MRI of Pancreatitis and Its Complications: Part 2, Chronic Pancreatitis
Frank H. Miller1,
Ana L. Keppke1,
Anubha Wadhwa1,
John N. Ly2,
Kshitij Dalal1 and
Vilim-Alan Kamler1
1 Department of Radiology, Northwestern Memorial Hospital, Northwestern
University, The Feinberg School of Medicine, 676 N Saint Clair St., Ste. 800,
Chicago, IL 60611.
2 Department of Radiology, Saint Vincent Medical Imaging, 438 Victoria St.,
Level 5, Darling Hurst, NSW 2010, Australia.
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Fig. 1A. —24-year-old woman with small pancreatic duct stone causing
duct obstruction and segmental pancreatitis. Axial T2-weighted HASTE image
shows slightly increased signal intensity of pancreatic tail (arrow)
with mild dilatation of pancreatic duct.
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Fig. 1B. —24-year-old woman with small pancreatic duct stone causing
duct obstruction and segmental pancreatitis. Axial T1-weighted fat-suppressed
spoiled gradient-echo image shows abnormal low signal intensity of pancreatic
tail (arrow) while remainder of pancreas has normal bright signal
intensity.
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Fig. 1C. —24-year-old woman with small pancreatic duct stone causing
duct obstruction and segmental pancreatitis. Axial enhanced T1-weighted
fat-suppressed spoiled gradient-echo image obtained during arterial phase
shows delayed enhancement of pancreatic tail (arrow) relative to
normal pancreas due to fibrosis. Patient later developed atrophic changes in
this area that led to resection of pancreatic tail.
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Fig. 1D. —24-year-old woman with small pancreatic duct stone causing
duct obstruction and segmental pancreatitis. Contrast-enhanced CT scan shows
punctate high-density focus (arrow) in pancreatic duct representing
small intraductal stone. This example illustrates the advantage of CT in
showing tiny intraductal stone that was not seen on MRI. It, however, also
illustrates the advantage of MRI in showing changes of signal intensity
associated with chronic pancreatitis that are not visible on CT.
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Fig. 2A. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial T1-weighted fat-suppressed spoiled gradient-echo image
shows atrophy of pancreatic parenchyma and irregular dilatation of main
pancreatic duct (arrows), changes suggestive of chronic pancreatitis.
Calcifications are not as well seen on MRI as on CT.
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Fig. 2B. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo
image obtained during arterial phase shows diffusely decreased pancreatic
enhancement relative to marked enhancement seen normally. This decreased
enhancement relates to fibrosis due to chronic pancreatitis. Dilated
pancreatic duct (arrows) is visualized more clearly after contrast
administration.
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Fig. 2C. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo
image obtained during venous phase shows delayed enhancement of pancreas from
chronic pancreatitis with pancreas becoming brighter than normal pancreas,
which enhances rapidly and washes out.
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Fig. 3A. —55-year-old woman with abdominal pain, weight loss, and
history of pancreatitis. Coronal T2-weighted thick-slab RARE image shows
beaded pancreatic duct and pseudocyst (arrow) from chronic
pancreatitis. Stomach is distended and filled with fluid.
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Fig. 3B. —55-year-old woman with abdominal pain, weight loss, and
history of pancreatitis. ERCP image shows dilated pancreatic duct in
communication with pseudocyst.
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Fig. 4. —61-year-old woman with history of chronic pancreatitis.
Coronal T2-weighted HASTE image shows high-signal-intensity dilated main
pancreatic duct with multiple dilated side branches (arrows). These
findings constitute important early features of chronic pancreatitis.
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Fig. 5. —61-year-old woman with left lower quadrant pain and abnormal
findings on CT scan (not shown) that revealed cystic lesion of pancreatic
tail. Coronal T2-weighted thick-slab RARE image shows mild dilatation of side
branches (arrows) of pancreatic duct (PD). Main pancreatic duct and
common bile duct (CBD) have normal caliber. Multiseptated pseudocyst (P) is
seen in region of pancreatic tail.
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Fig. 6. —53-year-old woman with history of cholecystectomy who
presented with jaundice, abnormal results on liver function tests, and
pancreas divisum. Axial T2-weighted image shows noncommunicating main
pancreatic duct (straight arrow) and accessory duct (curved
arrow) draining separately into duodenum.
