Proceedings of the 2005 IEEE Engineering in Medicine and Biology 27th Annual Conference Shanghai, China, September 1-4,

2005

Preliminary Results from Clinical Application of a Natural Oral Contrast Agent in Magnetic Resonance Imaging (MRI) of the Gastrointestinal (GI) System
T. Arruda-Sanchez; L.E.A. Troncon; R. Brandt-Oliveira; J. Elias Jr., L.A. Colnago, D.B. Arajo, D.B. and Baffa O. University of So Paulo Ribeiro Preto SP - Brazil
tolerated but usually fails in opacifying the entire bowel. It also needs to be buffered when used orally since this chelate is not very stable at low pH found in the stomach, what can alter the gastric function. We herein present the preliminary implementation of a natural oral contrast agent, Euterpe Olercea (popularly named Aa), as a possible alternative contrast agent for MRI of the gastrointestinal (GI) tract. The pulp of Aa, a fruit from the Amazon area, can be widely found in tropical regions. Considering the biphasic contrast revealed in the preliminary study [4], this natural oral contrast agent could be clinically used, primarily to assist for a better contrast in images from stomach and from a rotine examination of the biliopancreatic tract, in Magnetic Resonance Cholangiopancreatography (MRCP). During MRCP, difficulties in the assessment of the gallbladder, cystic duct, common bile duct (CBD), and pancreatic duct may be encountered because these structures are frequently masked by the overlap of the signal hyper-intensity from the surrounding tissues contend [5]. We investigate the feasibility of using this natural solution as a gastrointestinal oral negative contrast agent to null the bowel signal during MRCP. METHODOLOGY All images were acquired using a Siemens 1.5 T Scanner (Magneton Vision). A body array coil was used to generate T1-weighted images (TR/TE = 177.8/4.1 ms, FOV 350 mm, 256 x 256, 6 mm slice thickness) and T2-weighted images (TR/TE = 4400/64 ms, FOV = 350 mm, 256 x 256, 6 mm slice thickness) at a standard turbo spin-echo (TSE) sequence. We studied 10 non-symptomatic subjects, with 12 hours of fasting. Ten axial slices centered at the stomach region were acquired, under three distinct experimental conditions: first in the fasting state with an empty stomach (baseline), followed by the ingestion of water and finally by the ingestion of Aa. As to implement the contrast agent in the clinical environment, these subjects more 35 patients were

Abstract A natural magnetic resonance imaging (MRI) contrast based on the pulp of a fruit Euterpe Olercea, popularly known as Aa, was investigated. T1 and T2 contrasted images shown the effects of the contrast agent increasing the ability to visualize the contour of segments of the gastrointestinal tract.

INTRODUCTION sing contrast agents is a common practice in medical imaging protocols, as is the case of Magnetic Resonance Imaging. The evaluation of GI tract by means of MRI has a close relation to availability of oral contrast agents. Oral contrasts are attractive to MRI if they have good digestive acceptance, uniform distribution in the bowel lumen, unchanged contrast effect when diluted throughout the gastrointestinal tract (GI), no toxicity, no peristalsis stimulus, and acceptable cost. Although some of them are commercially available, they are still not used routinely in most clinical centers nowadays, due to many factors, such as possible side effects. Oral contrast agents are usually classified by their increase (positive agents) or decrease (negative agents) of the magnetic resonance imaging signal within the bowel [1]. GI agents change intra-luminal signal either by a paramagnetic shortening of T1 or T2 of nearby tissues or by having intrinsically short relaxation times [1,2,3]. Actually, many contrast solutions would be capable of changing signal intensity, typically based on heavy metal ions, as of Gadolinium (III), Manganese (II), Manganese (III), Iron (III), and copper (II) [4]. However, they have generally intrinsic side effects when used orally [0]. Ferric iron, for example, can provoke teeth staining, gastric irritation, nausea, diarrhea, and constipation. Mannitol may cause nausea, vomiting, and diarrhea [2]. Gd-DTPA without Mannitol is well
Manuscript received March 10, 2005. This work was supported in part by the CNPq and CAPES. T. Arruda-Sanchez DFM FFCLRP Av Bandeirantes, 3900 14.040-901 Ribeirao Preto SP Brazul tiago@biomag.usp.br.

0-7803-8740-6/05/$20.00 2005 IEEE.

