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of case-based micro-learning courses across all key

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radiology subspecialties.

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Today we are honored to welcome Dr.

0:43

Alka Singal for a lecture entitled Ultrasound, gallbladder

0:46

and Biliary Tree, common and Uncommon Diagnosis.

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Dr. Singal is currently an associate director

0:53

of radiology at Madon Division of Radiology

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and nuclear medicine.

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She's a renowned expert in diagnostic whole body

1:01

ultrasound imaging.

1:03

Her areas of focus include the abdomen, obste, obstetric

1:07

and fetal USG with 3D

1:09

and four D imaging, elastography, Doppler, vascular studies,

1:13

neck parathyroid thyroid, and MSK ultrasound.

1:18

Dr. Singal, who is dedicated to quality, accuracy

1:21

and patient satisfaction, has earned fame as one

1:25

of the best radiologists in the area

1:27

and has a great passion for work, both

1:29

for diagnostics and academics.

1:32

At the end of the lecture, please join Dr.

1:34

Singal in a q and a session

1:35

where she will address your questions you may

1:37

have on today's topic.

1:39

Please remember to use the q

1:41

and a feature to submit your questions so we can get to

1:43

as many as we can before our time is up.

1:46

With that, we are ready to begin today's lecture. Dr.

1:49

Singal, please take it from here.

1:51

Thank you so much. Thank you so much everyone

1:54

for joining in at this time.

1:56

And today's topic is, uh,

1:59

pretty much the most basic ultrasound image

2:01

that we have been doing, ultrasound, gallbladder

2:04

and biliary tree, common and uncommon diagnosis.

2:07

However, it is also one of the areas

2:11

where you have a lot oft reporting.

2:14

Why is that then?

2:16

That is something which we really begin to have,

2:19

have having done when we started learning

2:22

ultrasound imaging.

2:24

However, even

2:25

after 2030 years of imaging that same organ in

2:29

that same area, why is there a discrepancy in the reporting

2:34

from tool often within the same operator, often

2:38

at a different time, or with a different machine

2:41

or with a different, uh, place?

2:44

Let's unravel that.

2:46

Okay, so the of course, as we all know,

2:48

there's a lot to do with the operator.

2:49

There's a lot to do with the technique.

2:51

There's lot to do with the patient preparation

2:54

and all those factors that go into

2:58

optimal imaging on ultrasound.

3:01

It's okay.

3:06

So the common and uncommon diagnosis, it's one

3:08

of the such a common areas that the first thing we, we,

3:13

we have actually narrowed down ourselves to think

3:16

that the gallbladder, whether is it there

3:18

or whether it's removed and whether does it have a calculus

3:22

or is there any mass obvious and that's it.

3:27

And we think that's, that's all for the gall bladder,

3:30

but sometimes we need to think beyond.

3:32

There's a lot more that ultrasound can unravel

3:36

and especially because ultrasound is the mortality of choice

3:41

and it is the first mortality

3:43

and it is the recommended mortality for the evaluation

3:46

of reta for the common inflammatory conditions right now.

3:51

So why the discrepancy?

3:53

Of course, is there any ion preparation needed

3:55

to evaluate the treat?

3:57

It's, of course there is.

3:58

However, in cases of acute abdomen, we bypass that.

4:03

So we have to evaluate whatever scenario

4:06

the patient has presented.

4:07

That doesn't remain as an hard and pass guideline as well.

4:11

However, optimally we do require the patient

4:14

to be four to six hours.

4:15

A asking why, because gallbladder is a peer shaped

4:19

structure, which is stored the bile juice.

4:22

Only when it's distended can we see the walls very clearly,

4:25

whether there is any lesion, any, any, uh,

4:29

any LAR in the sac and what is the thickness of the wall

4:33

and every area of the gallbladder,

4:36

whether there are any falls, any uh, junction falls

4:39

or any F cap or the walls of,

4:42

or the neck areas, everything,

4:44

because only when it's distant,

4:46

it just like the urinary bladder can you really unravel it.

4:49

Right? And of course the amount of fasting will vary, uh,

4:54

for infants and neonates and often two hours is good

4:58

and we do a postprandial scan in pediatric population

5:01

to see the and functionality when we are suspecting praz.

5:06

So that's another part of the dynamic scan.

5:08

And especially in patients in adult population,

5:12

sometimes even with four to six hours of fasting,

5:14

we are not able to see the gall bladder.

5:16

They could be thickened and inflamed

5:18

or contracted due to chronic chronic cystitis.

5:21

There you may require a longer fasting, which could be eight

5:25

to 12 hour fasting.

5:28

Okay? So with that now coming to the transer selection

5:33

and the patient position,

5:34

but transducer selection again goes to the crown root

5:38

of the ultrasound basics, the highest frequency transducer

5:42

that gives you the required depth of penetration.

5:45

So as simple as that.

5:46

So I would say if I would use a three

5:49

to five megahertz kby transducer for a, uh, for a patient

5:53

with a, with a large body habitus,

5:56

that would be correct appropriate.

5:58

But if I have a lean thin pediatric patient, right,

6:02

I wouldn't go with a 3.5 megahertz.

6:04

I would go with a linear transducer, maybe seven to 11

6:07

or maybe a linear, a higher frequency curve transducer

6:11

to get the better resolution.

6:13

So the transducer frequency selection then comes the

6:16

equipment, the both the harmonics and the compound imaging.

6:20

Now that part currently is actually taken care of

6:24

by the inbuilt applications within the machine.

6:26

So we do not do much changes to that.

