Secretin-Enhanced MRCP: How and Why—AJR Expert Panel Narrative Review
Abstract
Secretin-enhanced MRCP (S-MRCP) has advantages over standard MRCP for imaging of the pancreaticobiliary tree. Through the use of secretin to induce fluid production from the pancreas and leveraging of fluid-sensitive MRCP sequences, S-MRCP facilitates visualization of ductal anatomy, and the findings provide insight into pancreatic function, allowing radiologists to provide additional insight into a range of pancreatic conditions. This narrative review provides detailed information on the practical implementation of S-MRCP, including patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition. Also discussed are radiologists' interpretation and reporting of S-MRCP examinations, including assessments of dynamic compliance of the main pancreatic duct and of duodenal fluid volume. Established indications for S-MRCP include pancreas divisum, anomalous pancreaticobiliary junction, Santorinicele, Wirsungocele, chronic pancreatitis, main pancreatic duct stenosis, and assessment of complex postoperative anatomy. Equivocal or controversial indications are also described along with an approach to such indications. These indications include acute and recurrent acute pancreatitis, pancreatic exocrine function, sphincter of Oddi dysfunction, and pancreatic neoplasms.
MRI by means of a combination of T1-weighted, T2-weighted, and dynamic contrast-enhanced sequences has been used for noninvasive evaluation of the pancreas for several decades. Combined with MRCP sequences that suppress nonfluid signal to accentuate the pancreatic and biliary ducts, MRI affords excellent visualization of the pancreatic and biliary ductal systems. These techniques have been refined over time to allow MRI with MRCP to play a vital role in characterizing pancreatic ductal abnormalities and cystic neoplasms of the pancreas [1, 2].
Secretin-enhanced MRCP (S-MRCP) has been developed specifically for evaluation of the pancreas and pancreatic ducts [3] and further improves diagnostic yield and clinical utility compared with MRI with standard MRCP [1, 4]. Moreover, the use of secretin with MRCP allows dynamic evaluation of pancreatic exocrine volume reserve, which is not possible with standard MRCP. However, use of secretin increases the cost of an MRCP examination, adds at least 15 minutes to the examination, and for some practices requires a nurse to administer the IV infusion. In part related to these practical considerations, S-MRCP has not gained widespread use across radiology practices.
We are experienced in the clinical implementation of S-MRCP. In this article, we describe how and why to use secretin for MRCP. Approaches to optimal imaging acquisition and technique are discussed, and recommendations are made for reporting findings. Both established and controversial uses of S-MRCP are examined.
How to Use Secretin During MRCP
MRCP Technique
Sequences designed to accentuate fluid signal in the biliary and pancreatic ducts are the cornerstone of MRCP. These sequences rely on heavily T2-weighted techniques with TEs that are often greater than 1000 ms. Such sequences minimize the signal of soft tissue and moving fluids, given that the protons of such tissues completely relax over such long intervals. Stationary or slow-moving fluids, such as fluids in the bile duct and pancreatic ducts, have a longer T2 relaxation time, allowing their signal to dominate over subsided background signal from solid organs. Numerous MRCP methods are commercially available from different vendors for acquiring images in this manner.
Many MRCP techniques rely on half-Fourier pulse sequences and thick slices to substantially reduce image acquisition time, allowing short breath-holds of 2–6 seconds, which decrease motion artifact and improve diagnostic image quality [4]. Quick acquisition allows imaging of the entire pancreatic duct at different angles. These angles are centered on the distal common bile duct, yielding multiple radial thick-slice slab sets of images (Fig. 1). Acquisition of thin-slice MRCP images takes more time and therefore requires respiratory triggering, single coronal projection, and often 3D acquisition [5]. We recommend obtaining any 3D images before secretin administration given that expected increases in small bowel fluid after secretin administration may impair visualization of the pancreaticobiliary tree.
Although MRCP protocols generally follow the aforementioned guidelines, the specific MRI pulse sequences used vary by local practice patterns. Examples of standard MRCP sequences at 1.5 T and 3 T from one of our institutions are shown in Tables 1 and 2.
