Intraductal papillary mucinous neoplasm penetrating to the stomach, duodenum, and jejunum demonstrated on MR cholangiopancreatography with an oral negative contrast agent

Abstract

A 65-year-old man was referred to our hospital due to epigastric pain. Abdominal enhanced computed tomography (CT) demonstrated marked dilatation of the main pancreatic duct (MPD) and communication to the gastric and duodenal lumen was suspected. Esophagogastroduodenoscopy (EGD) showed a villous tumor with white mucous discharge in the posterior wall of the gastric corpus and duodenal bulb. Pathological specimens showed mucin-producing epithelium with nuclear atypia that had developed in a papillary form. Based on these findings, we diagnosed intraductal papillary mucinous neoplasm (IPMN) arising in the MPD with penetration into the gastric and duodenal lumen. Magnetic resonance cholangiopancreatography (MRCP) with an oral negative contrast agent (manganese chloride tetrahydrate) showed a fistulous tract not only to the stomach and duodenum, but also to the jejunum. MRCP demonstrated mucous streaming with remarkably high intensity. In this case, an oral negative contrast agent was useful to distinguish mucous discharge from gastric fluid, facilitating the diagnosis of penetration to the jejunum. This finding was unobtainable by CT or EGD. When IPMN penetrating to other organs is suspected, MRCP with an oral negative contrast agent may provide important information.

Efficacy of oral contrast agents for upper gastrointestinal signal suppression in MRCP: A systematic review of the literature

“…The shortest fasting period provided was 3 h ( 10 ), the longest was 12 h ( 11 ) with a median 6 h ( 12 – 16 ). The administered amount of contrast agent ranged from 10 mL ( 17 ) to 1000 mL ( 18 ); two articles did not supply any information on the administered amount of oral contrast ( 19 , 20 ). In most cases (n = 11), MRCP was performed immediately after the oral ingestion ( 11 , 17 – 27 ).…”

“…The administered amount of contrast agent ranged from 10 mL ( 17 ) to 1000 mL ( 18 ); two articles did not supply any information on the administered amount of oral contrast ( 19 , 20 ). In most cases (n = 11), MRCP was performed immediately after the oral ingestion ( 11 , 17 – 27 ). In all other cases (n = 14), time intervals between oral administration and the beginning of the scan ranged between 5 min ( 10 , 28 , 29 ) and 180 min ( 20 ).…”

“…Twenty-two publications studied MRCP in adult patients ( 9 – 14 , 16 – 33 ). Two studies investigated MRCP in pediatric patients ( 12 , 23 ).…”

“…Ten articles used additional diagnostic methods as a reference standard, e.g. ERCP ( 9 , 11 , 14 , 16 , 21 , 23 , 25 , 26 , 30 ), computed tomography (CT) ( 16 , 21 , 26 ), surgery ( 9 , 11 , 25 ), MRCP follow-up ( 9 , 25 ), ultrasound ( 11 , 16 ), and esophagogastroduodenoscopy ( 19 ). Six publications proved high iron and manganese concentrations of the evaluated oral signal suppressors with spectroscopy ( 13 – 15 , 22 , 24 , 31 ).…”

“…Advantages of using a signal suppressor include an improved visualization of the pancreatobiliary duct system compared to MRCP without the oral contrast agents ( 9 – 11 , 13 – 17 , 21 , 22 , 24 , 26 , 28 – 30 ). Furthermore, the use of signal suppressors assisted with differential diagnoses, such as fistulas between the duct system and the GI tract, ductal stones or duodenal diverticula ( 18 , 19 , 30 ). Two studies also emphasized the prevention of overlooking relevant diagnoses due to obscuring GI signal ( 9 , 30 ).…”