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MR Pancreatography: A Useful Tool for Evaluating Pancreatic Disorders

¹ Department of Radiology, Medical College of Virginia, Virginia Commonwealth University, 401 N 12th St, Richmond, VA 23298-0615.

View larger version (109K): [in a new window]   Figure 1a.  MR pancreatographic technique. (a) Coronal thick-slab scout image of the abdomen demonstrates the pancreatic duct (arrows) and biliary tract (arrowheads). (b) Coronal thick-slab scout image with a localizer (arrow) placed in the region of the pancreatic duct demarcates the area through which an axial thick-slab image will be obtained. (c) Axial thick-slab scout image obtained at the level of the pancreatic duct serves as a guide for prescribing angles (arrows) for obtaining thin-slab images of the duct in the coronal-oblique plane.

View larger version (121K): [in a new window]   Figure 1b.  MR pancreatographic technique. (a) Coronal thick-slab scout image of the abdomen demonstrates the pancreatic duct (arrows) and biliary tract (arrowheads). (b) Coronal thick-slab scout image with a localizer (arrow) placed in the region of the pancreatic duct demarcates the area through which an axial thick-slab image will be obtained. (c) Axial thick-slab scout image obtained at the level of the pancreatic duct serves as a guide for prescribing angles (arrows) for obtaining thin-slab images of the duct in the coronal-oblique plane.

View larger version (116K): [in a new window]   Figure 1c.  MR pancreatographic technique. (a) Coronal thick-slab scout image of the abdomen demonstrates the pancreatic duct (arrows) and biliary tract (arrowheads). (b) Coronal thick-slab scout image with a localizer (arrow) placed in the region of the pancreatic duct demarcates the area through which an axial thick-slab image will be obtained. (c) Axial thick-slab scout image obtained at the level of the pancreatic duct serves as a guide for prescribing angles (arrows) for obtaining thin-slab images of the duct in the coronal-oblique plane.

View larger version (130K): [in a new window]   Figure 2.  Normal pancreatic duct. Multiplanar reformatted image allows visualization of the normal-caliber duct (arrows) in the pancreatic head, body, and tail on a single image.

View larger version (13K): [in a new window]   Figure 3a.  Variations in the course of the pancreatic duct. Drawings show descending (a), sigmoid (b), vertical (c), and loop (d) configurations.

View larger version (10K): [in a new window]   Figure 3b.  Variations in the course of the pancreatic duct. Drawings show descending (a), sigmoid (b), vertical (c), and loop (d) configurations.

View larger version (10K): [in a new window]   Figure 3c.  Variations in the course of the pancreatic duct. Drawings show descending (a), sigmoid (b), vertical (c), and loop (d) configurations.

View larger version (10K): [in a new window]   Figure 3d.  Variations in the course of the pancreatic duct. Drawings show descending (a), sigmoid (b), vertical (c), and loop (d) configurations.

View larger version (130K): [in a new window]   Figure 4a.  Vertically oriented pancreatic duct detected incidentally in a 72-year-old man with abdominal pain. (a) MR cholangiopancreatogram reveals a vertically oriented pancreatic duct (arrows) mimicking the distal bile duct. The gallbladder (arrowheads) is seen adjacent to the pancreatic duct. (b) MR cholangiopancreatogram obtained 10 mm posterior to a depicts the course of the extrahepatic bile duct (arrows), which parallels that of the vertically oriented pancreatic duct (cf a). The gallbladder (arrowheads) and duodenal bulb (*) are also seen. (c) MR cholangiopancreatogram obtained 5 mm posterior to a shows the distal bile duct (arrow) lateral to the vertically oriented pancreatic duct (arrowheads). A fluid-filled periampullary diverticulum (*) is demonstrated incidentally.

View larger version (151K): [in a new window]   Figure 4b.  Vertically oriented pancreatic duct detected incidentally in a 72-year-old man with abdominal pain. (a) MR cholangiopancreatogram reveals a vertically oriented pancreatic duct (arrows) mimicking the distal bile duct. The gallbladder (arrowheads) is seen adjacent to the pancreatic duct. (b) MR cholangiopancreatogram obtained 10 mm posterior to a depicts the course of the extrahepatic bile duct (arrows), which parallels that of the vertically oriented pancreatic duct (cf a). The gallbladder (arrowheads) and duodenal bulb (*) are also seen. (c) MR cholangiopancreatogram obtained 5 mm posterior to a shows the distal bile duct (arrow) lateral to the vertically oriented pancreatic duct (arrowheads). A fluid-filled periampullary diverticulum (*) is demonstrated incidentally.

View larger version (130K): [in a new window]   Figure 4c.  Vertically oriented pancreatic duct detected incidentally in a 72-year-old man with abdominal pain. (a) MR cholangiopancreatogram reveals a vertically oriented pancreatic duct (arrows) mimicking the distal bile duct. The gallbladder (arrowheads) is seen adjacent to the pancreatic duct. (b) MR cholangiopancreatogram obtained 10 mm posterior to a depicts the course of the extrahepatic bile duct (arrows), which parallels that of the vertically oriented pancreatic duct (cf a). The gallbladder (arrowheads) and duodenal bulb (*) are also seen. (c) MR cholangiopancreatogram obtained 5 mm posterior to a shows the distal bile duct (arrow) lateral to the vertically oriented pancreatic duct (arrowheads). A fluid-filled periampullary diverticulum (*) is demonstrated incidentally.

