MR Enterography Silvio Mazziotti Alfredo Blandino (cid:129) MR Enterography In collaboration with: Giorgio Ascenti, Tommaso D’Angelo Silvio Mazziotti Alfredo Blandino Department of Radiological Department of Radiological Sciences Sciences University of Messina University of Messina Messina Messina Italy Italy ISBN 978-88-470-5670-1 ISBN 978-88-470-5675-6 (eBook) DOI 10.1007/978-88-470-5675-6 Springer Milan Heidelberg New York Dordrecht London Library of Congress Control Number: 2014942984 © Springer-Verlag Italia 2014 T his work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, repro- duction on microfi lms or in any other physical way, and transmission or infor- mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. 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While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Foreword It is with great pleasure and satisfaction that I present this volume dedicated to the potential contribution of magnetic resonance to the management of inflammatory bowel diseases, which are diagnosed today more frequently than in the past. A uthors wisely describe the technical tips, diagnostic pearls, and a variety of cases that they collected over the past 7 years of daily commitment. T he volume approaches this topic in gradual steps, allowing an easy consultation also to the novice, while the expert radiologist will have the opportunity to tailor, mod- ify, and expand his diagnostic approaches. The iconography they collected will allow identifying both the most patent and the subtle signs of the disease in order to allow accu- rate speculations regarding the stage, predict its evolution, and evaluate the response to therapy. The text, of straightforward comprehension in all its sec- tions, can offer interesting hints to the reader even if not a radiologist. v vi Foreword My personal appreciation for the rigorous approach of their research is widely deserved by the authors between the most motivated and skilled colleagues of the Department of Diagnostic Imaging that I have the honor to direct. I express to them my sincere congratulations. Emanuele Scribano, Head of Department of Radiological Sciences, University of Messina, Messina, Italy Contents 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Part I MR Enterography: Technique and Anatomy 2 Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.1 Enteric Contrast Agents . . . . . . . . . . . . . . . . 9 2.2 Patient’s Preparation and Positioning. . . . . 13 2.3 Protocols and Sequences. . . . . . . . . . . . . . . . 19 2.3.1 Half-Fourier Acquisition Single-Shot Turbo Spin Echo (HASTE). . . . . . . . . . . . . . . . . . . . . . . 20 2.3.2 Balanced Steady-State Free Precession (Balanced SSFP). . . . . . . 21 2.3.3 Pre- and Post-contrast T1-Weighted Ultrafast Gradient Echo. . . . . . . . . . . . . . . . . . . . . . . . . . . 24 2.4 Spasmolytics . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2.5 Intravenous Contrast Agent. . . . . . . . . . . . . 30 2.6 Advanced MR Techniques . . . . . . . . . . . . . . 31 2.6.1 MR Fluoroscopy. . . . . . . . . . . . . . . . . 32 2.6.2 Cine MR . . . . . . . . . . . . . . . . . . . . . . . 33 2.6.3 Diffusion-Weighted Imaging. . . . . . . 37 2.6.4 Perfusion (DCE-MRI). . . . . . . . . . . . 38 2.7 Perianal Imaging. . . . . . . . . . . . . . . . . . . . . . . 40 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 vii viii Contents 3 Normal MR Anatomy . . . . . . . . . . . . . . . . . . . . . . 45 3.1 Normal MR Anatomy of Duodenum and Small Bowel. . . . . . . . . . . . . . . . . . . . . . . 45 3.2 Normal MR Anatomy of Sphincters and Perianal Region. . . . . . . . . . . . . . . . . . . . 48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Part II MR Enterography: Clinical Applications 4 MR Findings in Crohn’s Disease . . . . . . . . . . . . . 57 4.1 Wall Thickening . . . . . . . . . . . . . . . . . . . . . . . 60 4.2 Ulcerations . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.3 Increased Vascularity. . . . . . . . . . . . . . . . . . . 70 4.4 Patterns of Wall Enhancement. . . . . . . . . . . 71 4.5 Perienteric Inflammation . . . . . . . . . . . . . . . 81 4.6 Reactive Adenopathy . . . . . . . . . . . . . . . . . . 83 4.7 Mesenteric Fibrofatty Proliferation. . . . . . . 86 4.8 Penetrating and Stricturing Patterns in CD . . . . . . . . . . . . . . . . . . . . . . . . 87 4.8.1 Penetrating Disease. . . . . . . . . . . . . . 88 4.8.2 Fibrostenosing Disease . . . . . . . . . . . 94 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 5 Extraintestinal Complications. . . . . . . . . . . . . . . . 103 5.1 Hepatobiliary Complications . . . . . . . . . . . . 104 5.1.1 Primary Sclerosing Cholangitis. . . . . 104 5.1.2 Gallstone Disease. . . . . . . . . . . . . . . . 107 5.1.3 Liver Abscess . . . . . . . . . . . . . . . . . . . 109 5.1.4 Portal Vein Thrombosis. . . . . . . . . . . 109 5.2 Pancreatic Complications . . . . . . . . . . . . . . . 111 5.3 Genitourinary Complications. . . . . . . . . . . . 113 5.3.1 Ureteral Obstruction. . . . . . . . . . . . . 113 5.3.2 Nephrolithiasis . . . . . . . . . . . . . . . . . . 113 5.3.3 Genitourinary Tract Fistulas. . . . . . . 116 Contents ix 5.4 Musculoskeletal and Cutaneous Manifestation . . . . . . . . . . . . . . . . . . . . . . . . . 116 5.5 Peritoneal Involvement. . . . . . . . . . . . . . . . . 120 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 6 Perianal Complications . . . . . . . . . . . . . . . . . . . . . 127 6.1 Classification of Fistulas . . . . . . . . . . . . . . . . 128 6.2 MRI in Perianal CD. . . . . . . . . . . . . . . . . . . . 130 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 7 Other Indications for MRE. . . . . . . . . . . . . . . . . . 143 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148