6:29

However, going back to my, um, uh,

6:33

like few years ago, we, we would change it to harmonics

6:37

and compound and various other factors

6:40

to get the best imaging.

6:42

And of course we will be adjusting the focal, uh,

6:46

focal point at the level of the pathology

6:49

because that's where the beam width is the narrowest,

6:52

and that's where you get the best resolution

6:55

and the best acoustic shadowing of calories.

6:58

So that's about the patient position.

7:00

Now what's the patient position again, comes

7:03

to the same principle.

7:05

The, we want the, it's examining part to be as superficial

7:09

to the transfuser as we can.

7:12

So we are going to rotate, uh, so

7:14

that we have the examining parts superficial.

7:17

However, we also gonna use a solid organ such as a liver,

7:22

as a window through which we are going

7:24

to scan the gallbladder.

7:25

So we try and position the patient sine a left lateral

7:29

and we use a liver as a window to see through to the,

7:33

which works better because if you try

7:36

and go the other way, you might have bowel gases in the

7:39

middle, uh, in the central part of the abdomen,

7:42

they'll cause their own dirty or postage shadowing

7:44

and will limit visualization

7:46

of any pathology which may be there in the gall bladder

7:50

transducer selection,

7:51

we discuss the higher frequency image optimization modes.

7:54

We will discuss ATE scan.

7:56

So we will evaluate

7:58

as we evaluate any solid organ in all the three orientation

8:02

and planes, s lung, uh, oblique, such trans oblique.

8:06

And of course all bladder scan doesn't finish until an,

8:10

unless any examination is performed in the erect position

8:14

because that's when

8:16

the de the fundus gravity dependent part comes down.

8:20

So if there's any small subtle not uh, the uh, calculus,

8:25

it'll just trickle down in the fundus, it would be very easy

8:28

to demonstrate.

8:31

Moving on. So now what do we mean

8:34

by the goldbe and the ary tree?

8:36

So we see, uh, we all know it's a peer shaped structure,

8:41

thin wall, smooth wall,

8:42

and it's seen in the right upper quadrant.

8:45

It's goes by and it's fasting.

8:47

It can be approximately 10 centimeters long.

8:52

Okay?

8:58

Okay. Right, right.

9:00

So certain features that, that are normal

9:05

a**l variations in the normal, we must remember.

9:09

So there is a fundus, there is a net area.

9:12

So that, why is this important is when you're labeling

9:15

technology, the communication remains the same

9:19

throughout in the neck.

9:21

There is especially an area called in fund development,

9:23

hartman's pouch, which is an common area

9:26

for impaction of gallstone.

9:27

So evaluating of the gallbladder, just seeing the fundus

9:32

and not seeing the cystic duct

9:34

and its confluence with the gallbladder

9:36

is like you're evaluating half the orbit

9:39

and you're saying that it's normal and not no sizing.

9:42

That is not the correct strategy.

9:45

So the correct strategy should always, always demonstrate,

9:54

always, always demonstrate the make

9:57

and the distal part of the very well clearly so

10:01

that there is no theology left out,

10:03

including if you can see the balls of hazel,

10:06

that is also good.

10:07

Now the cystic duct, which comes out of the gallbladder, you

10:12

if you can, you would try and see it and try

10:14

and see the confluence and where it merges.

10:17

Then you come into the common hepatic duct.

10:20

So normally if the biliary tracts are dilated,

10:24

you would often see them

10:26

and uh, the diameter of the common, uh, uh,

10:29

common pal duct often is four

10:31

to six millimeters in diameter.

10:33

But however, it can have a normal slight sif form dilatation

10:38

in, uh, elderly patients or post cystectomy.

10:42

You must see the duct in total in longitudinal

10:46

and transfer section to exclude any focal calculus

10:50

or any focal subtle mass lesion.

10:53

There may not be any other sign,

10:56

and believe me, catching that pathology very early.

11:00

Only you who's holding the ultrasound prob has the,

11:05

has the privilege to actually alert

11:07

and advise for a further imaging or a CT scan

11:10

before the patient present with symptoms.

11:13

When the patient present with symptoms, often this area,

11:16

because it's already such a narrow structure,

11:19

it often goes into a, uh,

11:22

nonresectable stage.

11:24

So a lot of responsibility goes in evaluating the reta

11:29

and the CBD completely

11:32

by the person who's holding the ultrasound.

11:35

And of course the common B duct is named

11:37

as supra pancreatic, retro pancreatic.

11:39

And the ary component,

11:40

which all must be evaluated very well,

11:43

intrahepatic period guts when dilated,

11:46

that's when we see them.

11:48

And if you don't see them, that's good.

11:50

So of course anatomy radiations are there

11:53

that you must remember and accordingly scan.

11:56

Now the role of ultrasound.

11:59

So of course we have other modalities

12:01

because going from pediatric to pregnancy to any age,

12:07

the goal ultrasound is like suitable, but every age,

12:11

and it's easy, it's quick, it's, you can move it around

12:16

and you can get the information,

12:17

you get the information in everybody.

12:21

So with the use of technology,

12:23

ultrasound is the first mortality

12:26

and it is, uh, it is a goal, uh,

12:29

recommended option for the gallstones.

12:31

Stones beyond the G

12:33

and the CBD are often requiring high ends

12:37

of suspicion and often require other imaging

12:40

to further conclude.

12:42

Right Now coming a little word about

12:45

the pediatric population.

12:47

So the bases we bases are the same In cases

12:51

of emergency, often we have to ignore the preparation.

12:54

Preparation. There could be cases of acute cholecystitis

12:57

or perforation or gangrene or any other.