View larger version (122K): [in a new window]   Figure 5a.  Loop configuration of the pancreatic duct in an 11-year-old girl with recurrent pancreatitis. (a) MR pancreatogram demonstrates a loop in the pancreatic duct (arrow) at the point of embryologic fusion of the ducts of Santorini and Wirsung. The loop mimics a stricture. (b) MR pancreatogram obtained at a slightly different angle shows the pancreatic duct in an uncoiled position (arrow) and excludes a stricture.

View larger version (137K): [in a new window]   Figure 5b.  Loop configuration of the pancreatic duct in an 11-year-old girl with recurrent pancreatitis. (a) MR pancreatogram demonstrates a loop in the pancreatic duct (arrow) at the point of embryologic fusion of the ducts of Santorini and Wirsung. The loop mimics a stricture. (b) MR pancreatogram obtained at a slightly different angle shows the pancreatic duct in an uncoiled position (arrow) and excludes a stricture.

View larger version (18K): [in a new window]   Figure 6a.  Variations in pancreatic duct drainage. Drawings illustrate the duct of Wirsung with atrophy of the duct of Santorini (a), persistent duct of Santorini with primary drainage through the duct of Wirsung (b), and isolation of the ducts of Wirsung and Santorini resulting in pancreas divisum (c).

View larger version (18K): [in a new window]   Figure 6b.  Variations in pancreatic duct drainage. Drawings illustrate the duct of Wirsung with atrophy of the duct of Santorini (a), persistent duct of Santorini with primary drainage through the duct of Wirsung (b), and isolation of the ducts of Wirsung and Santorini resulting in pancreas divisum (c).

View larger version (18K): [in a new window]   Figure 6c.  Variations in pancreatic duct drainage. Drawings illustrate the duct of Wirsung with atrophy of the duct of Santorini (a), persistent duct of Santorini with primary drainage through the duct of Wirsung (b), and isolation of the ducts of Wirsung and Santorini resulting in pancreas divisum (c).

View larger version (153K): [in a new window]   Figure 7. Figures 7, 8. (7) Duct of Wirsung and absent duct of Santorini in a 47-year-old woman with cirrhosis who was referred for MR imaging and MR cholangiopancreatography prior to undergoing liver transplantation. MR cholangiopancreatogram demonstrates drainage of the pancreas through the duct of Wirsung (arrow), which joins with the distal bile duct (arrowheads) to enter the major ampulla. Note the absence of the duct of Santorini. (8) Duct of Wirsung and persistent duct of Santorini in a 61-year-old woman with abdominal pain. (a) MR cholangiopancreatogram shows a persistent duct of Santorini (arrow) entering the minor ampulla and lying cephalad to the duct of Wirsung. (b) MR cholangiopancreatogram obtained posterior to a demonstrates the distal bile duct (arrowhead) extending caudad to the partially visualized duct of Santorini (arrow).

View larger version (155K): [in a new window]   Figure 8a. Figures 7, 8. (7) Duct of Wirsung and absent duct of Santorini in a 47-year-old woman with cirrhosis who was referred for MR imaging and MR cholangiopancreatography prior to undergoing liver transplantation. MR cholangiopancreatogram demonstrates drainage of the pancreas through the duct of Wirsung (arrow), which joins with the distal bile duct (arrowheads) to enter the major ampulla. Note the absence of the duct of Santorini. (8) Duct of Wirsung and persistent duct of Santorini in a 61-year-old woman with abdominal pain. (a) MR cholangiopancreatogram shows a persistent duct of Santorini (arrow) entering the minor ampulla and lying cephalad to the duct of Wirsung. (b) MR cholangiopancreatogram obtained posterior to a demonstrates the distal bile duct (arrowhead) extending caudad to the partially visualized duct of Santorini (arrow).

View larger version (144K): [in a new window]   Figure 8b. Figures 7, 8. (7) Duct of Wirsung and absent duct of Santorini in a 47-year-old woman with cirrhosis who was referred for MR imaging and MR cholangiopancreatography prior to undergoing liver transplantation. MR cholangiopancreatogram demonstrates drainage of the pancreas through the duct of Wirsung (arrow), which joins with the distal bile duct (arrowheads) to enter the major ampulla. Note the absence of the duct of Santorini. (8) Duct of Wirsung and persistent duct of Santorini in a 61-year-old woman with abdominal pain. (a) MR cholangiopancreatogram shows a persistent duct of Santorini (arrow) entering the minor ampulla and lying cephalad to the duct of Wirsung. (b) MR cholangiopancreatogram obtained posterior to a demonstrates the distal bile duct (arrowhead) extending caudad to the partially visualized duct of Santorini (arrow).

View larger version (131K): [in a new window]   Figure 9a.  Duct of Wirsung and diminutive duct of Santorini in a 51-year-old man with acute pancreatitis. (a) MR cholangiopancreatogram shows the major drainage route of the pancreas through the duct of Wirsung (arrow) at the major ampulla. Note the distal bile duct (arrowheads). (b) MR cholangiopancreatogram obtained 5 mm anterior to a reveals a persistent but diminutive duct of Santorini (arrow) entering the minor ampulla cephalad to the duct of Wirsung (arrowheads).

