MAGNETIC RESONANCE

Improvement of MR cholangiopancreatography (MRCP)

images after black tea consumption
Hossein Ghanaati & Hadi Rokni-Yazdi &
Amir Hossein Jalali & Firouze Abahashemi &
Madjid Shakiba & Kavous Firouznia
Received: 26 April 2011 / Revised: 11 June 2011 / Accepted: 2 July 2011 / Published online: 5 August 2011
# European Society of Radiology 2011
Abstract
Objective Evaluation of the efficacy of black tea as the
negative oral contrast agent in MRCP.
Materials and methods MRCP was performed before and
5 and 15 min after tea consumption for 35 patients.
Depiction of the gall bladder (GB), cystic duct (CD),
proximal and distal parts of the common bile duct (CBD),
intrahepatic ducts (IHD), ampulla of vater (AV), main
pancreatic duct (MPD) and signal loss of stomach and
three different segments of the duodenum were investigated
according to VAS and Likert scores.
Results Twenty-one of the patients (60%) were female
(mean age, 50.319.2 years). Regarding visibility of
different anatomical parts of the pancreatobiliary tree, the
post procedure images were better visualized in the distal
part of CBD, AV and MPD in Likert and VAS scoring (all
P0.001). Regarding obliteration of high signal in the
stomach and three different parts of the duodenum, all post
procedure images showed significant disappearance of high
signal in Likert and VAS scoring systems (all Ps0.001).
Conclusion Black tea is a simple and safe negative oral
contrast agent which reduces the signal intensity of
gastrointestinal tract fluid and provides improved depiction
of the MPD, the distal CBD and the ampulla during MRCP.
Key Points
Tea is an effective negative oral contrast agent for
gastrointestinal MRI
Ingestion of black tea improves conspicuity of the distal
CBD in MRCP
Keywords Cholangiopancreatography
.
Magnetic
resonance
.
Contrast media
.
Biliary tract
.
Gastrointestinal
tract
.
Tea
Introduction
Magnetic resonance cholangiopancreaticography (MRCP)
is a non-invasive imaging investigation for the evaluation
of the pancreaticobiliary system [14]. The magnetic
resonance techniques applied for the pancreaticobiliary
tract are mainly based on heavily T2-weighed sequences
[5]. Fluid in the stomach and the duodenum may obscure
the pancreatic and biliary ducts and may interfere with their
depiction or may mimic certain lesions [5, 6].
We can overcome this problemby asking the patients to fast
before the examination or by using multiple acquisitions of
sequence in different planes [68]. Unfortunately, sometimes
despite using these methods, unwanted signal may not be
eliminated.
Oral negative contrast agents which have a high
amount of high molecular metal ion such as manganese
and iron are used to shorten the T2 relaxation time and
also to decrease the T2 signal from gastric and intestine
fluid [9, 10].
Among the large number of negative oral contrast agents
which have been used such as blueberry and pineapple
juice, some are expensive and not available in all countries.
H. Ghanaati
:
H. Rokni-Yazdi
:
K. Firouznia (*)
Radiology, Advanced Diagnostic and Interventional Radiology
Research Center (ADIR), Imam Khomeini Hospital,
Tehran University of Medical Sciences,
Tehran, Iran
e-mail: k_firouznia@yahoo.com
A. H. Jalali
:
F. Abahashemi
:
M. Shakiba
Advanced Diagnostic and Interventional Radiology Research
Center (ADIR), Imam Khomeini Hospital,
Tehran University of Medical Sciences,
Tehran, Iran
Eur Radiol (2011) 21:25512557
DOI 10.1007/s00330-011-2217-0
Indeed, ingestion of a large amount of some of these
agents such as blueberry is difficult.
The first publication on the use of tea as a negative oral
contrast agent was by Varavithya et al. who used Rosella
flower tea [11].
Tea, whether green or black, made from camellia sinensis
leaves is the commonest drink after water in the world [12].
Because of the natural quality of this drink, the high
amount of mineral content, especially manganese [13], and
also its low price we propose black tea as a negative oral
contrast agent for MRCP.
The purpose of this study was to investigate the use of
black tea for the first time as a negative oral contrast agent
for MRCP studies.
