AJR 2005; 184:1563-1571
© American Roentgen Ray Society
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.
Received June 8, 2004;
accepted after revision October 6, 2004.
Address correspondence to L. M. Fayad
(lfayad1{at}jhmi.edu).
Abstract
OBJECTIVE. Our objective was to describe the technique and utility
of functional MR cholangiography (fMRC) in the evaluation of the gallbladder
and biliary tree.
CONCLUSION. FMRC has the potential to provide a comprehensive
examination for the anatomic and functional assessment of the gallbladder and
biliary tree. Complex anatomic abnormalities and functional disorders can be
shown by fMRC, including biliary obstruction and extravasation.
Introduction
Functional MR cholangiography (fMRC) is an emerging technique that has the
potential to provide a comprehensive evaluation for the anatomic and
functional assessment of the gallbladder and biliary tree. FMRC is performed
with a contrast agent such as mangafodipir trisodium (Teslascan, Nycomed
Amersham), which is excreted via the biliary system, where it causes T1
shortening of bile [1]. Hence,
an fMRC sequence can be performed as a high-resolution T1-weighted 3D
gradient-recalled echo (GRE) sequence. With its intrinsic high signal-to-noise
ratio, this sequence affords a smaller pixel size than that achieved by
conventional single-shot fast spin-echo MRC, sonography, and scinitigraphy. As
such, not only can anatomic abnormalities such as strictures, filling defects,
and subtle ductal anomalies be detected, but functional abnormalities such as
cholecystitis, ductal obstruction, and biliary extravasation can be
definitively established. In this pictorial essay, we will discuss the fMRC
technique, its advantages over other techniques, and provide examples that
illustrate the value of fMRC (Figs.
1A,
1B,
1C,
2A,
2B,
2C,
2D,
2E,
3A,
3B,
4A,
4B,
5A,
5B,
5C,
6A,
6B,
7A,
7B,
7C,
8,
9,
10A,
10B,
11A,
11B,
11C,
11D).
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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. 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. 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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Technique
Although several hepatobiliary contrast agents are being developed that may
be suitable for the performance of an fMRC sequence in the future
[2], mangafodipir trisodium is
a U.S. Food and Drug Administration–approved contrast agent for the
evaluation of liver lesions [3,
4] and is used for fMRC imaging
[1,
5]. FMRC imaging constitutes an
off-label use of mangafodipir trisodium. As of March 2004, manufacturing of
mangafodipir had been suspended by Nycomed Amersham, but resumption of
manufacturing is expected.
FMRC images of the biliary tree are obtained as follows: Approximately
10–20 min after the injection of mangafodipir (dose, 5 µmol/kg or 0.5
mL/kg administered at 2–3 mL/min), high-resolution 3D GRE images are
obtained in coronal, coronal oblique, and axial planes (TR/TE, 6/2.2; flip
angle, 40°; field of view, 28 cm2; matrix, 256 x 128;
3.0-mm slice thickness with zero fill interpolation to yield 64 images per
slab at 1.5-mm increments with 1.5-mm overlap; number of excitations, 0.5;
bandwidth ± 62 kHz), usually requiring two slab overlapping
prescriptions. If initial images do not show contrast material in the biliary
tree, this sequence can be repeated as needed at later intervals to obtain
additional delayed imaging. If clinically indicated, we advocate that delayed
imaging be performed at 2-hr intervals after injection as needed, until
visualization of the contrast agent in the gallbladder and duodenum is
possible (Figs. 2A,
2B,
2C,
2D,
2E and
3A,
3B). The exact time interval
at which delayed imaging is executed is in part dependent on the availability
of the MR scanner.
Because the excretion of mangafodipir into the biliary tree interferes with
successful visualization of biliary fluid on conventional T2-weighted MRC
sequences (Fig. 4A,
4B), conventional MRC imaging
must be performed before excretion of mangafodipir into the biliary tree. If a
conventional T2-weighted MRC sequence is not desired, delayed imaging of the
biliary tree may be performed after the IV administration of mangafodipir
without the performance of a conventional single-shot fast spin-echo MRC.