View larger version (145K): [in a new window]   Figure 9b.  Duct of Wirsung and diminutive duct of Santorini in a 51-year-old man with acute pancreatitis. (a) MR cholangiopancreatogram shows the major drainage route of the pancreas through the duct of Wirsung (arrow) at the major ampulla. Note the distal bile duct (arrowheads). (b) MR cholangiopancreatogram obtained 5 mm anterior to a reveals a persistent but diminutive duct of Santorini (arrow) entering the minor ampulla cephalad to the duct of Wirsung (arrowheads).

View larger version (156K): [in a new window]   Figure 10.  Anomalous union of the pancreatic and bile ducts detected incidentally in a 74-year-old woman. MR cholangiopancreatogram shows a 1.6-cm-long channel (straight arrow) common to the duct of Wirsung (curved arrow) and the distal bile duct (arrowhead).

View larger version (139K): [in a new window]   Figure 11a.  Pancreas divisum in a 62-year-old woman with recurrent pancreatitis. (a) MR cholangiopancreatogram demonstrates the distal bile duct (arrow) joining with the ventral pancreatic duct (arrowhead) to enter the major ampulla. (b) MR cholangiopancreatogram obtained 5 mm anterior to a shows the dorsal pancreatic duct (arrows), which is located anterior and superior to the ventral pancreatic duct (cf a). (c) Axial MR cholangiopancreatogram demonstrates the isolated ventral (arrow) and dorsal (arrowhead) pancreatic ducts. (d) Endoscopic retrograde cholangiopancreatogram obtained after injection of contrast material into the ventral duct (arrow) shows arborization of the duct. Residual contrast material from a prior injection at the minor ampulla is seen in the dorsal pancreatic duct (arrowheads).

View larger version (145K): [in a new window]   Figure 11b.  Pancreas divisum in a 62-year-old woman with recurrent pancreatitis. (a) MR cholangiopancreatogram demonstrates the distal bile duct (arrow) joining with the ventral pancreatic duct (arrowhead) to enter the major ampulla. (b) MR cholangiopancreatogram obtained 5 mm anterior to a shows the dorsal pancreatic duct (arrows), which is located anterior and superior to the ventral pancreatic duct (cf a). (c) Axial MR cholangiopancreatogram demonstrates the isolated ventral (arrow) and dorsal (arrowhead) pancreatic ducts. (d) Endoscopic retrograde cholangiopancreatogram obtained after injection of contrast material into the ventral duct (arrow) shows arborization of the duct. Residual contrast material from a prior injection at the minor ampulla is seen in the dorsal pancreatic duct (arrowheads).

View larger version (117K): [in a new window]   Figure 11c.  Pancreas divisum in a 62-year-old woman with recurrent pancreatitis. (a) MR cholangiopancreatogram demonstrates the distal bile duct (arrow) joining with the ventral pancreatic duct (arrowhead) to enter the major ampulla. (b) MR cholangiopancreatogram obtained 5 mm anterior to a shows the dorsal pancreatic duct (arrows), which is located anterior and superior to the ventral pancreatic duct (cf a). (c) Axial MR cholangiopancreatogram demonstrates the isolated ventral (arrow) and dorsal (arrowhead) pancreatic ducts. (d) Endoscopic retrograde cholangiopancreatogram obtained after injection of contrast material into the ventral duct (arrow) shows arborization of the duct. Residual contrast material from a prior injection at the minor ampulla is seen in the dorsal pancreatic duct (arrowheads).

View larger version (106K): [in a new window]   Figure 11d.  Pancreas divisum in a 62-year-old woman with recurrent pancreatitis. (a) MR cholangiopancreatogram demonstrates the distal bile duct (arrow) joining with the ventral pancreatic duct (arrowhead) to enter the major ampulla. (b) MR cholangiopancreatogram obtained 5 mm anterior to a shows the dorsal pancreatic duct (arrows), which is located anterior and superior to the ventral pancreatic duct (cf a). (c) Axial MR cholangiopancreatogram demonstrates the isolated ventral (arrow) and dorsal (arrowhead) pancreatic ducts. (d) Endoscopic retrograde cholangiopancreatogram obtained after injection of contrast material into the ventral duct (arrow) shows arborization of the duct. Residual contrast material from a prior injection at the minor ampulla is seen in the dorsal pancreatic duct (arrowheads).

View larger version (154K): [in a new window]   Figure 12a.  Annular pancreas detected incidentally in a 61-year-old man in whom cannulation of the bile duct was not possible during endoscopic retrograde cholangiopancreatography. The patient was referred for MR cholangiography for ductal delineation. (a) MR pancreatogram shows the curvilinear duct (arrows) in the annular pancreas. (b) Endoscopic retrograde cholangiograph helps confirm the annular pancreatic duct (arrows). (c) Coronal T1-weighted, fat-suppressed abdominal MR image (repetition time msec/effective echo time msec = 200/ 4.4) demonstrates the annular pancreas (arrows) lying lateral to the fluid-filled duodenum (arrowhead).

