DOI: 10.1148/rg.243035087
RadioGraphics 2004;24:677-687
© RSNA, 2004
MR Cholangiopancreatography: Improved Ductal Distention with Intravenous Morphine Administration1
Alvin C. Silva, MD,
Jeremy L. Friese, MD,
Amy K. Hara, MD and
Patrick T. Liu, MD
1 From the Department of Diagnostic Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (A.C.S., A.K.H., P.T.L.); and Department of Diagnostic Radiology, Mayo Clinic Rochester, Rochester, Minn (J.L.F.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received March 31, 2003; revision requested May 13; revision received July 31 and accepted August 5. All authors have no financial relationships to disclose. Address correspondence to A.C.S. (e-mail: silva.alvin@mayo.edu).
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Abstract
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Magnetic resonance (MR) cholangiopancreatography has proved a robust and noninvasive imaging modality for evaluating the biliary and pancreatic ducts without the use of ionizing radiation. Although MR cholangiopancreatography reliably depicts the main extrahepatic and intrahepatic bile ducts, it does not depict the segmental intrahepatic ducts unless they are dilated. The segmental ducts are difficult to visualize with MR cholangiopancreatography because of their small caliber and the limited spatial resolution and signal-to-noise ratio achievable with standard MR pulse sequences. However, visualization of the normal (ie, nondistended) biliary system is necessary for the evaluation of donor candidates for living related liver transplantation. Because of the prevalence of variant biliary anatomy, MR cholangiopancreatography is often used for preoperative evaluation of prospective liver donors. Intravenous morphine administered prior to MR cholangiopancreatography can improve image quality by causing the sphincter of Oddi to contract, which increases pressure in and distention of the biliary and pancreatic ducts. Morphine administration may also be particularly helpful for the evaluation of patients with primary sclerosing cholangitis, malignant neoplasms such as cholangiocarcinoma, or cystic and non–organ-deforming benign pancreatic neoplasms.
© RSNA, 2004
Index Terms: Bile ducts, MR, 76.121411, 76.92 • Liver, transplantation, 76.92, 774.92 • Magnetic resonance (MR), cholangiopancreatography, 76.121411, 774.121411, 76.12143, 774.12143 • Neoplasms, MR, 76.321, 774.312, 774.321 • Pancreas, MR, 774.121411, 774.12143, 774.92
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- Describe the effects of morphine on the sphincter of Oddi and the pancreaticobiliary system.
- Discuss the utility of morphine-augmented MR cholangiopancreatography for evaluation of pathologic conditions and planning of surgery in the biliary and pancreatic ducts.
- Identify typical and variant biliary anatomy.
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Introduction
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Magnetic resonance (MR) cholangiopancreatography is a valuable method for the evaluation of biliary disease. Since its introduction in 1991, the technique has dramatically improved, and today it can be used to obtain diagnostic images in a variety of clinical scenarios (1). MR cholangiopancreatography performed with moderately and heavily T2-weighted sequences preferentially depicts relatively static fluids with long T2 relaxation times, including the fluid present in pancreatic and biliary ducts; the technique is therefore a useful alternative to endoscopic retrograde cholangiopancreatography. Moreover, MR cholangiopancreatography is noninvasive and does not require the use of contrast material or ionizing radiation. Its primary clinical application has been in the evaluation of ductal obstructions such as occur in choledocholithiasis, iatrogenic stricture, cholangiocarcinoma, and pancreatic carcinoma.
MR cholangiopancreatography is also increasingly used for preoperative planning in donor candidates for living related liver transplantation. MR imaging of the nondistended biliary system, however, generally provides inadequate depiction of ductal anatomy for surgical planning. In addition, artifacts may occur at conventional MR cholangiopancreatography that may simulate various diseases. These include artifacts due to pulsatile compression by the right hepatic or gastroduodenal arteries, signal voids due to bile flow, and effects of the cystic duct, any of which may lead to a false-positive finding of a lesion (2–4).