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Fig. 7. —62-year-old woman with history of chronic pancreatitis and
pseudocysts. Coronal T2-weighted thick-slab RARE image shows stricture
(straight arrow) of pancreatic duct at level of pancreatic head.
Upstream pancreatic duct is dilated and irregular, and there is mild
dilatation of side branches. Note diverticulum (curved arrow) arising
from duodenum. Common bile duct is minimally prominent.
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Fig. 8. —69-year-old man with chronic pancreatitis. Axial T2-weighted
HASTE image shows irregular dilated main pancreatic duct and side branches
giving chain-of-lakes appearance. Note atrophic changes in pancreas and
signal-void areas (arrows) related to calcifications from chronic
pancreatitis.
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Fig. 9A. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial contrast-enhanced CT scan shows multiple calcifications
in pancreatic head. It is difficult to determine that a stone is in pancreatic
duct. Calcifications are seen commonly in chronic alcohol-related
pancreatitis, as in this patient.
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Fig. 9B. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial T2-weighted HASTE image shows stone (arrow) in
main pancreatic duct delineated by high-signal-intensity fluid.
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Fig. 10. —45-year-old woman with history of abdominal pain. Coronal
T2-weighted HASTE image shows pancreatic duct stone (straight arrow)
and gallstone (curved arrow). GB = gallbladder, CBD = common bile
duct, PD = pancreatic duct, DUOD = duodenum.
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Fig. 11A. —52-year-old man with history of recurrent pancreatitis. Axial
T2-weighted HASTE image shows large thick-walled multiloculated cystic
collection located primarily in lesser sac, representing pseudocyst (P). It
does not communicate with pancreatic duct.
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Fig. 11B. —52-year-old man with history of recurrent pancreatitis. Axial
T1-weighted fat-suppressed spoiled gradient-echo image shows
high-signal-intensity fluid within pseudocyst, suggestive of complicated
pseudocyst (P). Internal consistency of pseudocysts may be altered because of
presence of proteinaceous material, hemorrhage, or infection, and it may
require prompt drainage.
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Fig. 12. —55-year-old woman with abdominal pain, weight loss, and
history of pancreatitis. Axial T2-weighted HASTE image shows
high-signal-intensity pseudocyst (P) in pancreatic head with dilated and
irregular pancreatic duct. Pseudocyst can be seen communicating with main
pancreatic duct (arrow).
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Fig. 13. —59-year-old man with history of acute and chronic
pancreatitis. Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo
image obtained during venous phase shows multiple pseudocysts (P) lying
anterior and superior to pancreatic head and body genu. Pancreas is
hyperintense due to delayed enhancement. GB = gallbladder.
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Fig. 14A. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo
image obtained during venous phase shows chronic occlusion of portal vein with
collaterals (arrow): cavernous transformation of portal vein.
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Fig. 14B. —46-year-old man with history of chronic pancreatitis due to
alcohol abuse. Axial enhanced T1-weighted fat-suppressed spoiled gradient-echo
image obtained during venous phase shows collateral vessels (arrows),
which is suggestive of splenic vein occlusion. Pancreatitis with pseudocyst
caused splenic and portal vein thrombosis.
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Fig. 15. —59-year-old man with history of chronic pancreatitis. MR
image was obtained to evaluate biliary tract and complex pseudocysts seen on
prior CT scan (not shown). Coronal T2-weighted thick-slab RARE image shows
dilated common bile duct with funnel-shaped narrowing (arrowhead) due
to stricture in common bile duct. Pancreatic duct is dilated and contains
calculus (arrow) at pancreatic head level. Also seen are multiple
pseudocysts (P) extending both superior and inferior to pancreas. GB =
gallbladder.
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Fig. 16A. —58-year-old woman with breast cancer and chronic pancreatitis
related to alcohol abuse. Patient had 50-lb (23-kg) weight loss. ERCP image
(not shown) revealed stone in pancreatic duct, which was removed. Fine-needle
aspiration was suggestive of adenocarcinoma. Whipple procedure indicated
chronic pancreatitis without cancer. Axial T1 fat-suppressed spoiled
gradient-echo image shows low-signal-intensity pancreas due to chronic
pancreatitis.
