Functional MR Cholangiography: Diagnosis of Functional Abnormalities of the Gallbladder and Biliary Tree
Laura M. Fayad1,
Ihab R. Kamel1,
Donald G. Mitchell2 and
David A. Bluemke1
1 Department of Radiology and Radiological Science, Johns Hopkins Medical
Institutions, 601 N Wolfe St., JHOC 3171C, Baltimore, MD 21287.
2 Department of Radiology, Thomas Jefferson University Hospital, Philadelphia,
PA.
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Fig. 1A. —55-year-old woman with acute cholecystitis and metastatic
disease to liver. Axial single-shot fast spin-echo (SSFSE) MR cholangiography
(MRC) image (TR/TE, infinite/186) shows gallbladder (GB) wall thickening and
some distention.
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Fig. 1B. —55-year-old woman with acute cholecystitis and metastatic
disease to liver. Coronal SSFSE MRC image (infinite/190) shows calculus (C) in
GB neck.
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Fig. 1C. —55-year-old woman with acute cholecystitis and metastatic
disease to liver. Axial functional MRC image (6/2.2; flip angle, 40°) 4 hr
after mangafodipir trisodium injection shows contrast agent in common bile
duct (CBD). Calculus (C) is again noted in GB neck, but contrast agent has not
passed into GB, confirming acute cholecystitis and cystic duct obstruction by
calculus. Multiple metastatic liver lesions are present.
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Fig. 2A. —83-year-old woman with chronic cholecystitis. Precontrast
thick-slab single-shot fast spin-echo MR cholangiography (MRC) image (TR/TE,
infinite/800) shows distention of gallbladder and gallstones (arrow),
features of chronic cholecystitis. Distinction from acute cholecystitis is
difficult by conventional MRC images alone.
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Fig. 2B. —83-year-old woman with chronic cholecystitis. Early axial
mangafodipir trisodium–enhanced 3D gradient-recalled echo functional MRC
(fMRC) image (TR/TE, 6/2.2; flip angle, 40°) performed within 40 min of
injection shows contrast agent in duodenum (arrow) but no filling of
gallbladder (GB).
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Fig. 2C. —83-year-old woman with chronic cholecystitis. At 40 min,
coronal fMRC image (6/2.2; flip angle, 40°) shows contrast material in
duodenum (D) but no filling of gallbladder (GB).
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Fig. 2D. —83-year-old woman with chronic cholecystitis. Two hours
later, after injection of morphine sulfate, coronal fMRC image (6/2.2; flip
angle, 40°) shows contrast agent is present in cystic duct (CD) and
gallbladder (GB).
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Fig. 2E. —83-year-old woman with chronic cholecystitis. Axial fMRC
image (6/2.2; flip angle, 40°) shows contrast agent in gallbladder
layering on nondependent surface (arrow). It is useful to distinguish
excretion of contrast agent in gallbladder from native bile. Enhanced bile is
recently excreted bile that is not concentrated; it layers on top of
concentrated nonenhanced bile.
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Fig. 3A. —62-year-old woman with chronic cholecystitis. Axial
mangafodipir trisodium–enhanced 3D gradient-recalled echo functional MR
cholangiography (fMRC) image (TR/TE, 6/2.2; flip angle, 40°) shows
contrast agent in common bile duct (CBD) after 20 min. There is no filling of
gallbladder (GB).
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Fig. 3B. —62-year-old woman with chronic cholecystitis. Four hours
after injection of contrast material, coronal oblique
maximum-intensity-projection image obtained from reconstruction of axial fMRC
data set (6/2.2; flip angle, 40°) shows contrast agent entering cystic
duct (CD) and gallbladder (GB). Contrast agent is present in duodenum (D).
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Fig. 4A. —66-year-old woman with common bile duct calculi. Axial
single-shot fast spin-echo MR cholangiography (MRC) image (TR/TE,
infinite/186) obtained after mangafodipir trisodium administration shows
low-signal-intensity fluid in common bile duct (CBD), obscuring its
evaluation.
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Fig. 4B. —66-year-old woman with common bile duct calculi.
Corresponding axial functional MRC (image (6/2.2; flip angle, 40°) shows
filling defect (calculus) in CBD surrounded by contrast material. Duodenal
contrast material (D) indicates nonobstructing biliary calculus.
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Fig. 5A. —68-year-old man with carcinoma of pancreas, metastases to
liver, and partial obstruction of common bile duct. Coronal single-shot fast
spin-echo MR cholangiography (MRC) image (TR/TE, infinite/186) shows narrowing
of common bile duct (CBD) by mass (M). Multiple hepatic lesions are noted,
some of which represent metastatic disease.
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Fig. 5B. —68-year-old man with carcinoma of pancreas, metastases to
liver, and partial obstruction of common bile duct. Coronal oblique
maximum-intensity-projection mangafodipir-enhanced functional MRC (fMRC) image
(6/2.2; flip angle, 40°) obtained from reconstruction of 3D data set again
shows marked narrowing of CBD at level of mass (M). Contrast material is
present in duodenum (D) and appeared approximately 4 hr after IV
administration. Delayed transit time indicates partial obstruction by
mass.