| Parameter | Radial HASTE Slab | Coronal T2-Weighted 3D SPACE | Coronal HASTE Slab With Secretin |
|---|---|---|---|
| Pulse sequence | HASTE | SPACE | HASTE |
| TE (ms) | 756 | 698 | 603 |
| TR (ms) | 2000 | 2400 | 4500 |
| Receiver bandwidth (Hz/pixel) | 300 | 352 | 352 |
| FOV (mm) | 290 × 260 | 360 × 380 | 300 × 380 |
| Slice thickness (mm) | 40 | 1 | 46 |
| Gap | 50% | 0% | 50% |
| Matrix | 256/100% | 384/98% | 384/70% |
| Saturation | Fat saturation | Fat saturation | Fat saturation |
| Flip angle (°) | 180 | 140 | 180 |
| Parameter | Radial HASTE Slab | Coronal T2-Weighted 3D SPACE | Coronal HASTE Slab With Secretin |
|---|---|---|---|
| Pulse sequence | HASTE | SPACE | HASTE |
| TE (ms) | 622 | 699 | 749 |
| TR (ms) | 4500 | 2400 | 4500 |
| Receiver bandwidth (Hz/pixel) | 383 | 319 | 161 |
| FOV (mm) | 300 × 380 | 380 × 320 | 300 × 380 |
| Slice thickness (mm) | 42 | 1.2 | 40 |
| Gap | 50% | 0% | 50% |
| Matrix | 384/80% | 320/82% | 384/75% |
| Saturation | Fat saturation | Fat saturation | Fat saturation |
| Flip angle (°) | 180 | 100 | 180 |
Secretin and Patient Preparation
Secretin is a naturally occurring polypeptide hormone made up of 27 amino acids; it was discovered and originally described in 1902 [6]. Under physiologic conditions, secretin secretion is triggered when the duodenal mucosa senses increased acidity in the lumen, typically following emptying of gastric contents after a meal. The U.S. FDA has approved use of IV injection of synthetic purified secretin peptide (ChiRhoStim, ChiRhoClin) during ERCP. The standard dose recommended by the manufacturer is 0.2 µg/kg of body weight, or approximately 16 µg IV in most adults. Pediatric use requires titrating the dose according to the child's weight. Secretin administration is safe; mild side effects, including nausea, abdominal pain, and flushing, occur in only 0.5% of patients [7].
Secretin is short acting. Data from ERCP studies show increased pancreatic duct pressure within 1 minute and near complete relaxation within 5 minutes [8, 9]. Bicarbonate-rich fluid is released from the pancreatic ductal cells, increasing fluid signal in the pancreatic ducts that then progresses into the duodenum. To improve visualization of these small fluid-filled structures, we recommend that the patient fast for 4–6 hours before the examination to decrease contamination from preexisting gastrointestinal fluid signal, to diminish peristalsis, and to decrease motion artifact. The presence of ascites can also substantially degrade image quality. In these cases, it may be prudent to wait until the ascites has resolved before performing imaging. Paracentesis before MRCP may decrease fluid but may not be practical.
Negative enteric contrast agents can also be considered to decrease fluid signal in the stomach. These are usually administered 10–20 minutes before performance of MRCP sequences [10]. They can be administered with approximately 150–200 mL of pineapple or blueberry juice. However, patient compliance can be challenging with these sweet juices, and because they contain large amounts of fructose, caution is required for patients with diabetes.
Previously used oral agents containing iron were expensive and are generally no longer commercially available. The use of many other oral agents has been described [11]. Negative contrast agents have varying degrees of success at fluid suppression, and we do not recommend one agent over another. Local practice patterns and convenience may drive the decision to use negative contrast and the decision about which agent to use.
Secretin-Enhanced MRCP Technique
Secretin is administered IV. The effects of secretin change dynamically over time, and peak response time may depend on nonphysiologic factors, such as injection time. As such, we recommend using long IV tubing to avoid repositioning the patient in the MRI unit. To avoid losing secretin dose in the long IV tubing, a saline flush of approximately 20 mL immediately after secretin administration is recommended.
We do not recommend routine administration of a test dose of secretin before imaging the patient. Given a very low observed rate of adverse reactions, the FDA stopped requiring a test dose in 2017. Patients who are or have been taking nutrition by mouth are exposed to endogenous secretin at each meal, and severe side effects would usually be apparent before the examination.
After secretin administration, images should be acquired in a plane centered on the pancreaticobiliary ductal system. We recommend 2D heavily T2-weighted coronal slab images for evaluation of secretin-enhanced images. An angled coronal plane is most effective and can be selected on the basis of the radial slab that gave the best view of the main pancreatic duct (Fig. 1) on previous MRCP images. Once this angle is chosen, it should remain the same throughout secretin-enhanced imaging to improve visualization of dynamic changes in the pancreatic ducts.