Materials and methods
Because of the medium level of manganese in black tea, 3
tea-bags of non-flavored tea were soaked in 300 mL of
boiled water for l0 min without further heating to make the
tea infusion. We made different tea infusion samples with
non-flavored tea-bags of different trade marks to assess
whether tea brand has an impact on black tea signal
intensity. Then we added 40 g of sugar to each sample to
make them more pleasant and tolerable. Before volunteer
study we examined 15 mL of each tea infusion using 1.5
Tesla MR (Signa, echo-speed, General Electric, Milwaukee,
USA) with routine MRCP sequences: body coil, Single
Shot FSE, TR/TE: 3,000/800, 3,500/900,4,000/800.
The signal intensity of samples were measured by a circular
ROI (Area: 1 cm) put on the area of each sample. Signal
intensity of the air was measured similarly and assumed as
noise (loss of signal) and the samples with a signal intensity
equal to noise level were assumed as signal void or loss of
signal.
Volunteer examination
Three healthy volunteers were evaluated according to the
above mentioned protocol.
Initially, Axial T2-weighted slices through the liver and
pancreas were performed to survey the liver and to find the
CBD location. Then the MR examination was continued
with routine MRCP protocols before and after 5 and 15 min
ingestion of 300 mL of tea infusion using the previously
mentioned MR system. MRCP protocols included:
Twelve radial slabs of 40 and 20 mm thickness with
10 inter-slab angle.
coronal oblique 20 mm thickness with 50% over-
lapping slabs at the best angle to see the CBD and
ampulla of vater.
The study parameters were as follows: Torso coil,
AX.T2: frFSE; TR/TE: Automatic selection/90, FoV:
matched with patients size, matrix: 256160
12 Radial 40 mm/10 slabs, SSFSE; TR/TE: 3,500/900,
matrix: 256256, FoV: 34 cm
12 radial 20 mm/10 slabs, SSFSE; TR/TE: 3,500/900,
matrix: 224224, FoV: 34 cm
Coronal oblique 20 mm overlapped slabs: SSFSE; TR/
TE: 3,500/900, matrix: 224224 FoV: 34 cm
The volunteers were questioned about the tolerability of
taste and the volume of tea infusion they had no problem
about. No side-effects were observed during and after
examination.
Image quality investigation for volunteer examinations
The images were checked by an expert radiologist. The
signal intensity in the stomach and duodenum were
investigated in the images obtained before and 5 and
15 min after tea consumption. Signal loss was observed in
these areas after tea ingestion.
The signal intensity of samples were measured by e-film
workstation 2.1 program and with circular ROI (Area:
1 cm) put on the area of each sample.
ROI diameter for large organs such as liver, CBD, etc.
and for air (as noise) was 1 cm but for thin and small
organs such as pancreatic duct,cystic duct, etc. the ROI size
was defined according to the size of organ to include only
the organ, not the tissue around it.
Patient examination
Patients who were referred to our university affiliated
hospital for MRCP underwent examination after receiving
the informed consent and were ordered to keep a non-fatty
diet 14 h before the examination and to fast on the day of
examination.
Patients with ascites and diabetes mellitus were excluded
from this study. The permission for the study and tea
consumption by the patients was confirmed by the Ethics
Committee of our university affiliated hospital. The MR
system and the protocols were the same for volunteers and
200300 mL tea infusion was consumed by the patients
according to their tolerability. Additional coronal oblique
45 mm slices with the same angle of coronal oblique
20 mm overlapped slices were performed after 15 min
protocols for better evaluation of CBD with the following
parameters: SSFSE, TR/TE: 3,500/900, Matrix: 224224,
FoV: 34 cm.
We ordered 300 mL of tea infusion for all patients of
which some did not tolerate this volume, so we asked these
patients to use at least 200 mL of tea and to use extra
2552 Eur Radiol (2011) 21:25512557
volumes of tea up to the mentioned 300 mL. None of them
had a problem with 200 mL tea mixture.
Image quality investigation for patient examinations
Images were checked and scored by an expert radiolo-
gist. The visibility of gall bladder (GB), cystic duct
(CD), proximal and distal parts of the common bile duct
(CBD), intra hepatic ducts (IHD), ampulla of Vater (AV),
main pancreatic duct (MPD) and signal loss of the
stomach and three different segments of the duodenum
had been investigated before and 5 and 15 min after tea
ingestion.
Two scales: Likert [14] and visual analogue scale (VAS)
[15] were used to score the value of visibility.
