matos, C. et al. Radiographics 2002
Biological pancreatitis post-ERCP (< 24 h)
Parenchymogram = acute pancreatitis
�
N = 279
Abnormal Abnormal
non PD PD
ARP 11.6% 14.3% * Enzymes 16.2% 0%
Pain 7.1% 0%
Controls 2.1% 0%
* p = 0.41
Matos et al.Gastrointest Endosc 2001
baseline
BA BAB CB C
Non filled stricture = scar ( old rupture)
Acute pancreatitis
TE 45 ms TE 250 ms
�
normal abnormal
�
AIP
�
�
Acute Pancreatitis
T2-w 3D T1-w FS
Peri-pancreatic haemorrhagic infiltration: negative prognostic factor
Martin et al JMRI 2003
Gallstone pancreatitis Makary MA et al. Ann Surg 2005 : 94% sensitivity in detecting CBD stones
Acute pancreatitis: MRI vs CT
Lecesne et al Radiology 1999 • 30 P
MRCP could be an alternative to CECT for the initial staging of acute pancreatitis
Gd not nephrotoxic Better evaluation of fluid collections (hemorragic-like) No specific evaluation of the pancreatic ducts
from Matos et al. Radiographics 2002
Acute pancreatitis
Perfusion studies
T1-w arterial venous
T2-w
secretin
T1-w arterial venous
Acute pancreatitis
Arvanitakis et al. Gastroenterology, 2004
Arvanitakis et al. Gastroenterology, 2004
from Matos et al. Radiographics 2002
�Assessment of mpd disruption
Matos, C. et al. Radiographics 2002
Assessment of mpd disruption ��
Diagnosis of mpd disruption and assessment of pancreatic leak
with s-MRCP Gillams AR et al. AJR 2006;186:499-506.
• 17 p – 12/17 contributed to successful management
– 10/12 additional information was provided
T2-w
3D T1-w MPR
Acute Pancreatitis Pancreatic fluid collections role of DWI in determining presence of infection
Max ADC significantly lower in PFC with positive cultures ������������ � ����
A
DC
BA
DC
BA
DC
B
A
DC
BA
DC
BA
DC
BAA
DC
BA
DC
B
A
DC
BA
DC
B
MPR MIP
Acute Pancreatitis vascular compromise
Pseudo T acute pancreatitis MRI in acute pancreatitis ?
• MRCP w / secretin – Normal gland and ARP – To rule out central necrosis – To identify pancreatic leak
• DWI – To rule out infection
• Gd – Vascular complications
S entinel A cute P ancreatitis E vent Witcomb DC 2004
1 2 3
N
I II III IV
Non-enhanced CT in all cases
-s +s
92% specificity; 63% sensitivity ( Sai et al.2008)
�
+S
Chronic pancreatitis
Pancreatic adc
Duodenal pancreatitis
- s +s
Matos, C. et al. Radiographics 2002
+Gd
MPD stricture � � � �CE cross-sectional�
CE cross-sectional � � � � MPD stricture
-S +S�+Gd
Strategy 1
Strategy 2 MRCP T2-w DWI�
secretin�
Paraduodenal pancreatitis �
= Groove pancreatitis = cystic dystrophy of duodenal wall
• Paraduodenal pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area near the minor papilla between the head of the pancreas, the duodenal wall and the common bile duct.
• Imaging – Pure form : spares the head of the pancreas – Segmental form : the pancreas is affected – Non segmental form : secondary to chronic pancreatitis – Marked CBD dilatation should be considered as suspicious
Sheet like mass Thickened D wall Cyst like changes
Paraduodenal pancreatitis : pure form w / CBD dilatation�Paraduodenal pancreatitis : non pure form
- C + C
Paraduodenal pancreatitis
33 y-old, epgastric pain, weight loss, cbd stent for obstructive jaundice
-s
+s
AIP: main duct patterns
Double duct sign
Adenocarcinoma AI Pancreatitis
Autoimmune pancreatitis �
diffusion
gadolinium
Am J Gastroenterol 2010�
Moon, S-H et al. Gut 2008;57:1704-1712
2-week steroid trial for ΔΔ AIP and pancreatic cancer
Thank you
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