Sequences that can be rapidly performed (e.g., HASTE) allow acquisition of snapshots of the pancreaticobiliary system as se-cretin takes effect. We recommend breath-hold imaging every 30–60 seconds. This time range allows titration with the patient's ability to perform breath-holds while still allowing dynamic analysis. Secretin-enhanced evaluation with ERCP is performed over at least 15 minutes and often as long as 45 minutes. This procedure is generally not practical for MRI given time constraints. Our experience suggests that obtaining images for 8–9 minutes is a good compromise between efficiency and completeness.
An IV agent such as hyoscine butylbromide (Buscopan, Boeh-ringer Ingelheim) or glucagon may be used to attempt to decrease motion artifact and improve MRI or MRCP image quality [12]. However, we do not recommend routine use of these agents because they decrease peristalsis and limit physiologic filling of the duodenum with fluid after secretin administration.
Secretin-Enhanced MRCP Interpretation
Secretin-enhanced images should be interpreted in concert with standard MRI and MRCP images. Secretin-specific analysis relies on coronal slab 2D images obtained over 8–9 minutes and should start with an overall assessment of image quality. Pancreatic ductal morphology should be evaluated for anatomic variants, ductal side branches, and any cystic lesions that may communicate with the ducts. Table 3 shows considerations for reporting.
| Imaging Before Secretin Administration | Dynamic Secretin-Enhanced Imaging | Pancreatic Exocrine Function |
|---|---|---|
| Pancreatic parenchyma | Maximum diameter of main pancreatic duct | Duodenal fluid |
| Signal intensity | Reported in tenths of millimeters with location of measurement at baseline, 3 min after secretin administration, and on most delayed (at least 8 min) images after secretin administration | Grade 0—No increased fluid |
| Any surrounding free or organized fluid | Grade 1—Increased fluid in duodenal bulb only | |
| Any solid or cystic lesions | Grade 2—Increased fluid to proximal third duodenal segment | |
| Grade 3—Increased fluid in distal third duodenal segment or beyond | ||
| Main pancreatic duct | Changes after secretin administration | Peripancreatic fluid collections after secretin administration |
| Morphology | Qualitative presence or absence of dynamic changes to main pancreatic duct dilation after secretin administration | Presence or absence |
| Dilated or ectatic side branches | Increase in dilatation or ectasia of side branches | If present, any communication with main duct or side branches |
| Presence or absence of pancreas divisum | Indicators of ductal communication of cystic lesions or of side branches, such as increase in size or signal intensity on heavily T2-weighted MRCP images |
S-MRCP interpretation should include descriptions of main pancreatic duct (MPD) size over time. Secretin-induced fluid production leads to changes in MPD caliber, and changes as small as 0.5–1 mm can be appreciated. Given that the MPD varies in size with age [13], the specific diameter of the MPD at any given time in the examination is not as important as the presence of change over time. Dynamic compliance reflects the ability of the MPD to dilate and relax as secretin is administered (Fig. 2) and can be altered in the variety of pathologic states discussed later in this review. Therefore, it is important that S-MRCP reports provide an interpretation of this ability.
Fig. 2A —50-year-old woman with upper abdominal pain. Example of expected dynamic compliance of main pancreatic duct.
A, Coronal MRCP image shows normal configuration of main pancreatic duct with no visible dilated side branches.
Fig. 2B —50-year-old woman with upper abdominal pain. Example of expected dynamic compliance of main pancreatic duct.
B, Coronal secretin-enhanced MRCP image obtained 5 minutes after secretin administration shows expected dynamic dilatation of main pancreatic duct. Pancreatic fluid has started to fill duodenal lumen (long arrow). Duodenal diverticulum (short arrow) is incidental finding.
Complete reporting of S-MRCP should also include qualitative discussion of fluid volume in the duodenum as a marker of pancreatic secretory reserve. Qualitative description of duodenal fluid after secretin administration can be performed with the grading scale originally described by Matos et al. [14] (Fig. 3): grade 0, no increased fluid in the duodenum; grade 1, increased fluid in the duodenal bulb only; grade 2, increased fluid to the proximal third duodenal segment; grade 3, increased fluid in the distal third duodenal segment or beyond. Although quantitative methods have been described for evaluating the volume of fluid in the duodenum after secretin administration [15], these are often impractical for normal radiology workflow. As such, we recommend subjective qualitative grading in S-MRCP reports.
Fig. 3A —48-year-old man with right upper quadrant pain. Example of expected filling of duodenum with fluid after secretin administration.
A, MRCP image obtained before secretin administration shows duodenum with minimal physiologic fluid.
Fig. 3B —48-year-old man with right upper quadrant pain. Example of expected filling of duodenum with fluid after secretin administration.
