Usefulness of MR Cholangiopancreatography after Intravenous Morphine Administration

PURPOSE: We wanted to assess the usefulness of MRCP after intravenous morphine administration in the evaluation of the hepatopancreatic pancreatico-biliary ductal system. MATERIALS AND METHODS: We studied 15 patients who were suspected of having disease of hepatopancreatic ductal system and they did not have any obstructive lesion on ultrasonography and/or CT. MRCP was acquired before and after morphine administration (0.04 mg/kg, intravenously). Three radiologists scored the quality of the images of the anatomic structures in the hepatopancreatic ductal system. We directly compared the quality of the images obtained with using the two methods and the improvement of the artifacts by pulsatile vascular compression. RESULTS: The MRCP images obtained after intravenous morphine administration were better than those obtained before morphine administration for visualizing the hepatopancreatic ductal system. On direct comparison, the MRCP images obtained after morphine administration were better in 12 cases, equivocal in two cases, and the images before morphine administration were better in only one case. In three patients, MRCP before morphine injection showed signal loss at the duct across the pulsatile hepatic artery. In two of three patients, MRCP after morphine injection showed no signal loss in this ductal area. CONCLUSION: MRCP after intravenous morphine administration enables physicians to see the hepatopancreatic ductal system significantly better and the artifacts caused by pulsation of the hepatic artery can be avoided.

Intraluminal Filling Defects of the Bile Ducts: Differentiation of Stones from Tumors-the Value of Magnetic Resonance Cholangiography in Conjunction with a 3D Spoiled Gradient Echo Gadolinium Enhanced Dynamic Sequence

PURPOSE: We wanted to determinate the value of a dynamic volumetric interpolated breath-hold examination (VIBE) as a supplement to MR cholangiography for differentiating biliary stones from tumors when patient are suspected of having intraluminal filling defects on direct cholangiography. MATERIALS AND METHODS: A retrospective analysis was performed for 49 patients who underwent MRI among all the patients who showed intraluminal filling defects on direct cholangiography for evaluating the cause of their jaundice from June 2002 to June 2003. After dividing these patients into two groups, i.e., the group with stones and the group with tumors, we analyzed and compared each MR patterns of 1) signal intensity, 2) shape, and 3) enhancement. RESULTS: High signal intensity on T1-weighted images (p< 0.001, chi-square test), dark signal intensity on T2-weighted images (p< 0.01, Fisher's exact test) or smooth contour of intraluminal filling defects (p< 0.001, chi-square test) could be significantly suggestive findings of stone rather than a tumor mass. Dynamic VIBE is the most specific sequence for differentiating non-enhancing stone from an enhancing mass (p< 0.001, Fisher's exact test). CONCLUSION: We showed that MR cholangiography, when added to the dynamic VIBE sequences, could be an important imaging technique for patients who are suspected of having intraluminal filling defects on direct cholangiography to differentiate stones from tumors. Especially, the addition of dynamic VIBE images can provide the increased level of confidence in the diagnosis.

Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation

OBJECTIVE: To describe the anatomical variation occurring in intrahepatic bile ducts (IHDs) in terms of their branching patterns, and to determine the frequency of each variation. MATERIALS AND METHODS: The study group consisted of 300 consecutive donors for liver transplantation who underwent intraoperative cholangiography. Anatomical variation in IHDs was classified according to the branching pattern of the right anterior and right posterior segmental duct (RASD and RPSD, respectively), and the presence or absence of the first-order branch of the left hepatic duct (LHD), and of an accessory hepatic duct. RESULTS: The anatomy of the intrahepatic bile ducts was typical in 63% of cases (n=188), showed triple confluence in 10% (n=29), anomalous drainage of the RPSD into the LHD in 11% (n=34), anomalous drainage of the RPSD into the common hepatic duct (CHD) in 6% (n=19), anomalous drainage of the RPSD into the cystic duct in 2% (n=6), drainage of the right hepatic duct (RHD) into the cystic duct (n=1), the presence of an accessory duct leading to the CHD or RHD in 5% (n=16), individual drainage of the LHD into the RHD or CHD in 1% (n=4), and unclassified or complex variation in 1% (n=3). CONCLUSION: The branching pattern of IHDs was atypical in 37% of cases. The two most common variations were drainage of the RPSD into the LHD (11%) and triple confluence of the RASD, RPSD and LHD (10%).

Choledochal Cysts in Children: Pre- and Postoperative Radiological Evaluation

PURPOSE: To review the type, incidence and radiologic findings and to evaluate the clinical significance of intrahepatic duct dilatation of choledochal cysts in children. MATERIALS AND METHODS: Ultrasonography and operative cholangiography of 49 consecutive children with surgically confirmed choledochal cyst were reviewed and classified according to the Todani's classification. Patients with intrahepatic duct dilatation in preoperative evaluation were routinely followed by ultrasonography after surgery of extrahepatic bile duct. The status of bileduct was evaluated by comparing with the preoperative ultrasonography. RESULTS: According to the preoperative evaluation, there were 19 cases(39%) of type Ia, three cases(6%) of type Ib, ten cases(20%) of type Ic, 15 cases(31%) of type IVa, two cases(4%) of type V, but no case of the type II, III, IVb in Todani's classification.In twelve of 13 patients (five cases of type I and eight cases of type IVa) who had been followed up after surgery of choledochal cyst, the previously noted intrahepatic ductal dilatation were no longer seen. CONCLUSION: The incidence of the types of choledochal cysts by Todani's classification shows no significant difference between our result and the other authors'. The intrahepatic ductal dilatation seems to be reversible and mainly secondary to extrahepatic obstruction by choledochal cyst. Thus, postoperative follow up examination is more important than preoperative classification of bile duct dilatation.