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submitted to the same hospital protocol for MRCP that is based in the same T2-weighted standard TSE sequence parameters, which was approved by the institutional ethics committee. RESULTS T1 and T2 weighted images from the stomach of a fasting healthy volunteer are presented in figure 1. In figure 1a and figure 1d we observe an empty stomach. Subsequently, the subject ingested 200 ml of water, and another set of T1 (Fig. 1b) and T2 (Fig. 1e) was acquired. The expansion of the gastric volume is clearly observed and two phases can be identified on the images: a small dark region corresponding to air and a larger area of slight contrast increase corresponding to water. Finally, 200 ml of the Aa pulp was ingested by the subject and the last series of MR images were obtained. Figure 1c shows one T1weighted image. The increase of contrast due to the presence of Aa is conspicuous. Three well defined regions can be identified: air, water and Aa. Also, the T2 sequence presents a high contrast in the gastric lumen due to low signal intensity from Aai (Fig. 1f). We looked for intrinsic properties that could be responsible for the T1 signal enhancement and T2 opacification. Atomic Absorption spectra revealed the presence of Fe, Mn and Cu ions in Aai. Although there is no information yet about how these ions are complexed with the organic matrix, their presence is probably the main cause for the image contrast changes.

Figure 2. T2-weighed images from 2 patients (a) and (b) during fasting (left) and after Acai ingestion (right). Overlap is eliminated (pentagram) which allows gallbladder and biliary ducts (large and small arrows ) to be more visible after Aai ingestion. We can see the image clearance (Fig. 2) due to the reduced signal from the Aa pulp present in stomach and bowel loops. DISCUSSION AND CONCLUSION The contrast enhancement due to Aa in T1-weighed images is evident, producing a better definition of the gastric lumen. These results open a wide perspective for the clinical use of such contrast agent, as an alternative oral contrast for imaging the intestinal lumen, functional evaluation of dyspepsia and other pathological states. The contrast enhancement due to Aa in T1-weighted images is evident (Fig. 1c), producing a better definition of the gastric lumen. Thus, these results open a wide perspective for Aa as an alternative oral contrast agent that can be employed for imaging the intestinal lumen, functional evaluation of dyspepsia, in addition to the applications of the gastrointestinal motility [6,7].

Figure 1. T1 and T2 weighed images in an axial plane. T1 images are on the top line, while T2 are on the bottom. (a) T1 image of an empty stomach. (b) T1 of the same volunteer with air and 200ml of water. (c) T1 image with air, 200ml of water and 200ml of Aai. (d) T2 image of an empty stomach. (e) T2 image of air and 200 ml of water. (f) T2 image of air, 200ml of water and 200ml of Aai. Figure 2 shows T2 images, in the coronal plane, from 2 patients submitted to MRCP. The MRI signal from bowel loops, superposed to the common bile duct, is subtracted, allowing the complete observation of the gall bladder after the ingestion of Aa.

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Aa has great advantages since is a natural and palatable food with no expected side effects or adverse reactions. In every patient studied thus fat, only one had nausea after ingesting the Acai pulp. As for MRCP, the results indicate a possible application from the signal reduction of gastric acid and intestinal loops. The Acai pulp may improve the visualization of pancreatic and biliary ducts. ACKNOWLEDGMENT The authors thanks the technical support of Loureno Rocha, Carlos Brunello, Matheus Guerreiro, Reginaldo Ferreira Chagas, Luciano Kazuo Akita and the MRI service of Hospital das Clinicas, Faculdade de Medicina de Ribeiro Preto to make available its facilities. REFERENCES [1] Giovagnoni A, Fabbri A, and Maccioni F. Oral Contrast agents in MRI of the Gastrointestinal Tract. Abdominal Imaging 2002;27:367-75. [2] Runge VM. Contrast Media in Magnetic Resonance Imaging: A Clinical Approach. J B Lippincott Company, 1992. [3] Lomas DJ, MRCP, FRCR, and Graves MJ. Small Bowel MRI using water as a Contrast Medium. The British Journal of Radiology 1999;72:994-7. [4] T.C. Fraga, D.B. de Arajo , T.A. Sanchez, J. Elias Jr., A.A.O. Carneiro, R. Brandt Oliveira, M. Sosa and O. Baffa Euterpe olercea (Aa) as an Alternative Oral Contrast Agent in MR Imaging (MRI) of the Gastrointestinal (GI) System: Preliminary Results, Magn Reson Imaging, vol. 22, no. 3, pp. 389-93. 2004. [5] Chan JHM, Tsui EYK, Yuen MK, Szeto ML, Luk SH, Wong KPC, Wong NOW. Gadopentetate Dimeglumine as an Oral Negative Gastrointestinal Contrast Agent for MRCP. Abdom Imaging 2000; 25:508-10. [6] de Zwart IM, Mearadji B, Lamb HJ, Eilers PHC, Masclee AAM, de Roos A, Kunz P. Gastric motility: Comparison of assessment with real-time MR imaging or barostat measurement - Initial experience. Radiology 2002;224(2):592-7. [7] Carneiro AAO, Baffa, O, Oliveira RB. Study of Stomach Motility Using Magnetic Tracers. Phys Med Biol 1999; 44: 1691-7.
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