ecr2010_c-0168

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Asymptomatic nonspecific serum hyperamylasemia andhyperlipasemia: Spectrum of secretin-enhanced MRCPfindings

Poster No.: C-0168

Congress: ECR 2010

Type: Scientific Exhibit

Topic: Abdominal Viscera (Solid Organs)

Authors: G. Restaino1, M. Barrassi1, E. Bufi2, M. Missere1, M. Occhionero1,

G. Sallustio1; 1Campobasso/IT, 2Rome/IT

Keywords: Asymptomatic serum hyperamylasemia and hyperlipasemia,Secretin-enhanced MRCP, Magnetic resonance imaging

DOI: 10.1594/ecr2010/C-0168

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Purpose

Persistently high serum pancreatic enzymes in asymptomatic subjects areconsidered a benign idiopathic condition called "non-pathological chronic pancreatichyperenzymemia" (CPH).

Advanced imaging techniques have brought to light abnormal pancreatic findings in asignificant proportion of these subjects.

The objective of this study was to describe secretin-enhanced magnetic resonancecholangiopancreatography (S-MRCP) findings in a large cohort of subjects with CPH.

Methods and Materials

Study population

69 patients (mean age: 52.7±12.2 y/o; M:F= 38:31) who underwent S-MRCP at ourInstitution with clinical indication of CPH, out of 371 patients studied with S-MRCP fromFebruary 2007 to August 2009.

Clinical indication had been defined by referral physicians; pancreatic serumhyperenzymemia were diagnosed by individual laboratories.

MRI protocol

All the examinations had been performed with a 1.5 T scanner and a 8-channel phased-array surface coils according the same image protocol.

The MR examination required 6 h of prior fasting in order to minimize intestinal peristalsis.

Administration of negative oral contrast agent helped to avoid obscuration of thepancreatic ducts by high signal intensity in the overlying stomach and duodenum. Wegave the oral contrast medium approximately 20 minutes before initiating the MRCPacquisitions. The examination were performed with the patient in supine position, whichminimizes discomfort and hence movement artifacts, but prone decubitus was allowed ifthe patient preferred it because of mild claustrophobia.

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After the acquisition of axial locator images, the pancreatic duct was imaged by applying asingle-shot fast spin-echo pulse sequence within a single 35-40-mm-thick oblique coronalslab positioned over the pancreas. The matrix size for most patients is 256x256; the FOVvaried from patient to patient but was generally 30 x 30 cm. Echo time was typically morethan 750 msec. Acquisition time was approximately 1-2 seconds per section, and imageswere acquired during breath holding.

Fig.: 2D-MRCP localizationReferences: G. Restaino; Radiology, Catholic University of Sacred Heart,Campobasso, ITALY

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The morphologic examination of pancreas was completed with:

•FSPGR T1-weighted fat-sat axial acquisition,

•FSPGR T1-weighted in-out phase axial acquisition,

•SSFSE T2-weighted axial and coronal acquisition,

•FIESTA axial acquisition,

•3D-LAVA triphasic acquisition during Gd-DTPA administration with 40", 70" and 180"delay.

Slice thickness is 5 mm except for LAVA, which has 3 mm thick volumetric slices, ZIP 2

Fig.: Morphologic pancreatic studyReferences: G. Restaino; Radiology, Catholic University of Sacred Heart,Campobasso, ITALY

S-MRCP studies were evaluated for the presence of anatomic variants of the pancreaticduct, acute or chronic pancreatitis, neoplastic pancreatic disease, pancreatic cysticlesions, and sphincter of Oddi dysfunction (SOD) defined as a 10-min persisting dilationof the main pancreatic duct after secretin injection.

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Results

MRCP-S showed abnormal pancreatic morphological findings in 38 of the 69 cases (55%)(Fig 1)

Fig.: S-MRCP findings in patients with asimptomatic pancreatic hyperenzymemiaReferences: G. Restaino; Radiology, Catholic University of Sacred Heart,Campobasso, ITALY

MRCP signs of chronic pancreatitis, according to the Cambridge classification, weredetected in 28 cases (41%), of whom 6 were mild and 22 moderate.

Pancreas divisum and SOD were each identified in 11 cases (16%).

Acinar filling was observed in 8 patients (12%);

pancreatic exocrine reserve was normal in 94% of patients and mildly impaired in 6%;

cysts < 5 mm were found in 6 cases.

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No pancreatic or extrapancreatic masses were detected.

Conclusion

Many different S-MRCP findings are associated to CPH.

The commonest among these are mild chronic pancreatitis, pancreas divisum and SOD.

S-MRCP is to be recommended in the diagnostic work-up of CPH subjects.

References

1. Mortelé KJ, Wiesner W, Zou KH, Ros PR, Silverman SG. Asymptomaticnonspecific serum hyperamylasemia and hyperlipasemia: spectrum ofMRCP findings and clinical implications. Abdom Imaging. 2004 Jan-Feb;29(1):109-14.

2. Donati F, Boraschi P, Gigoni R, Salemi S, Faggioni L, Bertucci C, Cecchi C,Bartolozzi C, Falaschi F. Secretin-stimulated MR cholangio-pancreatographyin the evaluation of asymptomatic patients with non-specific pancreatichyperenzymemia. Eur J Radiol. . [Epub ahead of print] PubMed PMID:20005059.

3. Gullo L, Lucrezio L, Calculli L, Salizzoni E, Coe M, Migliori M, CasadeiR, Costa PL, Nesticò V. Magnetic resonance cholangiopancreatographyin asymptomatic pancreatic hyperenzymemia. Pancreas. 2009May;38(4):396-400.

4. A, Curioni S, Giussani A, Masci E. Pancreatic ductal abnormalitiesdocumented by secretin-enhanced MRCP in asymptomatic subjectswith chronic pancreatic hyperenzymemia. Am J Gastroenterol. 2009Jul;104(7):1780-6.

5. Byrne MF, Mitchell RM, Stiffler H, Jowell PS, Branch MS, Pappas TN,Tyler D, Baillie J. Extensive investigation of patients with mild elevationsof serum amylase and/or lipase is 'low yield'. Can J Gastroenterol. 2002Dec;16(12):849-54.

6. Lankisch PG, Doobe C, Finger T, Lübbers H, Mahlke R, Brinkmann G,Klöppel G, Maisonneuve P, Lowenfels AB. Hyperamylasaemia and/orhyperlipasaemia: incidence and underlying causes in hospitalized patientswith non-pancreatic diseases. Scand J Gastroenterol. 2009;44(2):237-41.

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Personal Information

Dr. Gennaro Restaino, MD

Consultant Radiologist

Imaging Department

"John Paul II" Center for High Technology Research and Education in BiomedicalSciences

Catholic University of Sacred Heart

86100 Campobasso

ITALY

Phone: +39-0874-312338/6

Fax: +39-0874-312522

E:mail: [email protected]

ecr2010_c-0168

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