B, MRCP images show progressively increased fluid signal intensity throughout duodenum 2 (B) and 6 (C) minutes after secretin administration.
Fig. 3C —48-year-old man with right upper quadrant pain. Example of expected filling of duodenum with fluid after secretin administration.
C, MRCP images show progressively increased fluid signal intensity throughout duodenum 2 (B) and 6 (C) minutes after secretin administration.
Fig. 3D —48-year-old man with right upper quadrant pain. Example of expected filling of duodenum with fluid after secretin administration.
D, MRCP image obtained 9 minutes after secretin administration shows fluid is beyond duodenal genu (arrow), consistent with grade 3 response to secretin.
Why We Use Secretin
Established Indications for Use of Secretin
Pancreas divisum—Failure of fusion of the ventral and dorsal pancreatic ducts during embryonal development leads to pancreas divisum. Pancreas divisum is the most common ductal congenital variant and has a widely variable reported prevalence of 3–22% [16, 17]. The connections between pancreas divisum and both acute and chronic pancreatitis (CP) and between divisum and recurrent acute pancreatitis (RAP) remain controversial [18], with studies yielding conflicting results. Only 5% of patients with divisum experience CP, RAP, or chronic abdominal pain [19]. A 2017 study showed that younger age and alcohol use significantly increased the risk of development of pancreatitis in the setting of pancreas divisum [20].
Flow of most of the pancreatic secretions through the minor papilla can place patients at higher risk of pancreas-associated pain due to increased upstream endoluminal pressure that eventually induces acute pancreatitis [4]. In addition, sphincterotomy and stent placement in patients with divisum have resulted in a response in symptoms in as many as 76% of patients [21]. Association between pancreas divisum and RAP is being investigated in a multiinstitutional clinical trial [22].
MRCP has been used to noninvasively evaluate ductal variants and can readily depict direct communication between the dorsal pancreatic duct and the MPD (Fig. 4). S-MRCP, however, has been found to have better diagnostic performance in identifying pancreas divisum given that secretin-induced increased fluid excretion through the minor papilla may accentuate fluid signal in an otherwise small dorsal duct. A 2014 meta-analysis [23] showed sensitivity and specificity up to 86% and 97%, which were significantly higher than those of standard MRCP (52% and 97%). Given this improved sensitivity, S-MRCP is well-suited for cases in which the diagnosis of pancreas divisum is unclear from previous imaging or diagnostic workup.
Fig. 4A —76-year-old woman with chronic abdominal pain due to pancreas divisum and Santorinicele.
A, Coronal MRCP image shows complete pancreas divisum. Common bile duct drains into duodenum at major papilla, and dorsal pancreatic duct (duct of Santorini) drains entirely through minor papilla (arrow). Ventral pancreatic duct is not visible.
Fig. 4B —76-year-old woman with chronic abdominal pain due to pancreas divisum and Santorinicele.
B, Coronal secretin-enhanced MRCP image shows saccular dilatation of terminal portion of dorsal duct, termed Santorinicele (long arrow). Ventral pancreatic duct becomes faintly visible (short arrow). Neither finding was visible before secretin administration.
Anomalous pancreaticobiliary junction—Congenital malunion of the biliary and pancreatic ducts outside of the duodenal wall is the pathognomonic finding in anomalous pancreaticobiliary junction (APBJ). In this rare condition, S-MRCP shows the pancreatic and biliary ducts combining to form a long common channel that extends 15 mm or more [24] (Fig. 5). This common channel allows the possibility of bidirectional flow of pancreatic secretions, and S-MRCP has been found to have sensitivity of 85.7% and specificity of 68% in the diagnosis of reflux into the common bile duct [25]. APBJ can be seen in conjunction with pathologic dilation of the common bile duct, specifically type I choledochal cysts, but not all patients with APBJ have associated cystic dilation.
Although ABPJ can be identified with either ERCP of MRCP, MRCP has the advantage of being noninvasive. However, in cases in which the common channel is shorter than 9 mm, ERCP may be needed to confirm the presence of ABPJ [26]. Identifying this variant is of clinical importance given that patients with ABPJ are at up to 10.6% increased risk of development of biliary malignancy [27]. S-MRCP can be used to evaluate APBJ in enough detail to show reflux of fluid into the common bile duct after secretin administration [28].
