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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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Eur Radiol (2011) 21:25512557 2557
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