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Fig. 16B. —58-year-old woman with breast cancer and chronic pancreatitis
related to alcohol abuse. Patient had 50-lb (23-kg) weight loss. ERCP image
(not shown) revealed stone in pancreatic duct, which was removed. Fine-needle
aspiration was suggestive of adenocarcinoma. Whipple procedure indicated
chronic pancreatitis without cancer. Axial enhanced T1-weighted fat-suppressed
spoiled gradient-echo image obtained during arterial phase shows diffusely
decreased enhancement of pancreas due to chronic pancreatitis. Note dilated
pancreatic duct.
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Fig. 16C. —58-year-old woman with breast cancer and chronic pancreatitis
related to alcohol abuse. Patient had 50-lb (23-kg) weight loss. ERCP image
(not shown) revealed stone in pancreatic duct, which was removed. Fine-needle
aspiration was suggestive of adenocarcinoma. Whipple procedure indicated
chronic pancreatitis without cancer. Axial T2-weighted HASTE image shows
markedly dilated main pancreatic duct (arrow) penetrating through
pancreas with chronic inflammatory and fibrotic changes: "duct
penetrating sign." This finding suggests chronic pancreatitis over
adenocarcinoma.
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Fig. 17A. —71-year-old woman with weight loss due to adenocarcinoma of
pancreas with associated chronic pancreatitis. Axial contrast-enhanced CT scan
shows atrophy of pancreatic tail and duct dilatation (arrow) to level
of suspected mass, which is difficult to see.
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Fig. 17B. —71-year-old woman with weight loss due to adenocarcinoma of
pancreas with associated chronic pancreatitis. Axial T2-weighted HASTE image
shows dilatation of pancreatic duct with abrupt termination (arrow)
due to tumor. T2-weighted images are helpful in showing high-signal-intensity
fluid in pancreatic duct.
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Fig. 17C. —71-year-old woman with weight loss due to adenocarcinoma of
pancreas with associated chronic pancreatitis. Axial T1-weighted
fat-suppressed spoiled gradient-echo image shows low-signal-intensity mass
(arrowhead), measuring less than 1 cm, in pancreatic neck due to
adenocarcinoma. Note atrophy and decreased signal intensity of pancreatic tail
(curved arrow) related to associated chronic pancreatitis. Normally
high signal intensity of pancreatic head (straight arrow) is
preserved.
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Fig. 17D. —71-year-old woman with weight loss due to adenocarcinoma of
pancreas with associated chronic pancreatitis. Axial enhanced T1-weighted
fat-suppressed spoiled gradient-echo image obtained during late venous phase
shows delayed enhancement of tumor (arrowhead). This example shows
value of MRI to depict nondeforming pancreatic mass and smooth dilatation of
pancreatic duct with associated chronic pancreatitis in upstream pancreas.
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Fig. 18A. —57-year-old man with 2-year history of chronic pancreatitis
and groove pancreatitis. Contrast-enhanced CT scan shows solid mass with small
low-density cystic lesion (arrow) lying in groove between head of
pancreas (P) and duodenum (D).
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Fig. 18B. —57-year-old man with 2-year history of chronic pancreatitis
and groove pancreatitis. Axial T1-weighted fat-suppressed spoiled
gradient-echo image shows low-signal-intensity mass (arrow)
containing small cystic component and lying between high-signal-intensity
pancreatic head (P) and duodenum.
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Fig. 18C. —57-year-old man with 2-year history of chronic pancreatitis
and groove pancreatitis. Axial enhanced T1-weighted fat-suppressed spoiled
gradient-echo image obtained during arterial phase shows normal enhancement of
pancreas and duodenal wall. Heterogeneous mass (arrow) has decreased
enhancement due to fibrosis.
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Fig. 18D. —57-year-old man with 2-year history of chronic pancreatitis
and groove pancreatitis. Axial enhanced T1-weighted fat-suppressed spoiled
gradient-echo image obtained during venous phase shows delayed enhancement of
heterogeneous mass (arrow) in groove due to fibrosis. P = pancreatic
head.
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Copyright © 2004 by the American Roentgen Ray Society.