13:01

So then you take it as it is.

13:02

Now, why is the child sent bi atia

13:06

as a communist diagnosis that you're looking at?

13:09

So what are you looking at?

13:10

Often there is a streak gallbladder

13:12

or there's a tiny gallbladder.

13:14

So what kind of a transducer would you require?

13:17

You would require a high frequency linear transducer

13:20

to demonstrate the gallbladder

13:23

and that's what you have to see

13:25

and give a measurement to the size to the length

13:28

that you see, to the width that you see.

13:30

And if you can get a volume, that's also great.

13:33

So that is a little different way

13:36

of scanning the gallbladder.

13:37

So, so in REIA you may not see the gallbladder

13:40

or you may see a tiny gallbladder,

13:42

which is like a streak gallbladder.

13:44

And this may be uh, even

13:47

after two to three hours of fasting.

13:50

Okay, so another common area when you're uh, suspecting

13:54

razia is a triangular sign, which is a thickening

13:57

of the ligament that you see, uh,

13:59

of the triangular portal area.

14:02

So when you see this area, hyper coic interior to the fo

14:07

really, really suspect the abnormality and

14:11

accordingly, uh, classify and give the diagnosis.

14:17

So the most important uh, different uh,

14:20

difference in imaging in cases of pediatric

14:22

and versus adult population is uh, looking at the cues

14:27

and using the appropriate transducer frequency

14:30

to evaluate the detail.

14:34

Now, I mean just moving on with the age.

14:36

So what are poly cy in the pediatric population?

14:40

The commonest abnormality that you would see is either a,

14:43

like we discussed or often the child is presented

14:46

for al cyst, the con.

14:49

Now the al cyst, they will just come to you,

14:53

they'll actually present as cystic lesion at times

14:57

of various shape and various locations for you to be able

15:02

to establish the connection with the biliary tree.

15:04

And that's what's going to lead to a diagnosis

15:06

and help you differentiate whether you're dealing with a

15:11

cyst in the bary tree

15:12

or whether a cyst in the hepatic or the liver.

15:17

So the challenge will come in differentiating

15:20

between the two for which you really need to be able

15:23

to establish the connection of it with the beary tree.

15:26

So what are poly cyst represent?

15:28

Conjun cystic dilatations of biliary

15:31

and diagnosis relies on exclusion of other conditions such

15:34

as gall stone inflammation as a cause

15:36

of biliary tract dilatation.

15:38

And the 60% are diagnosed before the age of 10 years.

15:43

Clinically child presence with pain, jaice, mass

15:48

ultrasound, you often see assisted structure

15:52

and seeing that assisted tructure may be often in the

15:56

appropriate clinical se settings be an in enough indication

15:59

to better uh, further imaging back cross-sectional imaging

16:04

and often de cyst over a period

16:07

of time may collect sludge stone or even grow a new plasma.

16:12

So sometimes this is are so large that the connection

16:16

with the duct is not easily

16:18

recognized on ultrasound imaging.

16:20

And of course we have to do our best maneuvers,

16:22

various windows to demonstrate that relationship.

16:26

For example, here we have a case, now we see IHVR,

16:30

we see the dation data with radicals

16:34

and we see a cystic structure in the region

16:37

of the portal, right?

16:39

So it's a dilated probably this is a c dilated CBD

16:43

and there's a few form kind of a dilatation of the distal

16:47

portion of the mid and the distal portion of the V.

16:53

Now what are the types of al cyst? There are uh, five types.

16:57

First is the diffuse dation of the extra hepatic bile duct.

17:00

This which is the most common type.

17:02

Second is the true tubulu of the biotech very way.

17:06

The third is also called the choto seal,

17:08

which is a diffused dation

17:09

of the very distal indual common bile duct.

17:13

Type four is multifocal dations to the in hepatic

17:16

and extra hepatic bile duct type five ISIS disease is

17:20

omitted because it's not a true choto cyst.

17:23

So accordingly you can have the commonest is dilatation

17:27

of the extra hepatic bio duct seen in 80 to 90% of cases.

17:31

And depending upon the shape they could be cystic,

17:33

secular or fusic.

17:36

So you could have this kind of an appearance.

17:38

Now let's look at this case.

17:40

Now here we have a picture which is showing an ultrasound

17:44

image, which is an image of a right upper.

17:47

I see that's the dome of the diaphragm

17:50

and I see a large cystic region right

17:54

now I've got a video clip.

17:56

So with this case that I've done few days ago

18:00

and I see in this cystic area, I see some, some, uh, sludge

18:04

and debris here in this area and I try

18:07

and establish a connection.

18:08

So maybe, uh, it's connecting here with the V tree.

18:12

Now these are some still images of the same patient.

18:15

You see the V tract, you see the dilatation,

18:18

you see the cystic area

18:20

and you see some internal content that moves.

18:24

Obviously the diagnosis can be very challenging,

18:27

whether it's a hepatic or it's a affiliated tree.

18:31

However, this was a confirmed case of colorectal cyst

18:37

and the patient was also sent for a ela uh, assessment

18:41

of the, uh, parent chime to see if it was still functional

18:46

or it had, it had concourse on.

18:49

Okay, so that's, uh, the other part

18:52

of the imaging that you would do.

18:54

So this was a case of quality of cyst with the stenting.

18:58

So again, we look at the establish the connections.

19:00

So see we done stenting to release some pressure

19:04

and we can hear, establish some connection with the B three,

19:08

which is pretty convincing

19:10

and consistent with the diagnosis.