Morphine sulfate is an opioid analgesic that has been used extensively in clinical medicine. In addition to its primary analgesic effects, this drug induces contraction of the sphincter of Oddi (5–11). The resultant obstruction to fluid outflow at the ampulla of Vater produces increased intraluminal pressure and, thereby, increased distention of the biliary and pancreatic ducts. This effect of the drug has led to its use at scintigraphy for diagnosis of cholecystitis, but, to our knowledge, not yet at imaging with other modalities. In this article, we review the anatomy of the biliary system and the physiologic effect of morphine on the pancreaticobiliary ducts. We demonstrate the use of morphine for improving visualization of typical and variant ductal anatomy, and we discuss various clinical applications for morphine-augmented MR cholangiopancreatography, including evaluation of donor candidates for living related liver transplantation, cancer treatment planning, and diagnosis of ductal obstruction and disease.
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Anatomy of the Biliary System
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In the 4th week of human gestation, a hepatic diverticulum develops from the ventral foregut that eventually will become the bilobed liver and gallbladder, and a solid stalk connects the developing liver to the descending duodenum. By 3 months of gestation, the entire biliary system and gallbladder have canalized to form a continuous lumen. From hepatocytes, biliary canaliculi form biliary ductules, which in turn unite to form segmental bile ducts. The typical biliary anatomy (Fig 1) consists of anterior and posterior segmental right hepatic ducts that fuse to form the main right hepatic duct. A variable number of segmental left hepatic ducts likewise join to form the main left hepatic duct. The main right and left hepatic ducts typically converge approximately 1 cm from the liver margin to form the common hepatic duct. The transition from the common hepatic duct to the common bile duct occurs at the site of cystic ductal insertion, which is typically midway between the convergence of the right and left hepatic ducts and the retroduodenal common hepatic duct. The common bile duct consists of supraduodenal, retroduodenal, pancreatic, and intraduodenal segments (12–14). The sphincter of Oddi is a muscle that typically encircles the terminal portions of the biliary and pancreatic ducts and their common channel (15–17) (Fig 2). There remains some debate as to whether the sphincter of Oddi is a single continuous structure or consists of two or three separate structures.
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Figure 1. Diagram of the normal biliary anatomy. Anterior (RAD) and posterior (RPD) segmental right hepatic ducts join to form the main right hepatic duct (R), which may vary in length. The right and left (L) main intrahepatic ducts become extrahepatic proximal to their confluence in the common hepatic duct (CHD), which joins with the cystic duct (C) to form the common bile duct (CBD). Biliary and pancreatic duct (PD) flow is regulated by the sphincter of Oddi (SO).
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There is great variability in the anatomy of the hepatic biliary system (Fig 3), gallbladder, and pancreatic ducts. In approximately 30% of the general population, two segmental ducts drain the right hepatic lobe and separately join with the left hepatic duct, cystic duct, or common bile duct (14). Rarely, the cystic duct is absent or duplicated. The length and course of the cystic duct are frequently anomalous, with the clinically most important anomaly involving the opening of the cystic duct into the right hepatic duct (13). There is less variability in the common bile duct, except in size (12). In 5%–15% of the population, the common bile duct and main pancreatic duct enter the duodenum separately (17,18).
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Figure 3. Schematics of right hepatic duct anatomic variants (red lines) show typical anatomy (A), found in 58% of the general population; aberrant drainage of the posterior segmental right hepatic duct into the left hepatic duct (B), found in 13%-19%; trifurcation anomaly (C; Fig 7), found in 11%; distal confluence of the posterior and anterior segmental right hepatic ducts (D; Fig 8), found in 12%; direct confluence of the posterior segmental right hepatic duct with the common hepatic duct (E; Fig 5), found in 5%; distal confluence of the posterior and anterior segmental right hepatic ducts, with a separate accessory right duct draining into the left hepatic duct (F; Fig 9), rarely found; and quadriform anomaly (G; Fig 10), also rarely found.