Santorinicele and Wirsungocele—Saccular dilatations of the dorsal and ventral pancreatic ducts at their insertions into the duodenal wall have been termed Santoriniceles and Wirsungoceles, respectively. Given expected age-related variability of MPD diameter, there is no specific measurement cutoff for these entities, and diagnosis is based on focal saccular morphology and relative dilatation. Although these changes may be seen with standard MRCP, S-MRCP may be more sensitive for Santorinicele. In one study [29] Santorinicele was visualized with standard MRCP in 7 of 81 (8.6%) patients and with S-MRCP in 20 of 81 (24.7%) patients. Detecting these entities is important given that sphincterotomy may be performed as an attempt to control symptoms in patients who have abdominal pain. S-MRCP may also be used to evaluate changes after minor sphincterotomy, when decreases in Santorinicele size and dorsal duct diameter may be seen [29].
Although Wirsungocele is more commonly thought to be an incidental finding, results of a recent study [30] suggested that Wirsungocele is significantly more likely to be present in patients with RAP than in those without RAP. Further evidence indicates that patients who have both pancreas divisum and a Santorinicele are at increased risk of RAP, possibly owing to transient obstruction of the minor papilla [31] (Fig. 4B).
Chronic pancreatitis—CP is a progressive inflammatory condition of the pancreas. It leads to fibrosis, parenchymal morphologic changes, and distortion of expected pancreatic ductal morphology. Although CP is a well-known condition, the mechanisms by which it leads to fibrosis remain poorly understood, and the clinical course, symptoms, and imaging findings are variable. As such, work is ongoing to define the evolution of CP [32, 33] and to improve standardization of imaging technique and reporting [34].
In the early phase of inflammation associated with CP, pancreatic duct side branches may become enlarged and rounded, which allows visualization with ERCP. This phenomenon led to development of the Cambridge criteria as a tool for characterizing disease severity [35]. These criteria were eventually modified for use with MRCP [36]. The modified Cambridge criteria for MRCP use the presence of three or more prominent side branches as a marker of mild CP and then use abnormalities of the MPD to stratify moderate and severe CP [37]. However, even prominent ductal side branches can be difficult to visualize with standard MRCP given their small size. The ability of secretin to induce fluid signal in the pancreatic ducts may increase conspicuity of these side branches, improving visualization compared with that achievable with standard MRCP [10, 38]. A multiinstitutional study [39] showed good agreement among subspecialized radiologists using S-MRCP for assignment of Cambridge grade (weighted κ = 0.68).
Early CP presents a diagnostic challenge given that the clinical findings and imaging findings with MRCP and endoscopic ultrasound may be heterogeneous and at times contradictory [40, 41]. To this end, S-MRCP may play an important role in improving diagnostic certainty in early CP, as in patients with normal MRCP findings and continued clinical suspicion of CP [42]. S-MRCP findings correspond to ERCP scoring of mild CP [43, 44] and may delineate differences in duct morphology between mild, moderate, and severe CP [45].
S-MRCP has also had a strong association with histopathologic pancreatic fibrosis score. A study [46] showed that the presence of two or more S-MRCP features (MPD irregularity, MPD dilatation, MPD stenosis, ectatic side branches) had sensitivity of 65% and specificity of 89% for identifying nonfibrotic versus fibrotic glands and sensitivity of 88% and specificity of 78% for identifying severe fibrosis. Evidence-based guidelines recommend the use of S-MRCP to increase the diagnostic utility of MRI in known or suspected CP [47].
As CP progresses to moderate and severe forms, it can cause dilation, irregularity, and stricture of the MPD. This can lead to loss of dynamic compliance of the MPD, which can be delineated on S-MRCP as diminished dilatation of the MPD after secretin administration and delayed return to normal duct caliber [4].
Main pancreatic duct stenosis—Stenosis of the MPD can have malignant (e.g., pancreatic adenocarcinoma or neuroendocrine tumors) or benign (e.g., abdominal trauma, CP, autoimmune pancreatitis) causes. Inflammation associated with benign disease can lead to enlargement or distortion of the pancreatic parenchyma, and this parenchymal edema can complicate identification of the cause of MPD stenosis.
Although solid pancreatic masses can be identified with MRI and standard MRCP, nonmalignant entities can mimic solid lesions. When the diagnosis is unclear, S-MRCP can help differentiate benign from malignant causes of MPD stenosis by depicting the duct-penetrating sign (Fig. 6). This sign refers to the presence of pancreatic duct signal intensity within an area of masslike enlargement of the pancreas. Malignant stenosis tends to lead to duct obstruction and a more abrupt cutoff of the MPD, and the duct-penetrating sign is absent in as many as 96% of these cases [48]. Our experience suggests that although it is useful, this sign alone is not sufficient to rule out a mass. We recommend using S-MRCP findings in concert with findings on other MRI and MRCP images to evaluate for pancreatic neoplasms.