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Fig. 5C. —68-year-old man with carcinoma of pancreas, metastases to
liver, and partial obstruction of common bile duct. Axial fMRC image (6/2.2)
taken at level of severe ductal narrowing shows contrast in CBD. Partially
obstructing mass (M) is marked. Multiple lesions are again identified in
liver.
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Fig. 6A. —57-year-old woman with pancreatic cancer. Thick-slab
single-shot fast spin-echo MR cholangiography (MRC) image (TR/TE,
infinite/800) shows classic double duct sign of pancreatic carcinoma.
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Fig. 6B. —57-year-old woman with pancreatic cancer. Axial delayed
funtional MRC (fMRC) image (TR/TE, 6/2.2; flip angle, 40°) obtained
several hours after mangafodipir trisodium injection shows enhancement of
liver parenchyma without excretion of contrast agent into biliary tree. This
finding persisted at 24 hr. Tumor completely obstructs biliary tree.
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Fig. 7A. —55-year-old woman with biliary obstruction caused by
metastatic ovarian carcinoma, requiring stent placement across common bile
duct. Patency of stent was evaluated by MRI. (Reprinted with permission from
[1]) Coronal single-shot fast
spin-echo MR cholangiography (MRC) image (TR/TE, infinite/186) shows limited
visualization of common bile duct stent. Functionality of stent cannot be
assessed.
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Fig. 7B. —55-year-old woman with biliary obstruction caused by
metastatic ovarian carcinoma, requiring stent placement across common bile
duct. Patency of stent was evaluated by MRI. (Reprinted with permission from
[1]) Axial mangafodipir
trisodium–enhanced functional MRC (fMRC) image (6/2.2; flip angle,
40°) shows excretion of contrast material into dilated intrahepatic
biliary tree.
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Fig. 7C. —55-year-old woman with biliary obstruction caused by
metastatic ovarian carcinoma, requiring stent placement across common bile
duct. Patency of stent was evaluated by MRI. (Reprinted with permission from
[1]) Coronal mangafodipir
trisodium–enhanced fMRC image (6/2.2; flip angle, 40°) shows
excretion of contrast material around stent into duodenum (D), confirming
patency.
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Fig. 8. —45-year-old woman with anatomic variant of biliary tree.
Axial mangafodipir trisodium-enhanced functional MR cholangiography image
(TR/TE, 6/2.2; flip angle, 40°) shows low cystic duct insertion (CD) and
ductal configuration that may increase risk for bile duct injury at
laparoscopic cholecystectomy.
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Fig. 9. —38-year-old woman evaluated as liver transplant donor with
mangafodipir trisodium–enhanced functional MR cholangiography (fMRC)
shows variant ductal anomaly. Coronal oblique maximum-intensity-projection
fMRC image (TR/TE, 5.6/2.5; flip angle, 40°) shows segment IV biliary duct
draining into right hepatic duct. Other ducts are labeled. CHD = common
hepatic duct, CBD = common bile duct.
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Fig. 10A. —40-year-old man evaluated as liver transplant donor with
mangafodipir trisodium–enhanced functional MR cholangiography (fMRC)
shows variant ductal anomaly that is only seen by fMRC. Coronal single-shot
fast spin-echo MRC image (TR/TE, infinite/150) shows no significant
abnormality. Ductal system is not well defined.
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Fig. 10B. —40-year-old man evaluated as liver transplant donor with
mangafodipir trisodium–enhanced functional MR cholangiography (fMRC)
shows variant ductal anomaly that is only seen by fMRC. Coronal oblique
maximum-intensity-projection fMRC image (5.6/2.5; flip angle, 40°) shows
right posterior biliary duct (arrow) draining into left duct.
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Fig. 11A. —20-year-old man with end-stage liver disease secondary to
argininosuccinase synthase deficiency who underwent liver transplantation and
experienced postoperative complication. Axial single-shot fast spin-echo MRI
image (TR/TE, infinite/100) shows transplanted liver and marked ascites. Focal
perihepatic fluid collection (FL) is identified.
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Fig. 11B. —20-year-old man with end-stage liver disease secondary to
argininosuccinase synthase deficiency who underwent liver transplantation and
experienced postoperative complication. Coronal functional MR cholangiography
(fMRC) image (6/2.2; flip angle, 40°) shows mangafodipir trisodium in
common bile duct. Anastamosis is marked (A). Additional focus of contrast
material is present outside biliary tree, compatible with anastamotic leak
(arrow). Contrast agent has passed into duodenum (D); there is no
evidence of biliary obstruction.
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Fig. 11C. —20-year-old man with end-stage liver disease secondary to
argininosuccinase synthase deficiency who underwent liver transplantation and
experienced postoperative complication. Coronal fMRC image (6/2.2; flip angle,
40°) obtained more anteriorly shows contrast agent accumulating outside
biliary tree within fluid collection (arrow), compatible with biliary
leak.
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Fig. 11D. —20-year-old man with end-stage liver disease secondary to
argininosuccinase synthase deficiency who underwent liver transplantation and
experienced postoperative complication. Corresponding diisopropyl
iminodiacetic acid scan shows biliary leak (arrow), but site of leak
is not clearly depicted. For optimal surgical management, it was important to
determine site of biliary extravasation before reoperation.
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Copyright © 2005 by the American Roentgen Ray Society.