19:13

And this case child presented with vomiting

19:15

and pal thrive lump abdomen increasing in size, known case

19:19

of political is diagnosed at five months

19:21

and gene on antenatal, uh, uh, ultrasound five months

19:27

and which was uh, size of 18 and 14 to 14

19:31

after birth and followup ultrasound,

19:33

there was further dilatation and increase in size

19:37

and it was then MRCP, there was a cross dilatation.

19:41

So finally the patient was, uh, planned for hepatectomy

19:46

with cyst resection and HEPA anastomosis

19:49

and child was disturb.

19:53

So that's mainly where the pediatric population not coming

19:56

to the normal adult population

19:58

that we are scanning every day.

20:00

So of course like we discussed positioning,

20:03

we taken the lip window, why we are displacing the bowel

20:07

and we are getting a nice contrast to CD clear

20:10

and equally uht role of breathing,

20:16

role of breath holding in p it doesn't apply

20:18

because you won't be able to give that command

20:20

and role of dynamic scan in various patient positions.

20:23

Not all these factors.

20:25

How persistent, how passionate you're

20:27

to really see the verta in total would reduce your

20:33

uh, uh, redos, right?

20:35

So I'm like, I'm very, uh, like, you know, particular

20:39

for the positioning to do the gall often when we are trying

20:43

to do the lateral disposition.

20:46

So the most common pitfall

20:48

or the error that is made is when you're trying

20:50

to meet the patient is supine and we try

20:52

and meet the patient in decubitus.

20:54

So instead of a full decubitus,

20:56

often this patient is scanned in a slammed position In

20:59

that position, whatever you do, you will not be able

21:03

to scan the complete neck area.

21:06

That is one of the very commonest, um, positioning, uh,

21:11

pitfall because yes, we have to roll the patient this side

21:15

and that side and all those things, but

21:18

however, if you haven't put the patient completely

21:21

in the depth disposition, you wouldn't or,

21:24

or rather slightly forward faster the disposition

21:28

and then you really begins to be able

21:30

to see the complete neck area that is very, very important

21:33

to evaluate the area fully.

21:36

So the is best viewed in the left lateral disposition.

21:39

However, it can be viewed

21:41

with the patient's spine on right it are useful

21:45

to determine if the students are mobile

21:47

or impacted in the neck

21:48

or sometimes even if they're just uh, mobile

21:51

and it may not be seen on the routine scan,

21:54

but if we do the last finishing touch in then position,

21:57

he would just say that something just drop down, right?

22:00

Role of 3D, not really, I don't use it,

22:03

but just outta curiosity.

22:04

But an image of a a polyp, we are just trying

22:08

to see the old surfaces.

22:10

Whatever you can, if there are any IAC polarities

22:13

as we'll come to the topic polyps.

22:15

So small benign polyps are okay,

22:17

but where like 10 millimeters

22:20

or more come into the significant category.

22:24

So as we all know, GBA is a peer shape structure.

22:28

Now what are the dimensions? Do they really mean anything?

22:31

Do we really need to be worried about the dimension?

22:33

What do we mean by what dis tend, what do we mean

22:36

by understanding what do we mean by postprandial?

22:39

Like these are the things which are um, used

22:44

but were not with very defined criteria, right?

22:47

So we can only give a,

22:50

it's about seven centimeters long post centimes wide

22:53

and this is capacity

22:55

and when it's markedly distended it can up

23:00

to 300 ml F fluid.

23:01

Now coming to the size size we have pediatric

23:06

nomograms are charts that we have to follow by the age

23:09

because that's where we are trying to see uh, to exclude as

23:14

to what is the minimum size of the Colorado.

23:16

So we have at least a length of six, uh mm

23:20

and at least a two mm width, uh,

23:25

uh, two centimeters width

23:27

and a six centimeter length is what we uh, have at least.

23:32

So that's the gallbladder wall

23:35

and the wall is normally about two millimeters,

23:38

but not more than anything.

23:40

More than three is defined as abnormal.

23:43

So you should be able to see the make completely through

23:47

and through and establish a connect with the cystic duct.

23:50

That is very, very important.

23:53

Septe are seen in the ver sometimes they divide the ver

23:57

into compartments.

23:59

So septe are normally through

24:00

and through junction holes that we see are often half part.

24:05

So they is considered as a serial duplication

24:07

of the Colorado and may be associated with some complication

24:11

during poly system,

24:12

but I don't really think that's mainly a literature review.

24:18

Uh, water are dimensional folds.

24:19

These are the holes that just fold onto himself in the part

24:23

just like uh, hydros we have the folds, right?

24:27

So these are usually taken incomplete

24:29

and the CEP are maybe complete

24:32

and they may be associated with cases of small polyps

24:36

or multiple coele artifacts in case sub ayo

24:41

coming to the ian cap.

24:43

That is interesting because ian cap often lodges some,

24:48

it can lodge a calculus

24:49

and it can become so dense

24:51

that the whole area can become dense

24:53

and sometimes it can be just missed pathology of a uh, of a

24:58

calculi or any lesion or any mass lesion in that area.

25:02

So when the fi cap is there, you have

25:05

to look at it very carefully that it is distended

25:09

and you can demonstrate the pathology.

25:15

We all edema is thickening of the edema,

25:18

which could be non-specific due to any inflammation

25:21

or cystitis.

25:23

We will come to that. So the commonly list, uh, appearance

25:28

that we see is hepatitis.

25:30

We see the GB wall ine cases of uh,

25:33

typhoid hepatitis and placebo.

25:36

Now what is gall bladder sludge?