View larger version (126K): [in a new window]   Figure 12b.  Annular pancreas detected incidentally in a 61-year-old man in whom cannulation of the bile duct was not possible during endoscopic retrograde cholangiopancreatography. The patient was referred for MR cholangiography for ductal delineation. (a) MR pancreatogram shows the curvilinear duct (arrows) in the annular pancreas. (b) Endoscopic retrograde cholangiograph helps confirm the annular pancreatic duct (arrows). (c) Coronal T1-weighted, fat-suppressed abdominal MR image (repetition time msec/effective echo time msec = 200/ 4.4) demonstrates the annular pancreas (arrows) lying lateral to the fluid-filled duodenum (arrowhead).

View larger version (155K): [in a new window]   Figure 12c.  Annular pancreas detected incidentally in a 61-year-old man in whom cannulation of the bile duct was not possible during endoscopic retrograde cholangiopancreatography. The patient was referred for MR cholangiography for ductal delineation. (a) MR pancreatogram shows the curvilinear duct (arrows) in the annular pancreas. (b) Endoscopic retrograde cholangiograph helps confirm the annular pancreatic duct (arrows). (c) Coronal T1-weighted, fat-suppressed abdominal MR image (repetition time msec/effective echo time msec = 200/ 4.4) demonstrates the annular pancreas (arrows) lying lateral to the fluid-filled duodenum (arrowhead).

View larger version (161K): [in a new window]   Figure 13.  Anomalous union of the pancreatic and bile ducts with associated type 1 choledochal cyst in a 25-year-old woman. Coronal non–fat-suppressed RARE image (/60) reveals an anomalous union of the pancreatic and bile ducts (arrowhead) associated with a choledochal cyst (arrows).

View larger version (137K): [in a new window]   Figure 14a.  Acute disruption of the pancreatic duct in a 39-year-old man. The patient presented with left upper quadrant pain and hyperamylasemia after sustaining extensive splenic lacerations in a motor vehicle accident. Splenectomy was performed 1 week prior to MR pancreatography. (a) Scout MR cholangiopancreatogram demonstrates the pancreatic duct (arrowheads) terminating in an 8-mm fluid collection (arrow) in the pancreatic tail. An adjacent pseudocyst (*) is also seen. (b) Coronal non–fat-suppressed RARE image (/60) helps confirm the 8-mm fluid collection in the pancreatic tail (arrow), indicating ductal disruption. The disrupted duct was confirmed at surgery and shown to communicate with the pseudocyst (*). (c) Endoscopic retrograde cholangiopancreatogram shows complete filling of the pancreatic duct (arrows) but no evidence of the fluid collection and duct disruption noted at MR cholangiopancreatography.

View larger version (156K): [in a new window]   Figure 14b.  Acute disruption of the pancreatic duct in a 39-year-old man. The patient presented with left upper quadrant pain and hyperamylasemia after sustaining extensive splenic lacerations in a motor vehicle accident. Splenectomy was performed 1 week prior to MR pancreatography. (a) Scout MR cholangiopancreatogram demonstrates the pancreatic duct (arrowheads) terminating in an 8-mm fluid collection (arrow) in the pancreatic tail. An adjacent pseudocyst (*) is also seen. (b) Coronal non–fat-suppressed RARE image (/60) helps confirm the 8-mm fluid collection in the pancreatic tail (arrow), indicating ductal disruption. The disrupted duct was confirmed at surgery and shown to communicate with the pseudocyst (*). (c) Endoscopic retrograde cholangiopancreatogram shows complete filling of the pancreatic duct (arrows) but no evidence of the fluid collection and duct disruption noted at MR cholangiopancreatography.

View larger version (108K): [in a new window]   Figure 14c.  Acute disruption of the pancreatic duct in a 39-year-old man. The patient presented with left upper quadrant pain and hyperamylasemia after sustaining extensive splenic lacerations in a motor vehicle accident. Splenectomy was performed 1 week prior to MR pancreatography. (a) Scout MR cholangiopancreatogram demonstrates the pancreatic duct (arrowheads) terminating in an 8-mm fluid collection (arrow) in the pancreatic tail. An adjacent pseudocyst (*) is also seen. (b) Coronal non–fat-suppressed RARE image (/60) helps confirm the 8-mm fluid collection in the pancreatic tail (arrow), indicating ductal disruption. The disrupted duct was confirmed at surgery and shown to communicate with the pseudocyst (*). (c) Endoscopic retrograde cholangiopancreatogram shows complete filling of the pancreatic duct (arrows) but no evidence of the fluid collection and duct disruption noted at MR cholangiopancreatography.

View larger version (131K): [in a new window]   Figure 15a.  Stricture of the pancreatic duct resulting from trauma in a 68-year-old woman with abdominal pain and pancreatitis. The patient had experienced severe blunt abdominal trauma 17 years earlier. (a) Coronal MR cholangiopancreatogram demonstrates a normal-caliber pancreatic duct in the head, neck, and distal body of the pancreas (arrows). Marked ductal dilatation in the remainder of the pancreas (arrowheads) is present due to stricture formation. (b) Axial MR pancreatogram shows an abrupt point of transition between the normal pancreatic duct (arrow) and the dilated duct (arrowheads) in the body and tail of the pancreas.

