Recurrent attacks of pancreatitis. MRI in acute pancreatitis. Acute and Chronic pancreatitis

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1 Acute and Chronic pancreatitis why MRI? Why should we consider the use of MRI in acute pancreatitis? Specific ductal evaluation (MPD and CBD) Mechanical obstruction, necrosis, pancreatic leak Better contrast resolution (hemorrhage, fluid collections) Repeated imaging is often required in complicated pancreatitis Lecesne et al. Radiology 1999 Martin DR, et al. JMRI 2003 Arvanitakis et al. Gastroenterology 2004 Gillams AR, et al. AJR 2006 MRI in acute pancreatitis Recurrent attacks of pancreatic pain associated with abnormal amylase and lipase in the setting of a normal morpho-functional gland Staging when the diagnosis is established Recurrent attacks of pancreatitis Rule out a mechanical factor that may induce a transient outflow obstruction sphincter dysfunction / obstruction major / minor ampullary orifice stricture w/o a visible mass IPMN Matos et al. Radiology 1997 Matos et al. Radiographics 2002

Decreased pancreatic duct compliance (pdc)

Papillary stenosis (n=5) 3.6 ± 0.7 5.5 ± 1.

2 Normal response to secretin stimulation Matos et al. Radiology 1997 Manfredi et al. Radiology 2000 Capelliez et al. Radiology 2000 Matos et al. Gastrointest Endosc 2001 Matos et al. Radiographics 2002 Hellerhoff et al. AJR 2002 Fukukura et al. Radiology 2002 Mean caliber variation of the MPD Diameter (mm) Time to peak Subjects Baseline Maximum Final Controls (n=10) 2.3 ± ± ± 0.5 < 150 s MRCP and sphincter obstruction Decreased pancreatic duct compliance (pdc) Parenchymogram (acute pancreatitis) Papillary stenosis (n=5) 3.6 ± ± ± 1.2* 30 s No p stenosis (n=8) 2.6 ± ± ± s * p = Matos et al. Radiology 1997 Abnormal flow dynamics : persistent dilatation Parenchymogram Matos, C. et al. Radiographics 2002 Progressive enhancement of the pancreatic parenchyma after stimulation with secretin Reduced duodenal filling Matos et al. AJR 1998 Gosset et al. JOP 2004

3 Parenchymogram Parenchymogram = acute pancreatitis Biological pancreatitis post-ercp (< 24 h) Matos, C. et al. Radiographics 2002 N = 279 Abnormal Abnormal non PD PD ARP 11.6% 14.3% * Enzymes 16.2% 0% Pain 7.1% 0% Controls 2.1% 0% * p = 0.41 baseline Matos et al.gastrointest Endosc 2001 B A B C

4 Non filled stricture = scar ( old rupture) Acute pancreatitis TE 45 ms TE 250 ms normal abnormal AIP

5 Acute Pancreatitis T2-w 3D T1-w FS Peri-pancreatic haemorrhagic infiltration: negative prognostic factor Martin et al JMRI 2003 Gallstone pancreatitis Makary MA et al. Ann Surg 2005 : 94% sensitivity in detecting CBD stones Acute pancreatitis: MRI vs CT Lecesne et al Radiology P MRCP could be an alternative to CECT for the initial staging of acute pancreatitis Gd not nephrotoxic Better evaluation of fluid collections (hemorragic-like) No specific evaluation of the pancreatic ducts from Matos et al. Radiographics 2002 Acute pancreatitis T2-w Perfusion studies T1-w arterial venous T1-w arterial venous secretin

6 Acute pancreatitis Arvanitakis et al. Gastroenterology, 2004 Arvanitakis et al. Gastroenterology, 2004 Assessment of mpd disruption from Matos et al. Radiographics 2002 Assessment of mpd disruption 17 p Diagnosis of mpd disruption and assessment of pancreatic leak with s-mrcp Gillams AR et al. AJR 2006;186: /17 contributed to successful management 10/12 additional information was provided Matos, C. et al. Radiographics 2002

7 Acute Pancreatitis Pancreatic fluid collections role of DWI in determining presence of infection T2-w Max ADC significantly lower in PFC with positive cultures A 3D T1-w MPR Acute Pancreatitis vascular compromise MPR MIP Pseudo T acute pancreatitis MRI in acute pancreatitis? MRCP w / secretin Normal gland and ARP To rule out central necrosis To identify pancreatic leak DWI To rule out infection Gd Vascular complications

8 S entinel A cute P ancreatitis E vent Witcomb DC

9 N I II III IV Non-enhanced CT in all cases -s +s 92% specificity; 63% sensitivity ( Sai et al.2008)

10 +S Chronic pancreatitis Pancreatic adc Duodenal pancreatitis - s +s Matos, C. et al. Radiographics 2002

11 Strategy 1 MPD stricture CE cross-sectional +Gd CE cross-sectional MPD stricture +Gd -S +S Strategy 2 MRCP T2-w DWI secretin Paraduodenal pancreatitis = Groove pancreatitis = cystic dystrophy of duodenal wall Paraduodenal pancreatitis is a distinct form of chronic pancreatitis characterized by inflammation and fibrous tissue formation, affecting the groove area near the minor papilla between the head of the pancreas, the duodenal wall and the common bile duct. Imaging Pure form : spares the head of the pancreas Segmental form : the pancreas is affected Non segmental form : secondary to chronic pancreatitis Marked CBD dilatation should be considered as suspicious Sheet like mass Thickened D wall Cyst like changes

12 Paraduodenal pancreatitis : pure form w / CBD dilatation Paraduodenal pancreatitis : non pure form - C Paraduodenal pancreatitis + C 33 y-old, epgastric pain, weight loss, cbd stent for obstructive jaundice

13 -s AIP: main duct patterns +s Double duct sign Adenocarcinoma AI Pancreatitis Autoimmune pancreatitis

14 diffusion gadolinium 2-week steroid trial for ΔΔ AIP and pancreatic cancer Am J Gastroenterol 2010 Moon, S-H et al. Gut 2008;57: Thank you

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