25:38

We use that word very commonly called bladders shows hyper

25:42

sl or hyper slage or genic slage

25:45

or soft with no shadowing.

25:49

So what is sludge?

25:51

So gall liver produces bile stored in the gall bladder.

25:55

So when it's not draining well when it's

25:57

staying for a long time.

25:59

So the green pile can often be collected there, it can be,

26:03

it can form a sludge, it can also convert to mucus

26:08

and it can be a mucus seal as well.

26:10

So the mucus from the reta can mix with the cholesterol

26:13

and the calcium combining to create the sludge, okay?

26:19

And over a period of time, sometimes it may be so um,

26:24

thickened and dense that it's actually giving an appearance

26:27

of almost the same equ

26:29

and echogenicity as a it HEPA paradigm.

26:33

Now this word called he of

26:37

could happen due to various factors.

26:39

One of them is SL collecting over a period

26:41

of time sometimes there could be an actual lesion which is

26:45

hiding behind this kind of an appearance.

26:48

So do you when you see he of re

26:51

so really you cannot comment on ultrasound imaging whether

26:55

there is a pathology or mass lesion in the GB

26:58

or there is not a a lesion there.

27:01

You would need a contrast enhanced CD scan

27:04

for further evaluation, right?

27:08

So uh, of course yes we see longstanding cases with stasis.

27:12

So when there is inadequate drainage,

27:14

that's when it collects and it pop.

27:17

Another common finding that we see is adeno

27:21

omes are called that.

27:22

Now what is that? Basically your ultrasound,

27:25

what we see is tiny echogenic shadowing from the wall.

27:28

Now what it is, it is an acquired,

27:31

it is a benign acquired anomaly characterized atrophy

27:34

of the mucosal epithelium

27:35

and invaginates into the interes of the

27:38

thickened muscularis forming the OENs of sinuses.

27:43

So this is basically hyperplastic polys of the gall

27:47

and on ultrasound what we see is genic, which are giving it

27:53

atail is like a tapering artifact.

27:56

So a thicker at the bottom and lower narrower

28:00

and usually suggest benign pathology.

28:04

Tiny polyps, tiny hyper

28:07

lesions which are attached to the wall.

28:10

So when you move around the patient you do your maneuvers in

28:13

various position breath.

28:15

When you see they're not moving,

28:16

that's when you label them as polyps.

28:18

And of course, uh,

28:20

less than once in media we would just follow up.

28:24

Adults do cross-sectional imaging.

28:27

The GB polyps are often asymptomatic may cause IC colleagues

28:33

and they're often incidental findings

28:35

and primary limitation to distinguish benign

28:38

and malignant is always there.

28:40

So there is no way we can tell about a histopathology

28:43

on basis of ultrasound fluid, any polyp that we see,

28:49

whatever if their patients base is not of ease and the skin

28:52

or if you think you can go

28:54

for a higher frequency transducer, try

28:57

and evaluate the detail

28:59

and get an assessment whether there is a flow or not.

29:03

That is very important.

29:09

Okay, so

29:13

what about uh, the next commonest finding

29:16

that we see every day,

29:17

which is the calcula in the gall bladder poly lithia.

29:22

Now, now sounds simple again is a an area

29:27

of a lot of discrepant reports

29:28

because patient comes, okay I got an ultrasound done at so

29:32

and so place, they said there is a gold stone.

29:35

I got an ultrasound set at another place.

29:37

They said there is not a goldstone,

29:39

I got an ultrasound from so and so.

29:41

They said the size of my stones is this.

29:43

I got done from another piece.

29:45

They said the size of the stone is this. Why this variance?

29:49

Okay, so the positioning has to be important

29:52

and for the size factor we have to understand

29:55

that the ball rather is like a peer shaped,

29:59

it's like a balloon

30:00

or a bag that you are holding if there are stones in it.

30:04

Now it depends upon which stone

30:06

and which angle of the beam are you

30:09

or uh, insulating how you would measure it.

30:13

So there would be a variance in the report

30:18

provided you try

30:19

and really do a four three dimensional orientation

30:23

of the available stone.

30:25

It is one and if they're not adherent to one another

30:28

and get the longest measurement in play

30:31

and then you freeze it and then you record it

30:33

and then you document it.

30:35

So that way you might have a reduced discrepancy in the

30:39

ultrasound imaging group coming to the gallstones.

30:42

They may be symptomatic in about 25%.

30:45

The most common presentation is with biliary colic,

30:47

right upper quadrant or epi pain, especially

30:51

after a fat rich meal.

30:54

Other symptoms include belching including ulence and uh,

31:02

and abdominal pain is often referred to the right shoulder

31:05

because of the nerve supply which is combined

31:09

uh, for that area.

31:11

And now ultrasound is a gold standard.

31:13

Now what is the pitfall telephone?

31:18

Now what is the pitfall?

31:21

There is a dirty acoustic gas shadowing

31:24

that is the commonest uh,

31:27

thank you during the time.

31:30

So it's, so we have

31:34

to differentiate the gall bladder shadowing from the uh,

31:37

gas shadowing in the area

31:39

because there's also ball in the area not to mis

31:44

misinterpret bowel shadowing with a GB shadowing

31:48

often the GP is removed

31:51

and then the shadowing in the fossa could be mis as

31:57

BCO shadow complex and a GB could be reported there.

32:01

So we have to prevent these pitfall by thorough scanning

32:06

and understand calculi is a dense shadowing

32:10

and the gas shadowing is a ring, uh, is a dirty shadowing,

32:15

meaning it's not completely dense.

