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Small Bowel Imaging with MRI

Posted Oct 31, 2012 Updated Apr 10, 2023
By Thomas C. Lauenstein MD , Lale Umutlu MD , Christian Kloeters MD , Andrik J. Aschoff MD , Mark E. Ladd PhD , Sonja Kinner MD
12 min read

Magnetic resonance imaging (MRI) has evolved as a powerful tool for the assessment of the small bowel. Strengths of MRI include the superb soft-tissue contrast, lack of radiation exposure, and the implementation of fast scanning techniques. Clinically relevant findings such as inflammation and tumor disease can be well-depicted. We describe in this article current techniques of small bowel MRI including its implementation and clinical outcome in comparison to other radiological and endoscopic procedures.

Because of considerable improvements in cross-sectional imaging, there is general consensus today to shift from fluoroscopic examinations to computed tomography (CT) or magnetic resonance (MR) imaging for small bowel imaging . Cross-sectional imaging allows for an assessment not only of the entire bowel wall, but also depicts changes in the perienteric fat. CT has become an attractive tool for small bowel imaging due to its high availability, relatively low cost, robustness, and short examination times . Furthermore, the administration of negative or neutral oral contrast agents results in an easy delineation of pathological structures of the bowel wall. However, similar to fluoroscopic procedures, CT is associated with radiation exposure of the patients. This may be of particular concern for young patients with chronic inflammatory bowel disease who have to undergo diagnostic procedures multiple times during the course of disease.

As a result, MR imaging has become increasingly important as a method for the evaluation of various small bowel disorders . It combines the advantages of excellent soft-tissue contrast, noninvasiveness, and lack of ionizing radiation. Furthermore, recent developments of MR imaging are associated with improved spatial and temporal resolution as well as decreased motion artifacts. In this article we describe technical aspects of small bowel MR imaging, discuss clinical indications for this technique, and compare the outcome of small bowel MR imaging with other imaging modalities.

MR enteroclysis or MR enterography?

Sufficient bowel distension is a prerequisite for small bowel imaging. Nondistended bowel loops may lead to false-positive and/or false-negative findings . Collapsed intestinal segments may falsely mimic inflammatory or tumorous changes of the bowel wall and may also conceal real existing pathologies. Two different techniques to provide sufficient luminal distension of the small bowel have been proposed: MR enteroclysis and MR enterography.

MR enteroclysis is performed in analogy to conventional enteroclysis: a methylcellulose and water solution is administered through a fluoroscopically placed nasojejunal tube . Image sets are acquired after rapid filling of the entire small bowel. This technique is associated with excellent image quality because of superb bowel distension ( Fig 1 ). Changes in the bowel wall can be easily depicted ( Fig 2 ). However, the procedure may be perceived as traumatizing by the patients because of duodenal intubation, which taints the noninvasive character of MR imaging. Furthermore, the duodenal intubation is performed under fluoroscopic guidance, which is associated with radiation exposure to the patient. Finally, the preparation of MR enteroclysis is to some degree cumbersome because the patient must be transferred from the fluoroscopy suite to the MR suite with the nasojejunal tube in place. Therefore, some centers have discontinued MR enteroclysis and preferentially perform MR enterography.

Figure 1, Two-dimensional single-shot RARE (rapid acquisition with relaxation enhancement) image of magnetic resonance enteroclysis. Note the excellent luminal distension throughout the small bowel.

Figure 2, Coronal TrueFISP (Siemens Healthcare) image of a patient with Crohn's disease. Bowel wall thickening ( arrow ) can be easily depicted on magnetic resonance enteroclysis.

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Figure 3, Coronal TrueFISP (Siemens Healthcare) image of the bowel in conjunction with magnetic resonance enterography. The ingestion of oral contrast agents containing osmotic additives results in consistent distension of the small bowel allowing for good visualization of the bowel wall.

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Practical aspects of small bowel MRI

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Table 1

Parameters of Key Small Bowel MRI Sequences

2D bSSFP without Fat Suppression 2D Single-shot T2w Spin Echo with Fat Suppression 3D T1w GRE with Fat Suppression TR (ms) 3.7 676 1.9 TE (ms) 1.9 100 3.9 Flip (°) 60 90 10 Slice thickness (mm) 4–5 6–7 2

2D, two-dimensional; 3D, three-dimensional; bSSFP, balanced steady-state free precession; GRE, gradient-echo; T1w, T1-weighted; T2w, T2-weighted; TE, echo time; TR, repetition time.

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Figure 4, Bowel wall thickening of the ileum in a patient with Crohn's disease. The lesion can be easily delineated on TrueFISP (Siemens Healthcare) images ( a , arrow ). Diffusion-weighted imaging exhibits high signal in this bowel loop ( b , arrow ) with low apparent diffusion coefficient values ( c , arrow ), which is consistent with active inflammation.

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IBD

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Figure 5, Coronal TrueFISP (Siemens Healthcare) imaging in a patient with Crohn's disease. Noticeable bowel wall thickening can be found in the terminal ileum ( arrow ).

Figure 6, Contrast-enhanced T1-weighted image of the same patient as in Figure 5 . The inflamed bowel segment shows increased contrast enhancement ( arrow ) after the intravenous administration of gadolinium.

Figure 7, T2-weighted single-shot fast spin echo image exhibits elevated T2 signal of the bowel wall in a patient with Crohn's disease ( arrow ). This finding is consistent with edema in the bowel wall and is a sign for active inflammation.

Figure 8, Coronal TrueFISP (Siemens Healthcare) image revealing a fistula ( arrow ) between an inflamed ileal loop and an adjacent segment of the sigmoid colon in a patient with Crohn's disease.

Figure 9, Diffuse inflammation of small bowel loops with adjacent abscess formation ( arrow ).

Figure 10, Vascular engorgement in the perienteric fat (“comb sign”, arrow ) as an indirect indicator for bowel wall inflammation.

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Figure 11, Contrast-enhanced T1-weighted image of a patient with fibrostenotic disease ( arrow ). Note the prestenotic dilatation of bowel loops.

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Indications beyond IBD

Tumor Disease

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Figure 12, Contrast-enhanced T1-weighted image displaying a large carcinoid tumor of the ileum with moderately increased contrast uptake ( arrow ).

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Figure 13, Contrast-enhanced T1w image of a small gastrointestinal stromal tumors in the jejunum with clearly increased contrast uptake ( arrow ).

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Figure 14, TrueFISP (Siemens Healthcare) image of a patient with small bowel lymphoma. A diffuse thickening of several small bowel loops can be seen ( arrows ).

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Non-Tumor Disease

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Figure 15, Patient with celiac disease. A fold pattern reversal of the small bowel can be seen. Note the increased number of small bowel folds in the ileum (“jejunization”, arrow ).

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Summary

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Academic Radiology, Volume 19, Issue 11
Journals General Radiology
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