View larger version (132K): [in a new window]   Figure 15b.  Stricture of the pancreatic duct resulting from trauma in a 68-year-old woman with abdominal pain and pancreatitis. The patient had experienced severe blunt abdominal trauma 17 years earlier. (a) Coronal MR cholangiopancreatogram demonstrates a normal-caliber pancreatic duct in the head, neck, and distal body of the pancreas (arrows). Marked ductal dilatation in the remainder of the pancreas (arrowheads) is present due to stricture formation. (b) Axial MR pancreatogram shows an abrupt point of transition between the normal pancreatic duct (arrow) and the dilated duct (arrowheads) in the body and tail of the pancreas.

View larger version (138K): [in a new window]   Figure 16a. Figures 16, 17. (16) Pancreatic duct dilatation, intraductal calculi, and bile duct stricture in a 47-year-old man with alcohol-induced chronic pancreatitis. (a) MR pancreatogram demonstrates dilatation of the pancreatic duct (arrows) and its side branches. Multiple intraductal calculi (arrowheads) are also seen. (b) MR cholangiopancreatogram (obtained at a different angle to allow optimal delineation of the bile duct) shows a stricture of the intrapancreatic bile duct (arrow) resulting in intrahepatic bile duct dilatation. The dilated pancreatic duct within the pancreatic head (arrowhead) is also seen. (c) Endoscopic retrograde cholangiopancreatogram demonstrates pancreatic and biliary duct dilatation, the biliary stricture (arrow), and the intraductal stones (arrowheads). (17) Bile duct stricture and pancreatic duct dilatation in a 50-year-old man with a long history of alcohol abuse and newly developed elevation of alkaline phosphatase levels. Maximum-intensity projection of an MR cholangiopancreatogram shows a smooth, tapering stricture of the intrapancreatic bile duct (arrowhead), characteristic of chronic pancreatitis. The pancreatic duct (arrows) is dilated and tortuous. The gallbladder (*) is distended.

View larger version (159K): [in a new window]   Figure 16b. Figures 16, 17. (16) Pancreatic duct dilatation, intraductal calculi, and bile duct stricture in a 47-year-old man with alcohol-induced chronic pancreatitis. (a) MR pancreatogram demonstrates dilatation of the pancreatic duct (arrows) and its side branches. Multiple intraductal calculi (arrowheads) are also seen. (b) MR cholangiopancreatogram (obtained at a different angle to allow optimal delineation of the bile duct) shows a stricture of the intrapancreatic bile duct (arrow) resulting in intrahepatic bile duct dilatation. The dilated pancreatic duct within the pancreatic head (arrowhead) is also seen. (c) Endoscopic retrograde cholangiopancreatogram demonstrates pancreatic and biliary duct dilatation, the biliary stricture (arrow), and the intraductal stones (arrowheads). (17) Bile duct stricture and pancreatic duct dilatation in a 50-year-old man with a long history of alcohol abuse and newly developed elevation of alkaline phosphatase levels. Maximum-intensity projection of an MR cholangiopancreatogram shows a smooth, tapering stricture of the intrapancreatic bile duct (arrowhead), characteristic of chronic pancreatitis. The pancreatic duct (arrows) is dilated and tortuous. The gallbladder (*) is distended.

View larger version (130K): [in a new window]   Figure 16c. Figures 16, 17. (16) Pancreatic duct dilatation, intraductal calculi, and bile duct stricture in a 47-year-old man with alcohol-induced chronic pancreatitis. (a) MR pancreatogram demonstrates dilatation of the pancreatic duct (arrows) and its side branches. Multiple intraductal calculi (arrowheads) are also seen. (b) MR cholangiopancreatogram (obtained at a different angle to allow optimal delineation of the bile duct) shows a stricture of the intrapancreatic bile duct (arrow) resulting in intrahepatic bile duct dilatation. The dilated pancreatic duct within the pancreatic head (arrowhead) is also seen. (c) Endoscopic retrograde cholangiopancreatogram demonstrates pancreatic and biliary duct dilatation, the biliary stricture (arrow), and the intraductal stones (arrowheads). (17) Bile duct stricture and pancreatic duct dilatation in a 50-year-old man with a long history of alcohol abuse and newly developed elevation of alkaline phosphatase levels. Maximum-intensity projection of an MR cholangiopancreatogram shows a smooth, tapering stricture of the intrapancreatic bile duct (arrowhead), characteristic of chronic pancreatitis. The pancreatic duct (arrows) is dilated and tortuous. The gallbladder (*) is distended.