32:17

So highly reproductive calculi will give highly re uh,

32:21

cal highly reflective echogenic ProCard within the Colorado

32:26

and with the normally prominent posterior caustic shadowing

32:30

regardless of the pathological type postage shadowing is

32:33

independent of the composition

32:34

and the calcium gravity dependent movement is often seen

32:39

with a change in the position.

32:41

The rolling stone side

32:43

and color doctor, as you all know when we evaluate stones in

32:47

the kidneys or anywhere demonstrates a twinkling art with

32:52

small stones on big stones, right?

32:54

So shadowing is more with more larger stones

32:59

with the higher frequency

33:01

and with the focal zone at the level of the gallstone.

33:05

So a gallstone may paradoxically be hard

33:07

to demonstrate when you have a ball eco complex

33:10

you come to that later.

33:12

So call stone will common in females.

33:16

However, when you see one pathology, what we learned,

33:20

we do not stop there.

33:22

We have to still look at more.

33:25

You see one stone, you do not stop there,

33:27

but there is another stone down in the tuck,

33:30

down in the CPD down in the PLE elevator.

33:33

So you really have to go,

33:35

especially when there are small gravel light

33:37

stones that's very important.

33:39

And the stone could be hiding a poly behind.

33:43

So that's another thing that you have to be aware of.

33:45

So this is an example of a case.

33:48

These both images belong to the same patient.

33:51

So there is a calcula with a dense postage tissue

33:54

and there are tiny little polys which are

33:57

attached to the wall as well.

33:59

So that meets the diagnosis a little bit different than just

34:03

quoting one pathology as the poly.

34:08

Of course you can sometimes have fine rebel like lar.

34:11

So it's a good idea to give some inclination to the surgeon

34:16

as to what is the approximate size of the scalp,

34:19

the scalp line that you're seeing

34:21

and where are they located funders or in the next region.

34:26

So which is very important to plan the next management,

34:32

the gas shadowing because cash shadowing is a ring down

34:35

and it's a dirty shadowing.

34:36

So you have to differentiate that from there.

34:39

You can have multiple lar you can have tiny multiple

34:42

shadowing lar you can have wall equal shadow complex,

34:46

you can have calculus impacted in the nitrogen

34:49

where you see an over distant wall bladder

34:53

and a nice large Lina.

35:00

So whenever the drainage to the gall bat is stopped, so the

35:05

the uh, the collections, the sta will lead to collection

35:09

and creation of the sludge we sl may be there.

35:13

These may include micro lids and protein

35:18

and lys cells and mucins.

35:21

You can have sludge, you can also have a polyp

35:24

or a mass, you can have small polyps.

35:26

So a thick and wall.

35:28

So that is another thing that you have to evaluate.

35:33

Now coming to the shadow complex absence

35:37

of gall bladder and just the TB fossa bowel shadowing

35:41

that is misinterpreted as a shadow complex

35:46

and of course Celine gallbladder.

35:48

Now these are three different scenarios.

35:51

These three have their own characteristic features and

35:54

and overlap of this.

35:56

This is disaster, right?

35:59

So let's understand wall equal shadow complex is a

36:03

double arc shadow sign.

36:05

The proximal hyper equ arc represents the wall of the gall.

36:09

So this hyper equate arc represents the wall of the gall

36:13

and the distal hyper equate art

36:16

represents the reflections from the gallstones, right?

36:21

And the hyper equate space in between the two.

36:25

It's a small pin sliver of fluid between of the vi

36:29

between the wall of the gall and the hyper, uh,

36:33

and the the gallstones, right?

36:36

So when error calcification is present,

36:38

the normal cul wall is not seen and only a bright eco

36:42

and the wall shadowing is that's

36:45

how we see this kind of an appearance.

36:47

So this is a classic wall eco shadow

36:50

and we'll look at the image a postal gall pattern.

36:53

Understand what's so understand here the e echogenicity was

36:58

inside the wall, it was not in the wall right now

37:02

of course scanning tears you have to go

37:04

through all the PO positions

37:06

and ask the patient to breath forward.

37:08

Now coming to this different uh, this thing uh,

37:11

call the postal gall pattern where we have

37:14

a dense calcification in the wall of the gall bladder

37:18

and we also see e echogenic contains, right?

37:22

So oline gallbladder refers

37:24

to the condition in which the inner gallbladder wall

37:26

is entrusted with calcium.

37:28

So wall becomes Britain heart and often takes a virtue.

37:32

And other names of course are calcifying cystitis

37:36

and calcified poly bladder, right?

37:40

Causes are known occurs in association

37:42

with ball stone disease

37:43

and may represent a form of cystitis.

37:45

The entire wall apart may be calcified.

37:48

Patients often have symptoms not uh,

37:51

prophylac coly technique often advised

37:54

because of there is a high in of relation with CHEB

38:00

Oma DD includes of course gallstones

38:03

and five cters coly cystitis and poly complex as well.

38:09

So here that's

38:10

because the calcification is occurring in the wall.

38:15

Now role of standing in erection,

38:18

sometimes we see a very clear movement,

38:20

we do not see a stone and we sta scan an requisition

38:24

and a stone just drops down into the front.

38:26

That's fine. Sometimes you see some hypo egos

38:31

that you think are polyps

38:34

but when you actually do a dynamic

38:36

maneuver you see oh they're boom.

38:38

Oh so it's probably just in inspirated

38:41

or collected sludge which was really looking like

38:44

as if it's a fit at that one spot

38:46

because getting vascularity

38:48

and ultrasound imaging in a Colorado poly is very

38:51

challenging unless you have a really very nice transducer

38:54

frequency and a really very lean in patient, right?

