Presentation
Deranged liver function test results, post-distal gastrectomy with Roux-en-Y gastric bypass.
Patient Data
In this case, the patient had an MR Conditional endoscopic clip applied at the distal esophageal region as fresh blood was observed oozing at the distal esophagus and gastric cardia during their endoscopy procedure.
The patient was scheduled for a magnetic resonance cholangiopancreatography (MRCP) on the same day, after the endoscopy procedure.
Magnetic susceptibility artifact is seen from one endoscopic clip (coronal T2, axial T2) at the distal esophageal region. The artifact is most prominent on the AX T1 VIBE/GRE sequences.
An interval CT abdomen without contrast was performed three days later.
A beam hardening artifact is seen from one endoscopic clip (axial, coronal) at the gastro-esophageal junction.
Note: though not pertinent to the main case discussion, these CT abdomen images depict the appearance of an endoscopic clip and its associated beam-hardening artifact. Viewers are encouraged to compare and contrast the clip on the MRI and CT images.
Case Discussion
MRI of the abdomen is often discouraged for patients with the presence of endoscopic clips due to the possibility of:
clip deflection/migration
metal susceptibility artifact
heating
These endoscopic clips often detach spontaneously between 9 days 1 and 2 weeks 2 after deployment, although there have been studies showing its retention for several years 1-2. Considering that MR Conditional and MR Unsafe endoscopic clips are in the market, care must be taken to prevent mishaps.
Due to the presence of magnetic susceptibility artifacts in the initial MRCP sequences, an abdominal radiologist was asked to review the case for its diagnostic value. Once the preliminary images were deemed diagnostic, the examination then continued, with successful completion and no side effects experienced by the patient.
These images highlight the artifacts that can present from performing an MRI of the abdomen with an endoscopic clip in-situ. It is important to note that the placement of the clip/s differs depending on a patient's unique pathology, and perhaps the difference between performing an MRCP (if not obscuring the main region of interest), versus deciding to delay the scan after the clip/s has detached naturally (note: an abdominal x-ray is a quick way to determine its presence prior to rescheduling an MRI).
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