View larger version (136K): [in a new window]   Figure 17. Figures 16, 17. (16) Pancreatic duct dilatation, intraductal calculi, and bile duct stricture in a 47-year-old man with alcohol-induced chronic pancreatitis. (a) MR pancreatogram demonstrates dilatation of the pancreatic duct (arrows) and its side branches. Multiple intraductal calculi (arrowheads) are also seen. (b) MR cholangiopancreatogram (obtained at a different angle to allow optimal delineation of the bile duct) shows a stricture of the intrapancreatic bile duct (arrow) resulting in intrahepatic bile duct dilatation. The dilated pancreatic duct within the pancreatic head (arrowhead) is also seen. (c) Endoscopic retrograde cholangiopancreatogram demonstrates pancreatic and biliary duct dilatation, the biliary stricture (arrow), and the intraductal stones (arrowheads). (17) Bile duct stricture and pancreatic duct dilatation in a 50-year-old man with a long history of alcohol abuse and newly developed elevation of alkaline phosphatase levels. Maximum-intensity projection of an MR cholangiopancreatogram shows a smooth, tapering stricture of the intrapancreatic bile duct (arrowhead), characteristic of chronic pancreatitis. The pancreatic duct (arrows) is dilated and tortuous. The gallbladder (*) is distended.

View larger version (147K): [in a new window]   Figure 18a.  Uncinate duct calculus mimicking distal bile duct calculus in a 74-year-old woman with acute pancreatitis. (a) Axial contrast material–enhanced CT scan reveals an intraductal high-attenuation focus at the junction of the inferior pancreatic head and uncinate process (arrow), suspicious for a distal common bile duct calculus. (b) MR cholangiopancreatogram demonstrates that the distal common bile duct (straight arrow) is free of calculi. Note the angular configuration of the extrahepatic bile duct (arrowheads), often seen in association with chronic pancreatitis. The pancreatic duct in the head (curved arrow) is identified. (c) MR pancreatogram obtained posterior to a shows a filling defect in the pancreatic duct in the uncinate process (arrow) representing a calculus and corresponding to the high-attenuation focus noted on the CT scan.

View larger version (132K): [in a new window]   Figure 18b.  Uncinate duct calculus mimicking distal bile duct calculus in a 74-year-old woman with acute pancreatitis. (a) Axial contrast material–enhanced CT scan reveals an intraductal high-attenuation focus at the junction of the inferior pancreatic head and uncinate process (arrow), suspicious for a distal common bile duct calculus. (b) MR cholangiopancreatogram demonstrates that the distal common bile duct (straight arrow) is free of calculi. Note the angular configuration of the extrahepatic bile duct (arrowheads), often seen in association with chronic pancreatitis. The pancreatic duct in the head (curved arrow) is identified. (c) MR pancreatogram obtained posterior to a shows a filling defect in the pancreatic duct in the uncinate process (arrow) representing a calculus and corresponding to the high-attenuation focus noted on the CT scan.

View larger version (133K): [in a new window]   Figure 18c.  Uncinate duct calculus mimicking distal bile duct calculus in a 74-year-old woman with acute pancreatitis. (a) Axial contrast material–enhanced CT scan reveals an intraductal high-attenuation focus at the junction of the inferior pancreatic head and uncinate process (arrow), suspicious for a distal common bile duct calculus. (b) MR cholangiopancreatogram demonstrates that the distal common bile duct (straight arrow) is free of calculi. Note the angular configuration of the extrahepatic bile duct (arrowheads), often seen in association with chronic pancreatitis. The pancreatic duct in the head (curved arrow) is identified. (c) MR pancreatogram obtained posterior to a shows a filling defect in the pancreatic duct in the uncinate process (arrow) representing a calculus and corresponding to the high-attenuation focus noted on the CT scan.

View larger version (155K): [in a new window]   Figure 19. Figures 19, 20. (19) Pseudocyst adjacent to the pancreatic tail in a 31-year-old man with chronic pancreatitis. MR pancreatogram reveals dilatation of the pancreatic duct and its side branches (arrows), which terminate in a pseudocyst (*) that is inseparable from the pancreatic tail (arrowhead). MR pancreatography was performed to delineate the ductal anatomy prior to pancreatojejunostomy. (20) Intrapancreatic pseudocyst in a 72-year-old woman with pancreatitis. (a) MR cholangiopancreatogram shows a pseudocyst (straight arrow) in the superior aspect of the pancreatic head, a normal-caliber main pancreatic duct (arrowheads), and ectatic side branches of the duct draining the uncinate process (curved arrow). The gallbladder (*) is seen lateral to the bile duct. (b) Endoscopic retrograde cholangiopancreatogram demonstrates a normal-caliber pancreatic duct (arrowheads) but does not opacify the pseudocyst. The ectatic side branches of the uncinate process duct (arrow) are also seen.

View larger version (149K): [in a new window]   Figure 20a. Figures 19, 20. (19) Pseudocyst adjacent to the pancreatic tail in a 31-year-old man with chronic pancreatitis. MR pancreatogram reveals dilatation of the pancreatic duct and its side branches (arrows), which terminate in a pseudocyst (*) that is inseparable from the pancreatic tail (arrowhead). MR pancreatography was performed to delineate the ductal anatomy prior to pancreatojejunostomy. (20) Intrapancreatic pseudocyst in a 72-year-old woman with pancreatitis. (a) MR cholangiopancreatogram shows a pseudocyst (straight arrow) in the superior aspect of the pancreatic head, a normal-caliber main pancreatic duct (arrowheads), and ectatic side branches of the duct draining the uncinate process (curved arrow). The gallbladder (*) is seen lateral to the bile duct. (b) Endoscopic retrograde cholangiopancreatogram demonstrates a normal-caliber pancreatic duct (arrowheads) but does not opacify the pseudocyst. The ectatic side branches of the uncinate process duct (arrow) are also seen.