38:58

So this is a case where the these,

39:02

what we thought was polyps were actually moved in the

39:06

gravity dependence scan

39:08

or requisitions scan right now

39:11

what are the complications called stones.

39:13

People have them, people stay on them with ears,

39:16

they just come for annual follow up and like goes on.

39:20

What are the complications?

39:22

Why should we have them need to we treat them?

39:25

That's up to the surgeon.

39:26

But let's just understand

39:28

of course sometime they can lead pain, they can lead

39:31

to poly cystitis, acute chronic cholangitis

39:34

and titis when they can go

39:36

and block the obstructive jaundice called

39:41

hydroxy muco and me syndrome

39:44

and increased risk of cholangiocarcinoma

39:48

identifying the presence of the peric coly cystic fluid

39:51

is useful because it's a highly specific for GB disease

39:55

and can be seen in cases of acute cholecystitis, peric,

39:59

cystic abscess and GB perforation right

40:03

now coming to the very common diagnosis which is acute

40:06

coly cystitis.

40:08

Now how do we diagnose that?

40:11

Now the this acute coly cystitis acute inflammation,

40:14

we called greater presence pain tenderness in the right

40:17

allic poa, positive sonography sign,

40:20

which means tenderness is seen when you put your probe in

40:22

the right, uh, in the right upper upper heart.

40:26

This could be ulu coly cystitis

40:30

or a calculus coly.

40:32

So the findings all are pretty much the same.

40:35

The only difference is in calculus cholecystitis the lead

40:39

point or the cause of the precipitate is a calculus that is

40:43

impacted in the neck.

40:46

Whereas in the a calculus it's just a mucosal swelling which

40:49

has caused obstruction and STAs and again collection

40:53

and lead into all the uh, symptoms.

40:57

Basically there is an obstruction

40:59

to the tree flowing drainage of the P.

41:02

Eventually it leads to gall bladder extension,

41:05

edema of the gall bladder.

41:06

Increased luminate lash again it leads to uh,

41:11

inflammation and acute oly cystitis, right?

41:16

So what will you see? You will see there's a blockage.

41:19

You'll see the stone which is lost the blockage.

41:22

You will see the collection hypo equate sludge

41:25

and you'll see the wall edema

41:27

and you can see perico cystic fluid which is ous

41:32

or you can also see some perforation

41:34

and other complications as well, right?

41:38

And in cases of a calculus, like I discussed,

41:41

the pathologist pathophysiology results from a gradual

41:44

increase in the bowel viscosity

41:46

because of prolonged sta that leads

41:47

to functional obstruction of the system.

41:51

I have to move on faster, right?

41:54

So chronic coly cystitis lead to wall thickening

41:57

and inflammation

41:58

and piers coly cystitis is a rare form

42:01

of acute cholecystitis

42:02

where the wall undergoes necrosis inflammation

42:06

and can lead to perforation as well.

42:09

So gang greenness, coly cystitis, again you see a lot

42:13

of heterogeneously looking bald bat with a lot

42:16

of air shadowing and there's hemorrhage necrosis

42:20

and micro abscess formation in over there

42:24

and it's a seen in about, uh, you you may be able

42:27

to see the mur sonographic murphy sign.

42:30

So what are the findings?

42:31

You have str of the wall, the intinate membranes

42:35

and marked asymmetry

42:37

of the GB wall focal irregularities mass like appearances SL

42:42

paralytic fluid collection.

42:44

First the se e that we don't do not wish

42:47

to see is the TB perforations.

42:50

That's why our role in early uh, diagnosis

42:54

and appropriate management is paramount.

42:57

So how would you see a perforation of the tv?

43:00

So remember the shape, it's a nice peer shape.

43:03

So if you see something,

43:04

but if you don't see any peer shaped structure,

43:07

the funders area or any other area,

43:10

'cause fundus is the most prone area inside of perforation

43:15

and uh, you can see a focal outpouching

43:19

and the collection over there in case the perforation

43:23

like this, you can have a focal collection out pouching and

43:28

because fundus commonly has a compromise

43:32

group, okay?

43:35

So you can have micro abscesses, thickness and LA right?

43:40

Coming to the next topic, polyposis

43:43

or calculi in the CPD.

43:46

Now as we all know, that's the portal vein,

43:49

that's the P artery and that is the CPD.

43:52

And obviously we can very well demo, uh,

43:55

very well see a large calculus

43:58

and that's the same calculus in transverse section.

44:01

So this we have to demonstrate

44:04

and look at the tree, tree longitudinally

44:09

and transversely pay attention to the very d part

44:13

of the common that as passes

44:14

through the pancreatic head 10 15.

44:18

So on ultrasound you'll see cal eye,

44:20

which could be two to 20 mm.

44:21

Shadowing is difficult to eit then

44:24

with cause stone within the call ladder

44:26

because of various positioning challenges and others.

44:29

So this is the dilated CBD, these are the

44:33

IC sizes for the surgeon.

44:35

So more images of the same case.

44:38

So we can just demonstrate the CBD calculus.

44:41

So here's a case with a ca calculus in the gall bladder

44:46

and another calculus in C.

44:49

So that's why even though this calculus is a big sized

44:53

calculus, we do not stop, we still have

44:57

to have a careful look at the entire period tree, especially

45:01

as we we know by experience.

45:03

If the are tiny and small ones it becomes very important.

45:07

But a large calculus would also have a

45:10

instance small calculus.