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Profile of Morphine Sulfate
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Morphine sulfate is a central nervous system depressant that activates opiate receptors, mimicking the effects of enkephalins and other endorphins (19). It is used as an analgesic for moderate to severe pain. Studies have demonstrated that narcotics in general, and morphine sulfate in particular, stimulate smooth muscle activity and may increase the frequency and amplitude of basal contractions of the sphincter of Oddi, thereby increasing the resting biliary pressure by as much as 10 times (10,12). An intravenous dose of 0.04 mg morphine sulfate per kilogram of body weight is often used at radionuclide imaging with technetium 99m dimethyl iminodiacetic acid, to stimulate sphincteric contraction and distend the biliary and cystic ducts so as to enable differentiation of acute from chronic cholecystitis (20).
Adverse effects of morphine sulfate may include miosis, nausea, vomiting, intestinal ileus, and respiratory depression, but such effects have not generally been observed with the low dose administered at radionuclide imaging. The half-life of this drug in the circulatory system is approximately 2 hours, and there is little danger of its interaction with other drugs (11). Overall, morphine sulfate is safe and effective when used with careful consideration of the patient’s clinical status.
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MR Cholangiopancreatographic Technique
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In 2001, we modified the MR cholangiopancreatographic protocol used at our institution for living related liver donor evaluations to include delayed imaging after an intravenous injection of 0.04 mg morphine sulfate per kilogram of body weight. To determine the optimal imaging delay for maximal biliary distention, we performed repeat MR cholangiopancreatography in five patients before and at 0, 10, 20, and 40 minutes after morphine injection and compared the resultant MR cholangiograms. From this small sample, we determined the optimal delay to be 10–20 minutes.
All MR cholangiograms in this article were obtained by using a 1.5-T whole-body imager (Gyroscan ACS-NT; Philips Medical Systems, Best, the Netherlands) equipped with a high-slew-gradient system (PowerTrak 6000; Philips) and software (release 8.1; Philips), and a four-element phased-array coil. MR cholangiopancreatography before morphine injection was performed as follows: T2-weighted single-shot turbo spin-echo pulse sequences were applied during patient breath holding to obtain thick-slab images in the coronal and coronal-oblique planes (repetition time msec/echo time msec, 5,000/650; flip angle, 90°; 256 x 256 matrix reconstructed with zero-fill interpolation to 1,024 x 1,024; 320 x 320-mm field of view; 55-mm slab thickness) and thin-section images in the coronal plane (2,349/180; flip angle, 90°; 256 x 192 matrix reconstructed with zero-fill interpolation to 512 x 512; 5-mm section thickness). A T2-weighted long-echo-time pulse sequence (1,036/180; flip angle, 90°; 256 x 204 matrix; 60 sections, each 4 mm thick, with a 0.4-mm gap between sections) was applied without patient breath holding to obtain axial thin-section images of the entire biliary tree. Afterward, morphine was administered with a slow intravenous injection (1–2 minutes). Routine postgadolinium T1-weighted sequences were then performed per our abdominal MR protocol. The premorphine MR cholangiopancreatographic sequences were repeated 15–20 minutes after morphine injection. Non–breath-hold three-dimensional MR cholangiopancreatography with a turbo spin-echo pulse sequence (1,500/450; flip angle, 90°; 256 x 179 matrix reconstructed to 512; 320 x 320-mm field of view; 70 sections, each 1 mm thick) also was performed after morphine injection.
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Clinical Applications
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MR cholangiopancreatography has proven utility for the diagnosis of various pancreatic and biliary conditions in which ductal obstruction is the most common indicator of disease. The method has high sensitivity and specificity for the depiction of choledocholithiasis (21–23) and localization of obstruction. MR cholangiopancreatography also has important uses in the identification of biliary and pancreatic masses, benign and malignant ductal strictures, and typical and variant native anatomy (23–27). The administration of intravenous morphine at MR cholangiopancreatography increases ductal distention and may improve the visualization of small segmental intrahepatic biliary and cystic ducts, as well as that of accessory ducts and main pancreatic ducts (Figs 4, 5). In addition, artifacts that may be caused by pulsation in the hepatic artery can be avoided with the increased distention from morphine injection (Figs 6, 7).
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Figure 4a. Coronal thick-slab images from MR cholangiopancreatography show a normal cystic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the cystic duct (long arrow), the left hepatic duct (arrowhead), and an accessory pancreatic duct (short arrows) after morphine administration.