View larger version (138K): [in a new window]   Figure 20b. Figures 19, 20. (19) Pseudocyst adjacent to the pancreatic tail in a 31-year-old man with chronic pancreatitis. MR pancreatogram reveals dilatation of the pancreatic duct and its side branches (arrows), which terminate in a pseudocyst (*) that is inseparable from the pancreatic tail (arrowhead). MR pancreatography was performed to delineate the ductal anatomy prior to pancreatojejunostomy. (20) Intrapancreatic pseudocyst in a 72-year-old woman with pancreatitis. (a) MR cholangiopancreatogram shows a pseudocyst (straight arrow) in the superior aspect of the pancreatic head, a normal-caliber main pancreatic duct (arrowheads), and ectatic side branches of the duct draining the uncinate process (curved arrow). The gallbladder (*) is seen lateral to the bile duct. (b) Endoscopic retrograde cholangiopancreatogram demonstrates a normal-caliber pancreatic duct (arrowheads) but does not opacify the pseudocyst. The ectatic side branches of the uncinate process duct (arrow) are also seen.

View larger version (136K): [in a new window]   Figure 21a.  Intramural duodenal fluid collection communicating with the pancreatic duct in a 55-year-old man with a history of alcohol abuse who presented with acute pancreatitis, nausea, and vomiting. (a) MR pancreatogram shows a communication (solid arrow) between the main pancreatic duct (arrowheads) and the fluid collection (*) in the wall of the duodenum. The gallbladder (open arrow) is also seen. (b) MR cholangiogram demonstrates the complex intramural duodenal fluid collection (*), which has significantly narrowed the lumen of the descending duodenum (arrows). (c) Upper gastrointestinal series shows narrowing of the descending duodenum (arrows) caused by the intramural duodenal fluid collection.

View larger version (132K): [in a new window]   Figure 21b.  Intramural duodenal fluid collection communicating with the pancreatic duct in a 55-year-old man with a history of alcohol abuse who presented with acute pancreatitis, nausea, and vomiting. (a) MR pancreatogram shows a communication (solid arrow) between the main pancreatic duct (arrowheads) and the fluid collection (*) in the wall of the duodenum. The gallbladder (open arrow) is also seen. (b) MR cholangiogram demonstrates the complex intramural duodenal fluid collection (*), which has significantly narrowed the lumen of the descending duodenum (arrows). (c) Upper gastrointestinal series shows narrowing of the descending duodenum (arrows) caused by the intramural duodenal fluid collection.

View larger version (131K): [in a new window]   Figure 21c.  Intramural duodenal fluid collection communicating with the pancreatic duct in a 55-year-old man with a history of alcohol abuse who presented with acute pancreatitis, nausea, and vomiting. (a) MR pancreatogram shows a communication (solid arrow) between the main pancreatic duct (arrowheads) and the fluid collection (*) in the wall of the duodenum. The gallbladder (open arrow) is also seen. (b) MR cholangiogram demonstrates the complex intramural duodenal fluid collection (*), which has significantly narrowed the lumen of the descending duodenum (arrows). (c) Upper gastrointestinal series shows narrowing of the descending duodenum (arrows) caused by the intramural duodenal fluid collection.

View larger version (139K): [in a new window]   Figure 22a.  Pancreaticopleural fistula in a 50-year-old man with acute pancreatitis and a right pleural fluid collection. Laboratory analysis of the pleural fluid revealed an elevated amylase level. (a) MR pancreatogram shows a 9 x 1-cm fistula (arrows) extending from the pancreas into the right pleural space. An adjacent pseudocyst (*) is also seen. (b) MR pancreatogram obtained 15 mm anterior to a demonstrates a dilated pancreatic duct (straight arrow) and a 5-mm intraductal calculus (arrowhead). The pseudocyst (*) is again noted and is inseparable from the stomach (curved arrow). (c) Endoscopic retrograde cholangiopancreatogram helps confirm the fistula (straight arrows), which fills from the pancreatic duct (arrowheads). The intraductal calculus (curved arrow) is also seen (cf b).

View larger version (158K): [in a new window]   Figure 22b.  Pancreaticopleural fistula in a 50-year-old man with acute pancreatitis and a right pleural fluid collection. Laboratory analysis of the pleural fluid revealed an elevated amylase level. (a) MR pancreatogram shows a 9 x 1-cm fistula (arrows) extending from the pancreas into the right pleural space. An adjacent pseudocyst (*) is also seen. (b) MR pancreatogram obtained 15 mm anterior to a demonstrates a dilated pancreatic duct (straight arrow) and a 5-mm intraductal calculus (arrowhead). The pseudocyst (*) is again noted and is inseparable from the stomach (curved arrow). (c) Endoscopic retrograde cholangiopancreatogram helps confirm the fistula (straight arrows), which fills from the pancreatic duct (arrowheads). The intraductal calculus (curved arrow) is also seen (cf b).

