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DOI: 10.1148/rg.263055077
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Dynamic Secretin-enhanced MR Cholangiopancreatography1

M. Fatih Akisik, MD, Kumaresan Sandrasegaran, MD, Alex A. Aisen, MD, Dean D. T. Maglinte, MD, Stuart Sherman, MD and Glen A. Lehman, MD

1 From the Department of Radiology (M.F.A., K.S., A.A.A., D.D.T.M.) and Division of Gastroenterology/Hepatology (S.S., G.A.L.), Indiana University School of Medicine, UH 0279, 550 N University Blvd, Indianapolis, IN 46202-5253. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received April 4, 2005; revision requested May 24 and received July 15; accepted July 29. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  A comparison of MR cholangiopancreatographic images shows the value of oral ferumoxsil. (a) Image obtained without secretin and ferumoxsil shows high signal intensity in the fluid-distended stomach (arrow) and small bowel (arrowhead) that obscures the pancreatic ducts. (b) Image obtained with the use of oral ferumoxsil (Gastromark; Mallinckrodt) as a negative contrast material shows a near absence of signal from the stomach and duodenum, a condition that allows better visualization of the pancreatic (arrow) and biliary ducts.

 

Figure 1
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  		Figure 1b.  A comparison of MR cholangiopancreatographic images shows the value of oral ferumoxsil. (a) Image obtained without secretin and ferumoxsil shows high signal intensity in the fluid-distended stomach (arrow) and small bowel (arrowhead) that obscures the pancreatic ducts. (b) Image obtained with the use of oral ferumoxsil (Gastromark; Mallinckrodt) as a negative contrast material shows a near absence of signal from the stomach and duodenum, a condition that allows better visualization of the pancreatic (arrow) and biliary ducts.

 

Figure 2
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  		Figure 2a.  Secretin-enhanced MR cholangiopancreatographic images obtained at 0 (a), 3 (b), 7 (c), and 10 (d) minutes after intravenous secretin injection. The pancreatic duct (arrowhead) is most visible at 5–7 minutes, when maximum response to secretin occurs. Note the progressive filling of the duodenum with high-signal-intensity fluid (arrows). The exocrine response to secretin can be semiquantitatively determined from the amount of high signal intensity in the duodenum after secretin injection.

 

Figure 2
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  		Figure 2b.  Secretin-enhanced MR cholangiopancreatographic images obtained at 0 (a), 3 (b), 7 (c), and 10 (d) minutes after intravenous secretin injection. The pancreatic duct (arrowhead) is most visible at 5–7 minutes, when maximum response to secretin occurs. Note the progressive filling of the duodenum with high-signal-intensity fluid (arrows). The exocrine response to secretin can be semiquantitatively determined from the amount of high signal intensity in the duodenum after secretin injection.

 

Figure 2
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  		Figure 2c.  Secretin-enhanced MR cholangiopancreatographic images obtained at 0 (a), 3 (b), 7 (c), and 10 (d) minutes after intravenous secretin injection. The pancreatic duct (arrowhead) is most visible at 5–7 minutes, when maximum response to secretin occurs. Note the progressive filling of the duodenum with high-signal-intensity fluid (arrows). The exocrine response to secretin can be semiquantitatively determined from the amount of high signal intensity in the duodenum after secretin injection.

 

Figure 2
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  		Figure 2d.  Secretin-enhanced MR cholangiopancreatographic images obtained at 0 (a), 3 (b), 7 (c), and 10 (d) minutes after intravenous secretin injection. The pancreatic duct (arrowhead) is most visible at 5–7 minutes, when maximum response to secretin occurs. Note the progressive filling of the duodenum with high-signal-intensity fluid (arrows). The exocrine response to secretin can be semiquantitatively determined from the amount of high signal intensity in the duodenum after secretin injection.