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Figure 4b. Coronal thick-slab images from MR cholangiopancreatography show a normal cystic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the cystic duct (long arrow), the left hepatic duct (arrowhead), and an accessory pancreatic duct (short arrows) after morphine administration.
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Figure 5a. Axial thin-section images from non-breath-hold MR cholangiopancreatography with a T2-weighted single-shot fast spin-echo sequence show a normal accessory pancreatic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the minor pancreatic duct of Santorini (arrow) after morphine administration.
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Figure 5b. Axial thin-section images from non-breath-hold MR cholangiopancreatography with a T2-weighted single-shot fast spin-echo sequence show a normal accessory pancreatic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the minor pancreatic duct of Santorini (arrow) after morphine administration.
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Figure 6a. Pulsatility artifact and tumor in a patient. (a) Three-dimensional image from non-breath-hold MR cholangiopancreatography before morphine injection shows signal loss (arrows) at the proximal common hepatic duct, caused by pulsation from the adjacent hepatic artery. (b) Three-dimensional image from non-breath-hold MR cholangiopancreatography after morphine injection shows improved distention in the duct, as well as a cystic pancreatic mass (arrowheads). The mass was diagnosed after surgical resection as an intraductal papillary mucinous tumor.
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Figure 6b. Pulsatility artifact and tumor in a patient. (a) Three-dimensional image from non-breath-hold MR cholangiopancreatography before morphine injection shows signal loss (arrows) at the proximal common hepatic duct, caused by pulsation from the adjacent hepatic artery. (b) Three-dimensional image from non-breath-hold MR cholangiopancreatography after morphine injection shows improved distention in the duct, as well as a cystic pancreatic mass (arrowheads). The mass was diagnosed after surgical resection as an intraductal papillary mucinous tumor.
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Figure 7a. Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).
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Figure 7b. Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).
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Figure 7c. Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).
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Evaluation of Prospective Liver Donors
MR cholangiopancreatography has become an essential component in the comprehensive evaluation of prospective donors for living right-lobe liver transplantation (28–31). Accurate depiction of biliary anatomy is required because variant anatomy can affect donor eligibility or increase the complexity of the surgical procedure. The most common anatomic variant, which occurs in approximately 19% of patients, involves ectopic location of the posterior segmental right hepatic duct (32). Anomalous drainage of the posterior segmental right hepatic duct into the left hepatic duct or the intrahepatic ductal confluence (trifurcation anomaly) may preclude right-lobe hepatectomy (Fig 8). Conversely, the distal confluence of the posterior and anterior segmental right hepatic ducts is favorable for surgery (Fig 9). Although less common, accessory right and left hepatic ducts that drain contralaterally can also have a negative effect at surgery (Fig 10). Other rare and complex variants also may be observed (Fig 11). Despite recent technical advances in MR imagers and protocols, these small intrahepatic ducts are inconsistently depicted when in their normal (ie, nondistended) state. The use of morphine during MR cholangiopancreatography at our institution has been helpful in this regard.
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Figure 8a. Trifurcation anomaly in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows a short right hepatic duct (arrow) in a location suggestive of trifurcation anomaly, but depiction is inadequate for a definitive determination. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows a posterior segmental right hepatic duct (arrow) that drains into the confluence of the anterior segmental right duct and the left hepatic ducts (ie, trifurcation anomaly). Note the improved distention and visualization of the pancreatic duct (PD) and segmental left hepatic duct (arrowhead).
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Figure 8b. Trifurcation anomaly in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows a short right hepatic duct (arrow) in a location suggestive of trifurcation anomaly, but depiction is inadequate for a definitive determination. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows a posterior segmental right hepatic duct (arrow) that drains into the confluence of the anterior segmental right duct and the left hepatic ducts (ie, trifurcation anomaly). Note the improved distention and visualization of the pancreatic duct (PD) and segmental left hepatic duct (arrowhead).
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Figure 9a. Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).
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Figure 9b. Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).
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Figure 9c. Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).
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Figure 10a. Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.
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Figure 10b. Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.
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Figure 10c. Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.
