HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) CME Test (opens in a new window) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Silva, A. C. Articles by Liu, P. T. Search for Related Content PubMed PubMed Citation Articles by Silva, A. C. Articles by Liu, P. T. Related Collections Magnetic Resonance Imaging Gastrointestinal Radiology

MR Cholangiopancreatography: Improved Ductal Distention with Intravenous Morphine Administration¹

¹ From the Department of Diagnostic Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259 (A.C.S., A.K.H., P.T.L.); and Department of Diagnostic Radiology, Mayo Clinic Rochester, Rochester, Minn (J.L.F.). Presented as an education exhibit at the 2002 RSNA scientific assembly. Received March 31, 2003; revision requested May 13; revision received July 31 and accepted August 5. All authors have no financial relationships to disclose. Address correspondence to A.C.S. (e-mail: silva.alvin@mayo.edu).

View larger version (45K): [in a new window]   Figure 1.  Diagram of the normal biliary anatomy. Anterior (RAD) and posterior (RPD) segmental right hepatic ducts join to form the main right hepatic duct (R), which may vary in length. The right and left (L) main intrahepatic ducts become extrahepatic proximal to their confluence in the common hepatic duct (CHD), which joins with the cystic duct (C) to form the common bile duct (CBD). Biliary and pancreatic duct (PD) flow is regulated by the sphincter of Oddi (SO).

View larger version (88K): [in a new window]   Figure 2.  Diagram of the sphincter of Oddi. (Fig 2 courtesy of the Mayo Foundation.)

View larger version (20K): [in a new window]   Figure 3.  Schematics of right hepatic duct anatomic variants (red lines) show typical anatomy (A), found in 58% of the general population; aberrant drainage of the posterior segmental right hepatic duct into the left hepatic duct (B), found in 13%-19%; trifurcation anomaly (C; Fig 7), found in 11%; distal confluence of the posterior and anterior segmental right hepatic ducts (D; Fig 8), found in 12%; direct confluence of the posterior segmental right hepatic duct with the common hepatic duct (E; Fig 5), found in 5%; distal confluence of the posterior and anterior segmental right hepatic ducts, with a separate accessory right duct draining into the left hepatic duct (F; Fig 9), rarely found; and quadriform anomaly (G; Fig 10), also rarely found.

View larger version (98K): [in a new window]   Figure 4a.  Coronal thick-slab images from MR cholangiopancreatography show a normal cystic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the cystic duct (long arrow), the left hepatic duct (arrowhead), and an accessory pancreatic duct (short arrows) after morphine administration.

View larger version (96K): [in a new window]   Figure 4b.  Coronal thick-slab images from MR cholangiopancreatography show a normal cystic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the cystic duct (long arrow), the left hepatic duct (arrowhead), and an accessory pancreatic duct (short arrows) after morphine administration.

View larger version (150K): [in a new window]   Figure 5a.  Axial thin-section images from non-breath-hold MR cholangiopancreatography with a T2-weighted single-shot fast spin-echo sequence show a normal accessory pancreatic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the minor pancreatic duct of Santorini (arrow) after morphine administration.

View larger version (150K): [in a new window]   Figure 5b.  Axial thin-section images from non-breath-hold MR cholangiopancreatography with a T2-weighted single-shot fast spin-echo sequence show a normal accessory pancreatic duct before (a) and after (b) morphine injection. Note the increased distention and improved depiction of the minor pancreatic duct of Santorini (arrow) after morphine administration.

View larger version (89K): [in a new window]   Figure 6a.  Pulsatility artifact and tumor in a patient. (a) Three-dimensional image from non-breath-hold MR cholangiopancreatography before morphine injection shows signal loss (arrows) at the proximal common hepatic duct, caused by pulsation from the adjacent hepatic artery. (b) Three-dimensional image from non-breath-hold MR cholangiopancreatography after morphine injection shows improved distention in the duct, as well as a cystic pancreatic mass (arrowheads). The mass was diagnosed after surgical resection as an intraductal papillary mucinous tumor.

View larger version (107K): [in a new window]   Figure 6b.  Pulsatility artifact and tumor in a patient. (a) Three-dimensional image from non-breath-hold MR cholangiopancreatography before morphine injection shows signal loss (arrows) at the proximal common hepatic duct, caused by pulsation from the adjacent hepatic artery. (b) Three-dimensional image from non-breath-hold MR cholangiopancreatography after morphine injection shows improved distention in the duct, as well as a cystic pancreatic mass (arrowheads). The mass was diagnosed after surgical resection as an intraductal papillary mucinous tumor.

View larger version (81K): [in a new window]   Figure 7a.  Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).

View larger version (77K): [in a new window]   Figure 7b.  Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).

View larger version (96K): [in a new window]   Figure 7c.  Pulsatility artifact and aberrant drainage of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows drainage of the posterior segmental right hepatic duct (RPD) into the common hepatic duct, with an area of signal loss (arrow) where the duct crosses the pulsatile hepatic artery, near the point of confluence. (b) Coronal thin-section image from MR cholangiopancreatography after morphine injection shows increased distention in this ductal area (arrow) and in the pancreatic duct (arrowheads). (c) Intraoperative cholangiogram helps confirm the patency of the hepatic duct (arrow).