 

Figure 3
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  		Figure 3.  Diagrams show normal and abnormal variants of ductal anatomy. In a normal variant (A), the main pancreatic duct drains via the major papilla, and a patent accessory duct drains via the minor papilla. In the first abnormal variant (B), the accessory duct is not patent at the minor papilla. In incomplete pancreas divisum (C), a filamentous ductal branch connects the ventral and dorsal pancreas. In another variant of pancreas divisum (D), the entire pancreatic ductal system drains via the minor papilla. In typical pancreas divisum (E), a small ventral duct drains half of the pancreas via the major papilla, and a large dorsal duct drains the other half via the minor papilla. In reversed pancreas divisum (F), the accessory ductal system drains a small portion of pancreatic parenchyma via the minor papilla, and the main pancreatic duct drains the major part of the pancreas via the major papilla. (Reproduced with permission from the Office of Visual Media, Indiana University School of Medicine.)

 

Figure 4
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  		Figure 4.  Incomplete pancreas divisum. Secretin-enhanced MR image shows the continuity of the main duct (curved white arrow) with the dorsal duct (black arrowhead) and of the ventral duct (black arrow) with the distal common bile duct (straight white arrow), features suggestive of pancreas divisum. However, a tenuous connection (white arrowhead) between the ventral and dorsal duct systems indicates incomplete division.

 

Figure 5
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  		Figure 5a.  Complete pancreas divisum. (a) Presecretin MR image does not clearly depict the main pancreatic duct. (b) MR image obtained 5 minutes after secretin injection clearly shows the main duct in the body of the pancreas (white arrow) and the dorsal duct (arrowhead) in continuity with the main duct. Note that the main duct does not join with the distal common bile duct (black arrow), a finding that indicates complete pancreas divisum. (c) Corresponding ERCP image obtained after injection via the minor papilla helps confirm pancreas divisum and shows a santorinicele (arrow) at the minor papilla.

 

Figure 5
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  		Figure 5b.  Complete pancreas divisum. (a) Presecretin MR image does not clearly depict the main pancreatic duct. (b) MR image obtained 5 minutes after secretin injection clearly shows the main duct in the body of the pancreas (white arrow) and the dorsal duct (arrowhead) in continuity with the main duct. Note that the main duct does not join with the distal common bile duct (black arrow), a finding that indicates complete pancreas divisum. (c) Corresponding ERCP image obtained after injection via the minor papilla helps confirm pancreas divisum and shows a santorinicele (arrow) at the minor papilla.

 

Figure 5
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  		Figure 5c.  Complete pancreas divisum. (a) Presecretin MR image does not clearly depict the main pancreatic duct. (b) MR image obtained 5 minutes after secretin injection clearly shows the main duct in the body of the pancreas (white arrow) and the dorsal duct (arrowhead) in continuity with the main duct. Note that the main duct does not join with the distal common bile duct (black arrow), a finding that indicates complete pancreas divisum. (c) Corresponding ERCP image obtained after injection via the minor papilla helps confirm pancreas divisum and shows a santorinicele (arrow) at the minor papilla.

 

Figure 6
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  		Figure 6a.  Santorinicele. (a) Presecretin MR image shows possible mild enlargement of the distal tip of the dorsal duct (arrowhead) and the presence of pancreas divisum. (b) Postsecretin MR image shows increased signal intensity in the duodenum from the exocrine response to secretin. The fusiform enlargement (santorinicele) of the tip of the dorsal duct also is more prominent (arrows).

 

Figure 6
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  		Figure 6b.  Santorinicele. (a) Presecretin MR image shows possible mild enlargement of the distal tip of the dorsal duct (arrowhead) and the presence of pancreas divisum. (b) Postsecretin MR image shows increased signal intensity in the duodenum from the exocrine response to secretin. The fusiform enlargement (santorinicele) of the tip of the dorsal duct also is more prominent (arrows).