The Likert scale is defined as follows:
A) Visibility and detectability of pancreato-biliary system:
1 Poor: completely not visible; 2- Moderate: difficult
to detect the anatomy; 3- Good: the anatomy is
visible but with some difficulty; 4- Excellent:
completely visible.
Table 1 Visibility of different biliary tree parts according to Likert
and VAS scores for before and 5 and 15 min after tea consumption
Different imaging sessions regarding
tea ingestion in terms of
anatomical parts
Assessment
method
Mean SD
GB before. Likert 3.60.5
VAS 85.913.7
GB 5 min after Likert 3.60.6
VAS 86.515.8
GB 15 min after Likert 3.60.5
VAS 85.913.7
CD before Likert 2.70.9
VAS 61.718.3
CD 5 min after Likert 2.70.8
VAS 62.515.9
CD 15 min after Likert 2.80.8
VAS 66.517.5
Prox. CBD before Likert 3.80.5
VAS 89.113.4
Prox. CBD 5 min after Likert 3.80.5
VAS 89.412.8
Prox. CBD 15 min after Likert 3.80.5
VAS 89.413.0
CHD before Likert 3.60.8
VAS 87.420.3
CHD 5 min after Likert 3.70.8
VAS 88.319.5
CHD 15 min after Likert 3.60.9
VAS 86.820.7
IHD before Likert 2.90.7
VAS 69.414.1
IHD 5 min after Likert 2.90.7
VAS 69.714.6
IHD 15 min after Likert 30.7
VAS 70.314.5
Dis. CBD & AMP before Likert 2.10.9
VAS 48.321.9
Dis. CBD & AMP 5 min after Likert 2.31
VAS 53.422.7
Dis. CBD & AMP 15 min after Likert 2.41
VAS 54.424.0
MPD before Likert 2.31.1
VAS 51.426.0
MPD 5 min after Likert 2.61.1
VAS 57.425.1
MPD 15 min after Likert 2.71.1
VAS 59.726.6
Prox proximal, Dis distal
Table 2 Obliteration of bright signal of different gastrointestinal parts
according to Likert and VAS scores for before and 5 and 15 min after
tea consumption
Different imaging sessions regarding
tea ingestion in terms of
anatomical parts
Assessment
method
Mean SD
Stomach before Likert 1.70.6
VAS 38.318.7
Stomach 5 min after Likert 3.70.5
VAS 86.613.7
Stomach 15 min after Likert 3.80.4
VAS 90.612
First part of duodenum before Likert 1.40.7
VAS 3019.6
First part of duodenum 5 min after Likert 3.60.8
VAS 85.420.5
First part of duodenum 15 min after Likert 3.80.7
VAS 90.316.6
Second part of duodenum before Likert 1.30.7
VAS 26.320
Second part of duodenum 5 min after Likert 3.10.9
VAS 73.421.1
Second part of duodenum 15 min after Likert 3.10.9
VAS 72.619.4
Third part of duodenum before Likert 2.10.7
VAS 49.723.1
Third part of duodenum 5 min after Likert 3.60.7
VAS 86.619.1
Third part of duodenum 15 min after Likert 3.70.7
VAS 89.118.9
Eur Radiol (2011) 21:25512557 2553
B) Visibility and detectability of the GI system :
1 Poor: completely visible; 2-Moderate: visible but the
signal is low; 3-Good: little visibility; 4-Excellent:
completely not visible
All SNR measurements were acquired using SSFSE;
TR/TE: 3,500/900 sequences, 12 radial 20 mm/10 slabs.
Although we know the liver parenchyma in these
sequences is almost signal free, we still acquired the
measuremens of signal for all organs in the same
sequence. In the duodenum the signal of its content
was measured, as also done for measurement of the
signal in stomach.
The formula for calculating SNR was: [mean of SI in
each region]/[standard deviation of air SI].
The formula for calculating CNR was [mean of SI in
each region- mean of SI in adjacent tissue]/[standard
deviation of air SI].
SPSS program version 11.5 was used for statistical
analyses. Difference of all three Likert measurements
before and after tea consumption was assessed by the
Friedman test. For VAS measurements, at first we evaluated
the normality of the data; if the data had normal
distribution, we used the repeated measure ANOVA;
otherwise, the data were analyzed by the Friedman test.
A P-value less than 0.05 was considered statistically
significant.