Fig. 6A —58-year-old woman with history of alcohol-related pancreatitis and evidence of dilated main pancreatic duct at prior CT. Example of duct-penetrating sign.
A, Radial-slab MRCP image shows abrupt-appearing stricture of main pancreatic duct (arrow).
Fig. 6B —58-year-old woman with history of alcohol-related pancreatitis and evidence of dilated main pancreatic duct at prior CT. Example of duct-penetrating sign.
B, Secretin-enhanced MRCP image shows narrow, but present, duct (arrow) downstream of stricture, consistent with duct-penetrating sign. Finding proved to be benign stricture related to chronic pancreatitis.
Postoperative evaluation of the pancreas—Partial pancreatectomy may be required in patients with malignant neoplasms and in some patients with CP for symptom management. This operation has variable approaches but leads to changes in pancreatic ductal anatomy that often include a pancreatic–small bowel anastomosis. The changes in bowel anatomy can impede ERCP evaluation of the pancreatic and biliary trees, so MRCP may be the preferred modality for follow-up of these patients [3].
Postoperatively, S-MRCP may delineate postsurgical anatomy and depict anastomoses in detail [49]. Fluid collections surrounding the pancreas postoperatively may indicate a ductal leak, which can be seen on secretin-enhanced images [1] (Figs. 7 and 8). In our experience, S-MRCP has limited sensitivity but excellent specificity for identifying ductal leak. Therefore, although S-MRCP should not be used to exclude a leak, the pancreatic ducts should be completely inspected during S-MRCP for communicating fluid collections.
Fig. 7A —53-year-old man with main pancreatic duct leak and multiple bouts of acute pancreatitis.
A, MRCP image obtained before secretin administration shows stricture of main pancreatic duct (arrowsheads).
Fig. 7B —53-year-old man with main pancreatic duct leak and multiple bouts of acute pancreatitis.
B, MRCP image obtained 1 minute after secretin administration shows fluid accumulation (arrow) in stomach consistent with pancreaticogastric fistula.
Fig. 7C —53-year-old man with main pancreatic duct leak and multiple bouts of acute pancreatitis.
C, MRCP images show fluid progressing into duodenum 2 (C) and 5 (D) minutes after secretin administration. Downstream main pancreatic duct is not dilated (arrow, C) given flow of pancreatic fluid through fistula.
Fig. 7D —53-year-old man with main pancreatic duct leak and multiple bouts of acute pancreatitis.
D, MRCP images show fluid progressing into duodenum 2 (C) and 5 (D) minutes after secretin administration. Downstream main pancreatic duct is not dilated (arrow, C) given flow of pancreatic fluid through fistula.
Fig. 8A —30-year-old man with postoperative pancreatic duct leak and history of distal pancreatectomy, splenectomy, and gastrojejunostomy.
A, Coronal MRCP image obtained before secretin administration shows remaining pancreatic duct (arrow).
Fig. 8B —30-year-old man with postoperative pancreatic duct leak and history of distal pancreatectomy, splenectomy, and gastrojejunostomy.
B, Coronal secretin-enhanced MRCP image shows new fluid collection upstream of remaining pancreatic duct, indicating postoperative leak (arrow).
Visualization of the postsurgical environment with S-MRCP may establish a new baseline, which can be useful because as many as 29% of patients who undergo surgery for CP may need a reoperation for recurrent abdominal pain [50]. Progressive dilation of the MPD and decreased excretion into the jejunum are common findings in anastomotic stenosis.
Asymptomatic pancreatic hyperenzymemia—Patients who have prolonged elevations in serum levels of amylase and lipase without associated abdominal symptoms or known pancreatic disease are considered to have chronic asymptomatic pancreatic hyperenzymemia. Imaging of these patients may assist in identifying or ruling out pancreatic disease. Imaging with S-MRCP depicts abnormalities in these patients more often than in control patients with normal enzyme levels [51] and depicts more underlying pancreatic disease than does standard MRCP [52]. The most common changes are dilated side branches, MPD dilation, and delayed emptying of the MPD. However, these changes may overlap with those of CP, highlighting that patients may need further workup after imaging analysis.
Equivocal Indications for Use of Secretin
Other situations in which S-MRCP may be performed have less robust or conflicting evidence to support their use. We discuss some of these indications and provide the panel's opinions to help guide practice.