 

Figure 7
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  		Figure 7a.  Disconnected pancreatic duct syndrome. (a) Presecretin MR image shows a lack of continuity of the main pancreatic duct (arrow) in the region of the pancreatic neck and proximal body. (b) Postsecretin MR image demonstrates the absence of duct connection (arrowhead) and lack of stenosis. Note the curved drain catheter at the site of a peripancreatic fluid collection (arrow). (c) ERCP image helps confirm disruption of the main duct in the pancreatic head (arrowhead). The patient subsequently underwent pancreatojejunostomy and percutaneous drain placement.

 

Figure 7
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  		Figure 7b.  Disconnected pancreatic duct syndrome. (a) Presecretin MR image shows a lack of continuity of the main pancreatic duct (arrow) in the region of the pancreatic neck and proximal body. (b) Postsecretin MR image demonstrates the absence of duct connection (arrowhead) and lack of stenosis. Note the curved drain catheter at the site of a peripancreatic fluid collection (arrow). (c) ERCP image helps confirm disruption of the main duct in the pancreatic head (arrowhead). The patient subsequently underwent pancreatojejunostomy and percutaneous drain placement.

 

Figure 7
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  		Figure 7c.  Disconnected pancreatic duct syndrome. (a) Presecretin MR image shows a lack of continuity of the main pancreatic duct (arrow) in the region of the pancreatic neck and proximal body. (b) Postsecretin MR image demonstrates the absence of duct connection (arrowhead) and lack of stenosis. Note the curved drain catheter at the site of a peripancreatic fluid collection (arrow). (c) ERCP image helps confirm disruption of the main duct in the pancreatic head (arrowhead). The patient subsequently underwent pancreatojejunostomy and percutaneous drain placement.

 

Figure 8
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  		Figure 8a.  Pancreatic duct stenosis following acute pancreatitis. (a) Presecretin MR image shows discontinuity of the main duct at the level of the pancreatic neck (white arrowhead), an adjacent high-signal-intensity fluid collection (black arrowhead), and diffuse ascites (arrow). (b) MR image obtained 7 minutes after secretin injection shows stenosis of the main pancreatic duct in the pancreatic neck (white arrowhead) and diffuse ascites (arrow). The fluid collection adjacent to the pancreatic neck (black arrowhead) appears brighter than on the presecretin image, a feature suggestive of a connection to the duct. (c) ERCP image helps confirm the presence of stenosis (white arrowhead) and absence of disconnection of the duct. The fluid collection (black arrowhead) is filled with injected contrast material, which indicates disruption of the duct. The patient underwent percutaneous placement of a pancreatic stent (not shown) and did not need open surgery.

 

Figure 8
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  		Figure 8b.  Pancreatic duct stenosis following acute pancreatitis. (a) Presecretin MR image shows discontinuity of the main duct at the level of the pancreatic neck (white arrowhead), an adjacent high-signal-intensity fluid collection (black arrowhead), and diffuse ascites (arrow). (b) MR image obtained 7 minutes after secretin injection shows stenosis of the main pancreatic duct in the pancreatic neck (white arrowhead) and diffuse ascites (arrow). The fluid collection adjacent to the pancreatic neck (black arrowhead) appears brighter than on the presecretin image, a feature suggestive of a connection to the duct. (c) ERCP image helps confirm the presence of stenosis (white arrowhead) and absence of disconnection of the duct. The fluid collection (black arrowhead) is filled with injected contrast material, which indicates disruption of the duct. The patient underwent percutaneous placement of a pancreatic stent (not shown) and did not need open surgery.

 

Figure 8
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  		Figure 8c.  Pancreatic duct stenosis following acute pancreatitis. (a) Presecretin MR image shows discontinuity of the main duct at the level of the pancreatic neck (white arrowhead), an adjacent high-signal-intensity fluid collection (black arrowhead), and diffuse ascites (arrow). (b) MR image obtained 7 minutes after secretin injection shows stenosis of the main pancreatic duct in the pancreatic neck (white arrowhead) and diffuse ascites (arrow). The fluid collection adjacent to the pancreatic neck (black arrowhead) appears brighter than on the presecretin image, a feature suggestive of a connection to the duct. (c) ERCP image helps confirm the presence of stenosis (white arrowhead) and absence of disconnection of the duct. The fluid collection (black arrowhead) is filled with injected contrast material, which indicates disruption of the duct. The patient underwent percutaneous placement of a pancreatic stent (not shown) and did not need open surgery.