View larger version (130K): [in a new window]   Figure 22c.  Pancreaticopleural fistula in a 50-year-old man with acute pancreatitis and a right pleural fluid collection. Laboratory analysis of the pleural fluid revealed an elevated amylase level. (a) MR pancreatogram shows a 9 x 1-cm fistula (arrows) extending from the pancreas into the right pleural space. An adjacent pseudocyst (*) is also seen. (b) MR pancreatogram obtained 15 mm anterior to a demonstrates a dilated pancreatic duct (straight arrow) and a 5-mm intraductal calculus (arrowhead). The pseudocyst (*) is again noted and is inseparable from the stomach (curved arrow). (c) Endoscopic retrograde cholangiopancreatogram helps confirm the fistula (straight arrows), which fills from the pancreatic duct (arrowheads). The intraductal calculus (curved arrow) is also seen (cf b).

View larger version (139K): [in a new window]   Figure 23a.  Pancreatic head carcinoma and bile duct stent in a 41-year-old man. (a) MR cholangiopancreatogram shows the dilated extrahepatic bile duct (straight arrow) terminating in a pancreatic head mass (*). A biliary stent is seen as a linear filling defect in the dilated bile duct. The stent is seen to contain fluid (arrowhead) as it traverses the pancreatic head mass. Note the absence of artifacts associated with the stent. The pancreatic duct (curved arrow) is narrowed by the mass. (b) MR pancreatogram reveals a dilated pancreatic duct (arrows) proximal to the obstructing pancreatic head mass. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the dilatation of the pancreatic duct in the body (arrows) and the distal stricture (arrowhead).

View larger version (153K): [in a new window]   Figure 23b.  Pancreatic head carcinoma and bile duct stent in a 41-year-old man. (a) MR cholangiopancreatogram shows the dilated extrahepatic bile duct (straight arrow) terminating in a pancreatic head mass (*). A biliary stent is seen as a linear filling defect in the dilated bile duct. The stent is seen to contain fluid (arrowhead) as it traverses the pancreatic head mass. Note the absence of artifacts associated with the stent. The pancreatic duct (curved arrow) is narrowed by the mass. (b) MR pancreatogram reveals a dilated pancreatic duct (arrows) proximal to the obstructing pancreatic head mass. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the dilatation of the pancreatic duct in the body (arrows) and the distal stricture (arrowhead).

View larger version (129K): [in a new window]   Figure 23c.  Pancreatic head carcinoma and bile duct stent in a 41-year-old man. (a) MR cholangiopancreatogram shows the dilated extrahepatic bile duct (straight arrow) terminating in a pancreatic head mass (*). A biliary stent is seen as a linear filling defect in the dilated bile duct. The stent is seen to contain fluid (arrowhead) as it traverses the pancreatic head mass. Note the absence of artifacts associated with the stent. The pancreatic duct (curved arrow) is narrowed by the mass. (b) MR pancreatogram reveals a dilated pancreatic duct (arrows) proximal to the obstructing pancreatic head mass. (c) Endoscopic retrograde cholangiopancreatogram helps confirm the dilatation of the pancreatic duct in the body (arrows) and the distal stricture (arrowhead).

View larger version (140K): [in a new window]   Figure 24a.  Uncinate process carcinoma with bile duct dilatation and normal pancreatic duct in a 69-year-old man with painless jaundice. (a) Scout MR cholangiopancreatogram provides a comprehensive image of the dilated biliary tract (straight arrows) and of a cystic mass (curved arrow) that proved to be adenocarcinoma at surgery. The pancreatic duct (arrowheads) is normal in caliber. (b) MR cholangiopancreatogram shows biliary duct dilatation with abrupt termination of the extrahepatic bile duct (arrow) at the pancreatic head. (c) MR cholangiopancreatogram of the distal bile duct demonstrates a cystic mass in the uncinate process (curved arrow) causing bile duct obstruction. Note the normal pancreatic duct (straight arrow).

View larger version (138K): [in a new window]   Figure 24b.  Uncinate process carcinoma with bile duct dilatation and normal pancreatic duct in a 69-year-old man with painless jaundice. (a) Scout MR cholangiopancreatogram provides a comprehensive image of the dilated biliary tract (straight arrows) and of a cystic mass (curved arrow) that proved to be adenocarcinoma at surgery. The pancreatic duct (arrowheads) is normal in caliber. (b) MR cholangiopancreatogram shows biliary duct dilatation with abrupt termination of the extrahepatic bile duct (arrow) at the pancreatic head. (c) MR cholangiopancreatogram of the distal bile duct demonstrates a cystic mass in the uncinate process (curved arrow) causing bile duct obstruction. Note the normal pancreatic duct (straight arrow).

View larger version (149K): [in a new window]   Figure 24c.  Uncinate process carcinoma with bile duct dilatation and normal pancreatic duct in a 69-year-old man with painless jaundice. (a) Scout MR cholangiopancreatogram provides a comprehensive image of the dilated biliary tract (straight arrows) and of a cystic mass (curved arrow) that proved to be adenocarcinoma at surgery. The pancreatic duct (arrowheads) is normal in caliber. (b) MR cholangiopancreatogram shows biliary duct dilatation with abrupt termination of the extrahepatic bile duct (arrow) at the pancreatic head. (c) MR cholangiopancreatogram of the distal bile duct demonstrates a cystic mass in the uncinate process (curved arrow) causing bile duct obstruction. Note the normal pancreatic duct (straight arrow).