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Figure 11a. Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection suggests but does not clearly depict quadriform anomaly. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly shows the confluence of the posterior (RPD) and anterior (RAD) segmental right hepatic ducts with the main (L) and segment IV (IV) left hepatic ducts, and faintly depicts an accessory anterior segmental right duct (arrow). The aberrant biliary anatomy in this patient precluded donor hepatectomy.
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Figure 11b. Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection suggests but does not clearly depict quadriform anomaly. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly shows the confluence of the posterior (RPD) and anterior (RAD) segmental right hepatic ducts with the main (L) and segment IV (IV) left hepatic ducts, and faintly depicts an accessory anterior segmental right duct (arrow). The aberrant biliary anatomy in this patient precluded donor hepatectomy.
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Cancer Staging and Treatment Planning
Cholangiocarcinomas are adenocarcinomas that arise from bile duct epithelium. The long-term survival of patients with cholangiocarcinoma depends on the complete surgical resection of the lesion. Accurate preoperative staging is crucial for defining patient eligibility for surgery, as well as for planning and successful performance of the procedure. Conventional MR cholangiopancreatography has been a helpful adjunct for evaluating the true longitudinal extent of tumors that obstruct the retrograde flow of contrast material at endoscopic retrograde cholangiopancreatography (33). A hilar tumor (ie, Klatskin tumor) is considered unresectable for cure if there is evidence of extensive or multifocal disease proximal to the segmental intrahepatic ducts (Fig 12). Without the use of morphine, however, it may be difficult to visualize these secondary ducts at MR cholangiopancreatography.
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Figure 12a. Cholangiocarcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregular areas of partial obstruction in the left hepatic duct (Lt) that indicate a mass, but relative patency in the right hepatic duct (Rt). (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows that the mass also involves the right hepatic duct (arrow) downstream from the confluence of the posterior (RPD) and anterior (RAD) segmental ducts, a finding that led to an upgrade in classification of the lesion from Bismuth type IIIb to type IV cholangiocarcinoma and a change in treatment planning from a standard left hepatectomy to an extended left hepatectomy.
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Figure 12b. Cholangiocarcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregular areas of partial obstruction in the left hepatic duct (Lt) that indicate a mass, but relative patency in the right hepatic duct (Rt). (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows that the mass also involves the right hepatic duct (arrow) downstream from the confluence of the posterior (RPD) and anterior (RAD) segmental ducts, a finding that led to an upgrade in classification of the lesion from Bismuth type IIIb to type IV cholangiocarcinoma and a change in treatment planning from a standard left hepatectomy to an extended left hepatectomy.
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Diagnosis of Cystic Pancreatic Lesions
Intraductal papillary mucinous tumors of the pancreas may be visually differentiated from other cystic lesions if direct communication of the tumor with the pancreatic duct is demonstrated and if filling defects attributable to mucin or tumor are observed (34). Morphine-augmented MR cholangiopancreatography may be useful for diagnosing such tumors in selected cases. This method also may provide better depiction of proximal non–organ-deforming obstructive masses (Fig 13). Although we did not perform MR cholangiopancreatography with morphine injection in patients suspected of having early-stage chronic pancreatitis, the method may be useful for identifying abnormal side-branch pancreatic ductal dilatation in these patients.
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Figure 13a. Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.
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Figure 13b. Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.
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Figure 13c. Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.
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Conclusions
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MR cholangiopancreatography is a valuable method for noninvasive clinical evaluation of the biliary and pancreatic ductal system. The additional use of intravenous morphine may be helpful in the preoperative evaluation of the normal (ie, nondistended) system, as well as of certain pathologic conditions of the ducts. Morphine injection provides increased distention and improved depiction beyond the levels achievable with the standard MR pulse sequences and thus enables the avoidance of pitfalls inherent in conventional MR cholangiopancreatography.
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Acknowledgments
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The authors gratefully thank Chelsea D. Johnson, Paul J. Weishaar, Cynthia M. Rippley, and Bonnie L. Shimek for their expert assistance in image preparation.
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References
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Abstract
LEARNING OBJECTIVES