 

Figure 9
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  		Figure 9a.  Mild chronic pancreatitis. (a) Presecretin MR image shows no abnormality of the main pancreatic duct (arrow). (b) MR image obtained 5 minutes after secretin injection shows a normal main pancreatic duct (arrow) and dilatation of several side branches (arrowhead), findings consistent with mild (grade 3) chronic pancreatitis. (c) ERCP image shows dilatation of more than three side branches (arrowheads) without irregularity in the main duct (arrow), findings that confirm mild chronic pancreatitis.

 

Figure 9
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  		Figure 9b.  Mild chronic pancreatitis. (a) Presecretin MR image shows no abnormality of the main pancreatic duct (arrow). (b) MR image obtained 5 minutes after secretin injection shows a normal main pancreatic duct (arrow) and dilatation of several side branches (arrowhead), findings consistent with mild (grade 3) chronic pancreatitis. (c) ERCP image shows dilatation of more than three side branches (arrowheads) without irregularity in the main duct (arrow), findings that confirm mild chronic pancreatitis.

 

Figure 9
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  		Figure 9c.  Mild chronic pancreatitis. (a) Presecretin MR image shows no abnormality of the main pancreatic duct (arrow). (b) MR image obtained 5 minutes after secretin injection shows a normal main pancreatic duct (arrow) and dilatation of several side branches (arrowhead), findings consistent with mild (grade 3) chronic pancreatitis. (c) ERCP image shows dilatation of more than three side branches (arrowheads) without irregularity in the main duct (arrow), findings that confirm mild chronic pancreatitis.

 

Figure 10
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  		Figure 10a.  Severe chronic pancreatitis. (a) MR image obtained 7 minutes after secretin injection shows severe cystic dilatation of side branches in the pancreatic head and irregular dilatation of the main pancreatic duct, with low-signal-intensity filling defects (arrows). The exocrine response to secretin was poor, as demonstrated by the lack of high signal intensity in the duodenum. (b) Corresponding ERCP image helps confirm the presence of main duct filling defects consistent with calculi (arrows), findings indicative of grade 5 chronic pancreatitis. MR cholangiopancreatography has lower sensitivity than does ECRP for depicting pancreatic ductal calculi.

 

Figure 10
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  		Figure 10b.  Severe chronic pancreatitis. (a) MR image obtained 7 minutes after secretin injection shows severe cystic dilatation of side branches in the pancreatic head and irregular dilatation of the main pancreatic duct, with low-signal-intensity filling defects (arrows). The exocrine response to secretin was poor, as demonstrated by the lack of high signal intensity in the duodenum. (b) Corresponding ERCP image helps confirm the presence of main duct filling defects consistent with calculi (arrows), findings indicative of grade 5 chronic pancreatitis. MR cholangiopancreatography has lower sensitivity than does ECRP for depicting pancreatic ductal calculi.

 

Figure 11
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  		Figure 11a.  IPMT with diffuse duct disease. (a) Postsecretin MR image shows severe dilatation of the main duct in the pancreatic body and tail. The appearance of the duct resembles that in chronic pancreatitis, but dilatation is diffuse, and there is no stricture. Cystic dilatation of the main duct is visible in the head of the pancreas (white arrow). Small low-signal-intensity filling defects in the duct (arrowheads) are likely to be mucous concretions. The ventral duct (black arrow) appears normal. (b) ERCP image shows an extrusion of mucus from a bulging major papilla. There is marked dilatation of the proximal main pancreatic duct (arrowhead). The ventral duct (black arrow) appears normal. The cystic dilatation of the main duct in the pancreatic head is not as well depicted as at MR cholangiopancreatography, but a mucin-related filling defect (white arrow) that was not visible on the MR images is shown. Thin mucin is indistinguishable from pancreatic juices at MR imaging.

