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