View larger version (77K): [in a new window]   Figure 8a.  Trifurcation anomaly in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows a short right hepatic duct (arrow) in a location suggestive of trifurcation anomaly, but depiction is inadequate for a definitive determination. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows a posterior segmental right hepatic duct (arrow) that drains into the confluence of the anterior segmental right duct and the left hepatic ducts (ie, trifurcation anomaly). Note the improved distention and visualization of the pancreatic duct (PD) and segmental left hepatic duct (arrowhead).

View larger version (76K): [in a new window]   Figure 8b.  Trifurcation anomaly in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows a short right hepatic duct (arrow) in a location suggestive of trifurcation anomaly, but depiction is inadequate for a definitive determination. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows a posterior segmental right hepatic duct (arrow) that drains into the confluence of the anterior segmental right duct and the left hepatic ducts (ie, trifurcation anomaly). Note the improved distention and visualization of the pancreatic duct (PD) and segmental left hepatic duct (arrowhead).

View larger version (66K): [in a new window]   Figure 9a.  Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).

View larger version (76K): [in a new window]   Figure 9b.  Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).

View larger version (71K): [in a new window]   Figure 9c.  Distal confluence of the posterior and anterior segments of the right hepatic duct in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection does not clearly depict the posterior segmental right hepatic duct. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly depicts distal drainage from the posterior segmental right hepatic duct (RPD) to the anterior segmental right hepatic duct, a favorable anatomic variant that allows surgical access to a longer right ductal segment (arrows). (c) Intraoperative cholangiogram helps confirm the location of confluence of the posterior and anterior segmental right hepatic ducts (arrow).

View larger version (94K): [in a new window]   Figure 10a.  Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.

View larger version (92K): [in a new window]   Figure 10b.  Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.

View larger version (104K): [in a new window]   Figure 10c.  Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows both the posterior (RPD) and anterior (RAD) segmental right hepatic ducts. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection depicts a small accessory right duct (arrow), not visible in a, that drains into the left hepatic duct. (c) Intraoperative cholangiogram helps confirm the presence of the accessory segment.

View larger version (93K): [in a new window]   Figure 11a.  Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection suggests but does not clearly depict quadriform anomaly. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly shows the confluence of the posterior (RPD) and anterior (RAD) segmental right hepatic ducts with the main (L) and segment IV (IV) left hepatic ducts, and faintly depicts an accessory anterior segmental right duct (arrow). The aberrant biliary anatomy in this patient precluded donor hepatectomy.

View larger version (87K): [in a new window]   Figure 11b.  Rare anatomic variants in a liver donor candidate. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection suggests but does not clearly depict quadriform anomaly. (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection clearly shows the confluence of the posterior (RPD) and anterior (RAD) segmental right hepatic ducts with the main (L) and segment IV (IV) left hepatic ducts, and faintly depicts an accessory anterior segmental right duct (arrow). The aberrant biliary anatomy in this patient precluded donor hepatectomy.

View larger version (88K): [in a new window]   Figure 12a.  Cholangiocarcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregular areas of partial obstruction in the left hepatic duct (Lt) that indicate a mass, but relative patency in the right hepatic duct (Rt). (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows that the mass also involves the right hepatic duct (arrow) downstream from the confluence of the posterior (RPD) and anterior (RAD) segmental ducts, a finding that led to an upgrade in classification of the lesion from Bismuth type IIIb to type IV cholangiocarcinoma and a change in treatment planning from a standard left hepatectomy to an extended left hepatectomy.

View larger version (84K): [in a new window]   Figure 12b.  Cholangiocarcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregular areas of partial obstruction in the left hepatic duct (Lt) that indicate a mass, but relative patency in the right hepatic duct (Rt). (b) Coronal thick-slab image from MR cholangiopancreatography after morphine injection shows that the mass also involves the right hepatic duct (arrow) downstream from the confluence of the posterior (RPD) and anterior (RAD) segmental ducts, a finding that led to an upgrade in classification of the lesion from Bismuth type IIIb to type IV cholangiocarcinoma and a change in treatment planning from a standard left hepatectomy to an extended left hepatectomy.

View larger version (111K): [in a new window]   Figure 13a.  Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.

View larger version (93K): [in a new window]   Figure 13b.  Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.

View larger version (112K): [in a new window]   Figure 13c.  Pancreatic carcinoma. (a) Coronal thick-slab image from MR cholangiopancreatography before morphine injection shows irregularly dilated ducts in the pancreatic tail (arrows), a finding suggestive of focal chronic pancreatitis, intraductal papillary mucinous tumor, or an obstructive mass. (b, c) Coronal thick-slab image (b) and axial single-shot fast spin-echo image (c) from MR cholangiopancreatography after morphine injection provide clearer delineation of the proximal and distal extent of the mass (arrows). Inset: Image from positron emission tomography depicts an area of high metabolic activity (arrow) in the pancreas, a finding consistent with neoplasm. Pancreatic adenocarcinoma was confirmed after surgical excision.