MRI Without Contrast for Mild Hyperlipasemia
For a patient with mild elevated lipase and GERD on omeprazole, start with MRI abdomen without and with IV contrast with MRCP as the initial imaging study. 1
Rationale for Contrast-Enhanced MRI
The American College of Radiology guidelines clearly establish that MRI abdomen without and with IV contrast with MRCP is the preferred modality for evaluating pancreaticobiliary pathology when there is clinical concern warranting imaging. 1
Why Contrast Is Essential
Contrast administration significantly improves sensitivity for detecting acute pancreatitis, pancreatic necrosis, and inflammatory complications that may explain elevated lipase. 1
Hepatobiliary contrast agents provide functional information about biliary patency and can identify subtle ductal abnormalities that might be missed on non-contrast sequences. 1
Contrast-enhanced sequences are superior for detecting pancreatic masses, which must be excluded in any patient with unexplained enzyme elevation, even if mild. 1
Contrast helps distinguish between inflammatory phlegmon and abscess formation, which has direct therapeutic implications. 1
Clinical Context: GERD and PPI Use
The patient's GERD history and omeprazole use are relevant but do not change the imaging approach:
PPIs can rarely cause drug-induced pancreatitis, though this is uncommon with omeprazole. 2
The timing of omeprazole administration (30-60 minutes before meals) should be verified to ensure therapeutic efficacy for GERD symptoms, but this does not affect pancreatic enzyme elevation. 2, 3
GERD itself does not cause lipase elevation, so the hyperlipasemia warrants independent evaluation. 2
Imaging Protocol Specifics
The complete MRI protocol should include: 1
- T1-weighted sequences (pre- and post-contrast)
- T2-weighted sequences
- MRCP sequences for ductal evaluation
- Diffusion-weighted imaging for inflammatory changes
- Hepatobiliary phase imaging if using hepatobiliary contrast agents
When Non-Contrast MRI Might Be Considered
MRI without contrast alone is insufficient in this clinical scenario because: 1
- Non-contrast MRI has reduced sensitivity for acute inflammatory changes in the pancreas
- Vascular complications cannot be adequately assessed without contrast
- Lesion characterization is significantly limited without enhancement patterns
The only scenario where non-contrast MRI might be acceptable is if the patient has severe renal impairment (eGFR <30 mL/min/1.73m²) precluding gadolinium administration, in which case non-contrast MRI with MRCP would be the alternative. 1
Common Pitfalls to Avoid
Do not order CT instead of MRI for initial pancreatic evaluation in a young patient without contraindications to MRI, as MRI provides superior soft tissue characterization without radiation exposure. 1
Do not assume mild lipase elevation is clinically insignificant without imaging correlation, as early or chronic pancreatitis may present with only modest enzyme elevations. 1
Do not delay imaging if the patient has persistent symptoms or progressive enzyme elevation, even if initially mild. 1
Ensure the radiology order specifically requests MRCP sequences in addition to standard abdominal MRI, as this is essential for complete pancreaticobiliary evaluation. 1