 

Figure 11
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  		Figure 11b.  IPMT with diffuse duct disease. (a) Postsecretin MR image shows severe dilatation of the main duct in the pancreatic body and tail. The appearance of the duct resembles that in chronic pancreatitis, but dilatation is diffuse, and there is no stricture. Cystic dilatation of the main duct is visible in the head of the pancreas (white arrow). Small low-signal-intensity filling defects in the duct (arrowheads) are likely to be mucous concretions. The ventral duct (black arrow) appears normal. (b) ERCP image shows an extrusion of mucus from a bulging major papilla. There is marked dilatation of the proximal main pancreatic duct (arrowhead). The ventral duct (black arrow) appears normal. The cystic dilatation of the main duct in the pancreatic head is not as well depicted as at MR cholangiopancreatography, but a mucin-related filling defect (white arrow) that was not visible on the MR images is shown. Thin mucin is indistinguishable from pancreatic juices at MR imaging.

 

Figure 12
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  		Figure 12a.  Recurrence of IPMT. (a) Postsecretin MR image, obtained 3 years after surgery with the Whipple procedure for IPMT, shows cystic dilatation of the duct in the remnant pancreatic tail (arrow). Low-signal-intensity foci with diameters of 2–3 mm (arrowheads), features likely due to viscid mucus, are seen within the duct. (b) Axial T2-weighted MR image shows a distended duct in the pancreatic tail (arrowheads) and the postsurgical site of pancreatojejunostomy (arrow). IPMT recurrence was found at pathologic analysis of a resected specimen. Right-sided hydronephrosis due to a ureteropelvic junction obstruction (not shown) was an incidental finding.

 

Figure 12
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  		Figure 12b.  Recurrence of IPMT. (a) Postsecretin MR image, obtained 3 years after surgery with the Whipple procedure for IPMT, shows cystic dilatation of the duct in the remnant pancreatic tail (arrow). Low-signal-intensity foci with diameters of 2–3 mm (arrowheads), features likely due to viscid mucus, are seen within the duct. (b) Axial T2-weighted MR image shows a distended duct in the pancreatic tail (arrowheads) and the postsurgical site of pancreatojejunostomy (arrow). IPMT recurrence was found at pathologic analysis of a resected specimen. Right-sided hydronephrosis due to a ureteropelvic junction obstruction (not shown) was an incidental finding.

 

Figure 13
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  		Figure 13a.  Whipple procedure. (a) Presecretin MR image obtained after Whipple surgery does not show any residual pancreatic duct. (b) MR image obtained 7 minutes after secretin injection clearly depicts the pancreatic duct in the body and tail (white arrow), mild stenosis at the junction with the roux limb of the jejunum (black arrow), and dilatation of a side branch (arrowhead). (c) ERCP image obtained with cannulation of the pancreatojejunostomy helps confirm mild distention of the main pancreatic duct and side branch.

 

Figure 13
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  		Figure 13b.  Whipple procedure. (a) Presecretin MR image obtained after Whipple surgery does not show any residual pancreatic duct. (b) MR image obtained 7 minutes after secretin injection clearly depicts the pancreatic duct in the body and tail (white arrow), mild stenosis at the junction with the roux limb of the jejunum (black arrow), and dilatation of a side branch (arrowhead). (c) ERCP image obtained with cannulation of the pancreatojejunostomy helps confirm mild distention of the main pancreatic duct and side branch.

 

Figure 13
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  		Figure 13c.  Whipple procedure. (a) Presecretin MR image obtained after Whipple surgery does not show any residual pancreatic duct. (b) MR image obtained 7 minutes after secretin injection clearly depicts the pancreatic duct in the body and tail (white arrow), mild stenosis at the junction with the roux limb of the jejunum (black arrow), and dilatation of a side branch (arrowhead). (c) ERCP image obtained with cannulation of the pancreatojejunostomy helps confirm mild distention of the main pancreatic duct and side branch.

 




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