Pancreatic exocrine function—Normal digestion depends on adequate pancreatic secretion of fluid and enzymes. Pancreatic enzyme insufficiency is a known complication of CP. As many as one-half of all patients with CP experience exocrine dysfunction within 12 years of disease onset [53]. Exocrine insufficiency can be evaluated by measurement of fecal fat content or through measurement of fecal elastase as a marker of the ability of the pancreas to secrete enzymes. Although these methods may be clinically useful, they have limitations, including false-positive rates as high as 10% [54] and weaker association with mild and moderate CP [55].
Pancreatic exocrine function can also be assessed by short ened endoscopic pancreatic function testing in which pancreatic fluid is directly collected under endoscopy. This study is performed over 15–45 minutes to measure the entire pancreatic fluid reserve, and the exocrine function is determined by measuring the bicarbonate level in the collected fluid [56]. Although this may be a more direct method of evaluation, it is invasive and requires specialized expertise to perform.
Secretin stimulation of the pancreas increases fluid signal not only in the pancreatic ductal system but also in the duodenal lumen as fluid is secreted through the papilla. Semiquantitative grading and more thorough quantitative methods of pancreatic response to secretin are available [14, 57]. Early work on S-MRCP [38] showed that patients with severe CP had diminished fluid signal in the duodenum. Subsequent work showed a correlation between S-MRCP findings and fecal elastase and fecal fat measurements [58, 59], including correlation (r) of 0.79 with fecal elastase in one study [60]. Furthermore, patients with abnormal results of endoscopic pancreatic function tests have clinically significant decreases in pancreatic duct caliber and changes in duodenal filling after secretin administration [61]. In addition, quantitative changes in the ducts on S-MRCP are associated with abnormal results of endoscopic pancreatic function tests, including ductal noncompliance and side branch visualization.
Other studies have shown a less clear association between S-MRCP and pancreatic exocrine function. In some cases, normal results of endoscopic pancreatic function testing may be present in patients with S-MRCP findings that suggest CP [62]. One study evaluating traditional pancreatic function testing [63] did not show any association between peak duodenal fluid bicarbonate secretion and S-MRCP duodenal filling 10 minutes after secretin administration. Secretin simulation may induce increased fluid secretion from cells in the jejunum itself as well as the pancreas. Hafezi-Nejad et al. [64], however, found that fluid signal intensity in the descending duodenum was significantly lower in patients with CP than those without CP.
Acute pancreatitis versus recurrent acute pancreatitis—Imaging in the evaluation of acute pancreatitis often focuses on patients with a severe clinical course or is performed to identify an underlying cause in patients without known risk factors [65]. Ultra-sound can assist in identifying gallstones, and CT is often used to assess severity through identification of signs of inflammation, pancreatic enhancement, and associated peripancreatic fluid collections.
MRCP has higher sensitivity than CT for identifying pancreaticobiliary anomalies and for evaluating for choledocholithiasis [66]. In patients with acute disease, the addition of secretin has a more limited role and should be reserved for the evaluation of specific clinical questions. A primary such question is the potential presence of a disconnected pancreatic duct or pancreatic duct leak, which is a concern when a pancreatic fluid collection along the duct is noted in the presence of viable upstream parenchyma. Use of S-MRCP improves visualization of the MPD and may show active leak of fluid in patients with duct disruption in a less invasive manner than can ERCP [67].
Patients who have more than one clinical bout of acute pancreatitis are considered to have RAP, a condition for which an underlying cause cannot be found in as many as 30% of cases. Identifying a cause is important given that untreated RAP can lead to CP [68]. Underlying MPD stricture can cause RAP, and increased pressure in the duct in patients with pancreas divisum with Santorinicele can also cause RAP. As such, S-MRCP affords effective noninvasive evaluation in patients with RAP given that it delineates the MPD in excellent detail.
Sphincter of Oddi dysfunction—Diminished flow of fluid through the sphincter of Oddi may be caused by sphincter stenosis or sphincter dyskinesia. Over time, these conditions have been grouped under the umbrella term sphincter of Oddi dysfunction (SOD) [69]. Data suggest that as many as 13% of patients may have SOD after cholecystectomy, although SOD may also be diagnosed in patients with a gallbladder [4]. SOD is classified into three types, all of which include right upper quadrant or epigastric pain. Type I also includes liver enzyme abnormalities and structural change in the bile duct; type II includes enzyme or structural change; and type III includes only pain [70].
