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1.5T Small bowel MRI - Winterthur

ExamCard
Prof. Wentz, Klaus-Ulrich Winterthur, Kantonsspital
Patak, Michael Winterthur, Kantonsspital

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ExamCard purpose

The dynamic 3D T1-TFE sequence can help distinguish acute from chronic bowel disease because of its enhancement pattern. For instance, in Crohn's disease, the chronic phase of the disease displays a delayed enhancement, whereas an early enhancement in the bowel wall is seen during the acute phase.

 

In addition, extraluminal pathologies (e.g. free intraperitoneal fluid, abscess and mesenteric lymphadenitis, fistulas) can be assessed.

ExamCard layout

Small bowel ExamCard
Scan 1Survey
Scan 2SENSE reference
Scan 33D/T2bFFE
Scan 43D/T1dyn
Scan 5THRIVE_dyn

Image examples

3D Balanced TFE 3D T1-TFE
3D Balanced TFE
3D T1-TFE

Two different sequences are used to examine the small bowel. Both sequences are optimized for speed, so that the whole abdomen can be covered in one breath hold.

 

  • The Balanced TFE images show the bowel content with high signal intensity.
  • On 3D T1-TFE images the bowel content has low signal.
  • After IV contrast administration, the bowel wall enhances strongly.
  • The first acquired T1-TFE sequence after contrast administration is also used for the MIP reconstruction images of the blood vessels.

 

The THRIVE_dyn is provided as a possible alternative to the 3DT1/dyn.

Patient preparation

Before the examination, patients are prepared for optimal distension of the entire small bowel by taking Metamucil (0.8 g/kg body weight, dissolved in at least 1000 ml water) hourly over 4 hours. No food is allowed during the preparation period.

 

Alternatively, patients with known gastrointestinal obstruction or low stool frequency are prepared with 1500 ml of 3% Mannitol, to be taken orally over 1.5 hours before imaging. No other beverage is allowed during preparation.

 

After the examination, patients should drink plenty of fluids and eat a light supper or abstain until the following morning to avoid pain or nausea due to the viscous filling of the stomach and duodenum, in addition to the jellified Metamucil in the bowel. Mannitol may induce mild diarrhea.

 

 

Patient positioning for the MRI examination:

After instruction about the examination, check again for MRI or drug contraindications or allergies. Then take the patient to the MRI room.

  • Place the patient in prone position. Center the patient's navel on the reference mark on the SENSE Body coil.
  • Extend the arms over the head.
  • Set up the IV access with a small Venflon size (22G).
  • Connect a 3-way tab to the extension line and the first syringe with saline.
  • Cover the patient's back with the SENSE cushion before applying the SENSE Body coil to generate best results.

Contrast agent / injection protocol

  • Before scan 4 (3D B-TFE):  Buscopan 40 mg. IV, flush with 20 ml NaCl.
  • Before scan 6 (dyn 3D T1 TFE): 30 ml of 0.5 mmol/ml Gd contrast agent at 4 ml/sec, flush with 20 ml NaCl at 4 ml/sec.

Image analysis

The MR images are evaluated on an EasyVision workstation. Contrast-enhanced early- and late-phase coronal images are analyzed. In addition, MIPs are generated of the early and interstitial phase data for intestinal angiographic view.

 

A study is considered successful when the following criteria are met:

  • The patient tolerated bowel preparation
  • Good distension of all small bowel loops (1.5 - 2 cm cross sectional diameter)
  • Images show good delineation of the bowel wall
  • Correct timing of the IV contrast

 

Clinical cases

Ovarian vein varicosis 35-year-old female with chronic pelvic pain, referred to exclude endometriosis. She was found to have a left ovarian vein varicosis.
Ovarian vein varicosis
35-year-old female with chronic pelvic pain, referred to exclude endometriosis. She was found to have a left ovarian vein varicosis.

Background information

The gold standard for imaging of the small intestines is x-ray enteroclysis using nasoduodenal intubation for contrast administration and distension. Homogeneous opacification, surface coating and adequate distension are critical for diagnosis.

 

Placement of the catheter, however, can be very cumbersome and is perceived as invasive and distressing for patients, particularly if they have to undergo this procedure repeatedly, such as patients with Crohn's disease.

 

Since 2001, Dr. Wentz and Dr. Patak have used a non-invasive MR small bowel imaging procedure. The images are of good diagnostic quality and the MR procedure is non-invasive and avoids exposing patients to ionizing radiation. For optimal bowel distension, the patient is directed to ingest a Metamucil or Mannitol solution before the examination. During the examination, Gd-DOTA is used as IV contrast agent.

References

Patak MA, Froehlich JM, von Weymarn C, Zollikofer CL,Wentz K.

Evaluation of Crohn's Disease Activity with MRI

ISMRM 2003

 

Patak MA, Froehlich JM, von Weymarn C, Ritz MA, Zollikofer CL,Wentz K.

Non-invasive distension of the small bowel for magnetic-resonance imaging.

Lancet 2001 Sep 22; 358(9286): 987-8

 

Dr. Patak has decribed the procedure in more detail in the "Cookbook for MR small bowel imaging". Click on the blue link below to download this document - the document is a 4.8MB pdf file, so download time will vary with the speed of your internet connection.




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ExamCard
Intera 1.5T
Release 10, Release 9
Body, Small bowel
 

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