Results
Thirty five patients of which 21 were female (%60) and 14
were male (%40) were enrolled into the study. The mean
age of the patients was 50.319.2 years [women, 54.8
16.9 years; men 43.522.4 years. (P=0.13)].
Black tea was tolerated well by all patients and there was
no sign of nausea, vomiting, diarrhea or abdominal pain.
All tea infusions made by different trade mark tea-bags
made the same result and were signal void.
Comparison of the visibility of the mentioned parts of
the billiary tree by Likert method showed a statistically
significant difference of scores before and after tea
consumption in the distal part of the CBD and the ampulla
of Vater [P=0.001], and the main pancreatic duct [P<0.001]
in favor of better image quality after tea consumption; the
other anatomical parts did not show score differences in
Likert method before and after consumption (P=1 for the
gall bladder, P=0.44 for the cystic duct, P=0.61 for the
proximal part of the common bile duct, P=0.61 for the
common hepatic duct and P=0.47 for the intrahepatic duct).
These statistical profiles were exactly repeated for the
VAS method, as the means of visibility assessed by VAS
were statistically higher in post consumption images only
for the distal part of the CBD and the ampulla of Vater
[P=0.001] and the main pancreatic duct [P<0.001] in favor
of image quality improvement after tea consumption. Other
anatomical parts did not show any differences by VAS
method before and after tea consumption (P=0.78 for the
gall bladder, P=0.17 for the cystic duct, P=0.371 for the
proximal part of the common bile duct, P=0.45 for the
common hepatic duct and P=0.25 for the intrahepatic duct).
All the means have been mentioned in Table 1.
Regarding obliteration of the high signal in the
gastrointestinal tract, we categorized the important parts
into four different sections; namely, the stomach, the first,
second and third part of the duodenum. The assessments
were performed by Likert and VAS methods again. All the
before and after comparisons which were carried out for
the above mentioned anatomical parts were statistically
significant (for both Likert and VAS); i.e. all the bright
signals were obliterated significantly after tea consumption
(Table 2).
For all the statistically significant different variables, we
sought what groups were different statistically. Regarding
Fig. 1 MRCP images of a
51-year-old man before and
5 min after black tea
consumption
2554 Eur Radiol (2011) 21:25512557
the fact that none of the variables had normal distribution,
all pairwise comparisons (one pre and two post intervention
groups) were performed by the Wilcoxon signed rank test
with Bonferroni correction.
As demonstrated, the statistically significant variables
were visibility of the distal part of the CBD and ampulla of
Vater and the main pancreatic duct and also signal
obliteration in the stomach and three parts of the duode-
num. Pairwise comparisons of the three pairs (before versus
5 min after ingestion, before versus 15 min after ingestion,
and 5 min after versus 15 min after ingestion) in all the six
mentioned variables showed the pre-consumption images
were statistically different compared to each of the two
post-consumption images, but there was no statistically
significant difference between the two post-consumption
images. This pattern was similar for all the assessments
with Likert and VAS methods. (all P-values<0.011) (Fig. 1)
There was no evidence about the effects of black tea in
gallbladder excretion.
The mean signal to noise ratio (SNR) in the liver was
3.91.9 before tea consumption while this value was 3.3
1.5 in five minutes and 3.51.8 in 15 min after tea
consumption (P-Value=0.33).
For contrast to noise ratio (CNR) calculation of Vaters
ampulla, we considered the two adjacent tissues as
reference tissue: head of the pancreas and the duodenum.
Considering duodenum as reference tissue, the mean CNR
was 55.168.5 before tea consumption while this value
was 36.821.3 and 3025.5 five and 15 min after tea
consumption, respectively (P-value<0.0001).
Considering pancreas as reference tissue, the mean CNR
was 47.323.3 before tea consumption while this value
was 37.819.8 and 39.224.4 five and 15 min after tea
consumption, respectively (P-value=0.089).
Similarly, the signal to noise ratio (SNR) and CNR were
calculated for the main pancreatic duct, distal CBD,
proximal CBD, CHD and cystic duct before and after tea
consumption and the data were compared to each other. The
results have been shown in Tables 3 and 4.
For the main pancreatic duct, proximal and distal CBD
the reference tissue was considered as the pancreas and
duodenum (similar to the ampulla of Vater) while for the
cystic duct and the common hepatic duct, the reference
tissue was the liver.