Reference standard diagnosis of SOD relies on sphincter manometry, an invasive endoscopic procedure. S-MRCP can assist in noninvasive evaluation of patients with suspected SOD. Stenosis at the sphincter may lead to changes in dynamic compliance of the MPD, such as lack of relaxation of the MPD after secretin-enhanced dilation. Increased prominence of pancreatic duct side branches or acinarization may also be seen [71, 72] (Figs. 9 and 10). Data comparing manometry with S-MRCP show that imaging is more effective in type II disease (accuracy 73%) than in type III disease (accuracy 46%) [70]. This distinction is important given that patients with type II and III disease are more likely to benefit from therapeutic sphincterotomy.
Fig. 9A —45-year-old woman with biliary-type pain and abnormal findings at endoscopic sphincter manometry due to sphincter of Oddi dysfunction.
A, Coronal MRCP image obtained before secretin administration shows nonspecific dilatation of common bile duct with smooth distal tapering. Main pancreatic duct measures up to 2 mm and does not have prominent side branches.
Fig. 9B —45-year-old woman with biliary-type pain and abnormal findings at endoscopic sphincter manometry due to sphincter of Oddi dysfunction.
B, Coronal secretin-enhanced MRCP image obtained 2 minutes after secretin administration shows increase in main pancreatic duct diameter up to 5.5 mm. Multiple duct side branches exhibit increased prominence (arrows).
Fig. 10A —55-year-old man with right upper quadrant pain and clinical diagnosis of type II sphincter of Oddi dysfunction.
A, Coronal MRCP image obtained before secretin administration shows main pancreatic duct without irregularity, dilatation, or abnormal side branches.
Fig. 10B —55-year-old man with right upper quadrant pain and clinical diagnosis of type II sphincter of Oddi dysfunction.
B, Coronal MRCP image obtained 3 minutes after secretin administration shows diffuse fluid signal intensity (arrows) surrounding main pancreatic duct. This represents acinarization, or diffusely increased T2 signal intensity surrounding main pancreatic duct. Increased pressure in main pancreatic duct is thought to lead to overfilling of pancreatic duct side branches with fluid.
Pancreatic neoplasms—The utility of S-MRCP in evaluation of pancreatic neoplasms differs for cystic and solid tumors. Cystic tumors include intraductal papillary mucinous neoplasms and serous and mucinous cystadenomas and cystadenocarcinomas. Identifying communication between a cystic lesion and the MPD helps differentiate intraductal papillary mucinous neoplasm from the other mucinous neoplasms, which have greater malignant potential. Data are mixed on the utility of S-MRCP for this indication [73, 74]. Conversely, diagnosis of solid neoplasms of the pancreas, such as pancreatic adenocarcinoma and neuroendocrine tumor, does not rely on communication with the MPD. Diagnosis relies more heavily on contrast-enhanced imaging to identify the lesions and delineate their relations to adjacent vessels.
Consensus Statements
•
High-quality S-MRCP requires attention to patient preparation, logistics of secretin administration, and dynamic secretin-enhanced MRCP acquisition.
•
Use of a reporting template is critical for standardizing S-MRCP interpretation, including assessment of dynamic ductal compliance. The panel cannot recommend a single MPD diameter cutoff value as abnormal given age-related variation in MPD diameter.
•
S-MRCP is an imperfect indirect test of pancreatic exocrine reserve given that pancreatic juice excreted as the result of secretin stimulation does not directly reflect pancreatic function. A highly subjective scale that depends on technical factors is used in clinical practice. Quantitative methods are impractical within typical radiology workflow.
•
S-MRCP has limited benefit in most cases of acute pancreatitis, unless there is a specific question, such as to evaluate for pancreatic ductal leak or pancreas divisum before ERCP.
•
S-MRCP may be useful in the setting of RAP, for example to help diagnose underlying causes. Imaging should not be performed until at least 4–6 weeks after initial presentation to allow acute inflammatory changes to decrease or subside. The length of time depends on the severity of the acute episode.
•
S-MRCP findings in SOD are nonspecific and may overlap with other findings of CP. S-MRCP is less accurate than endoscopic sphincter manometry but may be used when noninvasive evaluation is preferred or when endoscopic evaluation is not available or impractical.
•
S-MRCP has little benefit beyond standard MRCP in patients with cystic pancreatic neoplasms, although it may help accentuate side branch intraductal papillary mucinous neoplasm communication with the MPD.
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© American Roentgen Ray Society.
History
Submitted: September 23, 2020
Revision requested: October 13, 2020
Revision received: November 7, 2020
Accepted: November 19, 2020
First published: March 11, 2021
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Supported by National Cancer Institute and National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (1R01DK116963, U01DK127382) and the Consortium for the Study of Chronic Pancreatitis, Diabetes, and Pancreatic Cancer (U01DK108323) (T. Tirkes).
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