Hence, fMRC imaging can be performed in two ways, as a combined study with
conventional MRC (combined MRC) or as a delayed postcontrast study without
conventional MRC (fMRC alone). The advantage of combined MRC is that
additional information obtained from the T2-weighted contrast agent within the
ducts may further support findings seen on fMRC images. The disadvantage is
that additional delayed imaging may be required if mangafodipir has not been
excreted into the biliary system on early images. However, when additional
delayed imaging is performed, the transit time of contrast agent into the
biliary tree and gallbladder may be determined and be of value in some
instances, such as in the diagnosis of chronic cholecystitis and partial
biliary duct obstructions, entities in which delayed filling of the
gallbladder and biliary tree occurs (Figs.
2A,
2B,
2C,
2D,
2E and
3A,
3B). Also, on occasion,
high-signal-intensity bile may have a similar signal intensity to that of the
contrast material. It is useful to distinguish excretion of contrast material
in the gallbladder from native bile (Fig.
2E). If, however, imaging with fMRC alone is needed, mangafodipir
may be injected and subsequent imaging can take place several hours after
injection, potentially eradicating the need for delayed imaging. Suspected
acute cholecystitis is an ideal setting for which fMRC alone may be sufficient
(Fig. 1A,
1B,
1C). For indications other than
acute cholecystitis, including suspected biliary ductal obstruction (Figs.
5A,
5B,
5C,
6A,
6B,
7A,
7B,
7C) and biliary leaks (Fig.
11A,
11B,
11C,
11D), we perform combined MRC.
An fMRC sequence is valuable in the evaluation of a potential liver transplant
donor for detection of variant biliary ductal drainage
[5] (Figs.
9 and
10A,
10B).
Comparison with Other Techniques
Our arsenal of techniques for evaluation of the biliary tree includes
sonography, conventional MRC, hepatobiliary scintigraphy, CT, endoscopic
retrograde cholangiography (ERC), and percutaneous transhepatic
cholangiography (PTC).
Sonography is typically the initial technique used for the assessment of
the biliary tree and although it is a highly sensitive technique for the
evaluation of the gallbladder
[6], it is limited in cases in
which the biliary ducts are not dilated and for the evaluation of the
extrahepatic biliary tree [7].
Conventional MRC is a fast, heavily T2-weighted MR sequence that depicts the
fluid-containing biliary tree in a noninvasive manner, requires no contrast
agent administration or preparation, and portends none of the complications
associated with invasive cholangiography. Both MRC and CT have been
established as highly sensitive techniques for the diagnosis of anatomic
abnormalities of the gallbladder and biliary tree
[8,
9]. However, after imaging with
these cross-sectional techniques, a functional assessment of the biliary tree
can only be suggested based on associated anatomic findings, including biliary
ductal dilatation, stricture, and filling defects. Obstruction of bile flow
cannot be definitively diagnosed. For a functional assessment (noninvasively),
a second test such as cholescintigraphy is commonly performed.
Hepatobiliary scintigraphy with an iminodiacetic acid derivative such as
diisopropyl iminodiacetic acid provides functional information but lacks
resolution to show the anatomic cause of obstruction. Filling defects and
strictures are uncommonly visualized and the diagnosis of partial obstruction
is not made in up to 50% of patients
[10]. Scintigraphy also has
false-positive results in nonfasting patients, patients with severe hepatic
failure, and patients with hyperbilirubinemia.
Finally, ERC and PTC provide the opportunity for treatment at the time of
diagnosis that the noninvasive techniques discussed here lack. Although
invasive cholangiography studies are sensitive diagnostic methods,
complications result in as many as 11% of cases
[11].
Conclusion
FMRC has the potential to provide a comprehensive examination for the
anatomic and functional assessment of the biliary tree and gallbladder. Its
compelling advantage is its ability to depict functional information. Partial
and complete obstruction may be distinguished along with the inciting anatomic
abnormality, a feature particularly useful for treatment planning. In
addition, variant bile duct anatomy, complex biliary–enteric
anastamoses, biliary stent patency (particularly nonmetal stents), and
suspected biliary extravasation can be thoroughly evaluated with fMRC.
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Abstract
Introduction