Table 3 Comparison of SNR before and after tea consumption in the
liver
Anatomic
location
SNR
before
SNR 5 min
after
SNR 15 min
after
P Value
Liver 3.91.9 3.31.5 3.51.8 0.33
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Eur Radiol (2011) 21:25512557 2555
Discussion
MRCP is a useful noninvasive imaging technique intro-
duced in 1991 for morphological evaluation of the biliary
tract and pancreatic duct [14].
This technique is based on heavily T2-Weighted sequences
to enhance signal from fluid.
High signal intensity from the stomach and intestinal
fluid may obscure the MRCP images because it super-
imposes on the biliary tract. The signal from the GI tract is
especially problematic when single thickness slice images
are obtained without a thin multislice data set [16]. Fasting
before MRCP is not sufficient for elimination of these
signals in the gastro-intestinal tract [16].
Oral negative contrast agents depend on high amounts of
high molecular metal ions such as iron or manganese which
have paramagnetic and superparamagnetic properties.
These qualities will increase magnetic susceptibility causing
marked shortening in T2 relaxation time [17, 18] due to rapid
T2 decay. There are some studies that require negative oral
contrast agents - eg MRCP.
Although many agents may significantly obscure signal
intensity of the GI tract, their effects in depiction of some
parts of the biliary tract such as IHD may be limited. (11)
Several negative oral contrast agent products including
blueberry [19], pineapple juice [16] and Roselle [11] have
been used as negative oral contrast agents. All these agents
are characterized by a high manganese concentration.
One of the most usual drinks among Iranian people is black
tea which has 3502,200 g/gr manganese in dry leaf [13].
In this study, we have proposed that black tea is a good
alternative for signal suppression from the GI tract structures.
We used 300 mL of black tea as a negative oral contrast agent.
Because Iranians like to drink sweet tea, we added 40 gr
sugar in every 300 mL tea, and there was no change in the
negative contrast property of black tea.
Quantitative analysis using VAS and Likert showed
significant improvement in MPD, the distal part of the
CBD and ampulla.
Indeed, we found that black tea effectively reduced
signal intensity of the stomach and the duodenum.
Depiction of the MPD, the distal part of the CBD and
ampulla significantly improved statistically 5 and 15 min
following black tea ingestion. This suggests that follow-
ing black tea ingestion, the optimum time for MRCP is
5 min.
We noticed that visualization of the distal part of the
CBD significantly improved following black tea ingestion.
It might be due to the fact that duodenal signals only affect
the distal part of the CBD and there is no overlap between
GI signals and the proximal part of the CBD.
Similar to this study, in a study published by
Varavithya et al., the authors found that Rosella flower
tea can effectively reduce signal intensity of the stomach
and duodenum, and they found slight improvement of
ampulla and main pancreatic duct depiction in their
patients [11]. Chan and his colleagues used diluted
gadopentetate dimeglumine in their study in 23 patients
and found that gadopentetate dimeglumine with a concen-
tration of 1:15 is significantly effective for depiction of the
CBD and MPD in MRCP. For GB and CD, a slight to
moderate improvement was seen after oral gadopentetate
dimeglumine and they did not evaluate CHD, IHD and
ampulla in their study [20].
Papanikolaou et al. observed that there was a statistically
significant improvement in the depiction of CBD, CHD,
ampulla and MPD after using 430 mL of blueberry juice in
37 patients who suffered obstructive jaundice [19].
Riordan and his colleagues in 2004 published their study
about using pineapple juice (PJ) as a negative oral contrast
agent in MRCP. They demonstrated that PJ may be used as
a suitable negative oral contrast agent in MRCP [16].
It should be kept in mind that, although the use of
negative oral contrast agents is beneficial in suppressing the
signal in the stomach and intestine, visualization of some
parts of the biliary tract may be limited. Furtehrmore, when
a negative oral contrast agent is to be used, the patients
clinical condition should be carefully evaluated. Particularly,
when a patient has a history of endoscopic sphincterotomy,
negative oral contrast agent should not be given at first
because of the bile counterflow.
One limitation of this study was that only one radiologist
reported the images.
Another limitation was the exact volume of tea based on
the patients tolerance which was not equal in all cases. For
this reason we will design another study with use of lower
volumes of tea.
We conclude that black tea is an affordable, available,
safe and efficient oral negative contrast agent for MRCP
that reduces the signal intensity of fluids in the gastrointes-
tinal tract and also better depicts the MPD, the distal part of
the CBD and ampulla.
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