45:14

Okay, so dilated CPD by definition more than six

45:18

and more than 10 post fully

45:21

and could be there right dilated IHPR

45:26

more than three mm we can see them

45:29

and we have to understand that what is the root cause?

45:32

That's where we need to focus.

45:34

It could be a lesion in the, in the duct,

45:38

even a small lesion which is not passed.

45:41

But beyond the wall of the CBD we could still be resectable.

45:45

So early diagnosis is very good.

45:48

So whenever you are looking at scanning,

45:51

what all should you be looking for?

45:53

A GB mass, if you see, what do we look for?

45:57

We'll look, if we see any focal lesion in the verta, we have

46:00

to look at the size, shape, societal potentiated, ex extens,

46:04

ization spelling,

46:07

and the vascularity associated ized status

46:10

of cystic duct, C, BD.

46:11

And so masses can be projecting poly

46:16

foal masses

46:18

and they could be sometimes with ill-defined margins,

46:20

heterogene genicity.

46:24

And they could be hyper foci, they could be calcifications.

46:28

So here we have a typical, uh, uh, uh, solid

46:34

heterogeneous mass, um,

46:37

projecting in the fundal region into the cold movement.

46:41

And the ball appears maybe very thickened a bit.

46:45

And yes, of course we have vascularity

46:48

seen on colored doctors.

46:49

So findings are really, really suggestive

46:51

of suspicious etiology, right?

46:55

Coming to the next

47:01

we can have larger mass lesions as well.

47:04

Okay? Now the most important thing is

47:10

a cal life could be hiding mass lesions or sludge.

47:14

So you really need to be vigilant to look

47:17

for all the pathology.

47:18

Again, MAs and Cal life could be coexisting, so you have

47:22

to look at it very carefully.

47:24

Again, mass and caite could be coexisting.

47:27

You have to look at it very carefully.

47:30

Mass could be seen as large heterogeneous lobulated

47:34

and you could see you cannot appreciate any clear interface

47:39

between the liver and the mass region here.

47:43

Possibility of direct extension into the hip hs.

47:47

Hepatic parent is highly suggested in this case.

47:51

So again, you can have mass

47:53

with the heterogeneous appearance.

47:54

Again, we have another case with the CCPT mass.

47:58

Now over a period of time the vial is, could be replaced

48:02

with mucus and you could again have both

48:04

more than one pathology.

48:06

So here's this with collection and debris within.

48:10

You could also have, again,

48:13

all throughout echogenic contents or hyper.

48:18

So depending upon the various testing you have to

48:23

use your various transducers

48:25

and various, uh, optimization skills to be able

48:30

to evaluate the gallbladder.

48:32

It's a simple organ, it's very easy to see.

48:36

And however we together can reduce the

48:41

discrepancy in the reports in the gallbladder imaging.

48:44

Thank you so much. Thank you all for joining in.

48:48

Have any questions I'll be very happy

48:50

to do. Thank you. Thank

48:52

You so much Dr.

48:53

Singal. Yes. Uh, we will now open the floor up

48:56

to any questions our audience members may have.

48:59

It looks like we have a few in the q

49:00

and a, um, already set for you Dr.

49:04

Singal, if you're able to open that up,

49:07

I'll, I'll, okay, so what do you recommend,

49:12

uh, Ms. Sanchez asking when bladder, uh, is contracted

49:16

with gall stones even

49:17

after it does fasting, just a point of chronic inflammation

49:20

and how to exclude past?

49:22

Uh, yes, probably, uh, chronically inflamed

49:25

and thickened gall bladder may be contracted.

49:27

And how to exclude carcinoma.

49:29

We really need to do a contrast CT scan

49:31

to evaluate it further

49:33

because the adenocarcinoma gall bladder can pre,

49:37

we can present as a focal thickening

49:39

or a diffuse thickening.

49:41

So the answer would be a contrast CP scan in that case?

49:44

Correct. Thank you. Another question by Dr.

49:48

Sanja is how, what

49:50

to recommend when we see por seline RA on ultrasound.

49:54

Uh, por seline ra, like I said, it's a, the

49:59

literature says there's an increased risk of malignancy

50:02

and it's all contracted.

50:04

So of course a CT scan to evaluate

50:06

and exclude any further pathology

50:08

because when you have the shadowing from the wall,

50:11

you definitely cannot evaluate the internal contains

50:15

of the gallbladder.

50:17

So ultrasound could be limited in this scenario

50:20

to evaluate internal detail of the OSA lining

50:24

for any pathology and a contrast CT scale is needed

50:29

to solve the case.

50:31

Thank you. And uh, we've done that as well.

50:35

So next is, is there any significance

50:38

to count the gallstones in the report

50:40

or just give a size range

50:42

or just give the largest dimension?

50:45

Now this is an area where patients insist

50:48

and patients go, uh, left, right and center.

50:51

They say that so and so has already told me.

50:54

Now is there an increase or a decrease?

50:57

There's a lot of patient counseling that goes on about it.

51:00

I do try and explain that look, if I take a bag

51:03

and if I fill it with some coins

51:06

and then it would depend on which angle am I looking at

51:09

and if there's so many coins which are clustered together,

51:13

how can we really say until, unless someone pulls out

51:17

and spreads the coins on the table.

51:20

I like, I don't use the word coins,

51:22

I use a bag full of diamonds.

51:24

Like, you know, until someone spreads them you cannot.

51:27

So you'll have a difference in the reported however,

51:30

because um, more than 10 millimeter,

51:34

I think they have a surgical management criteria

51:37

and especially if they are four, five millimeter,

51:40

they could easily trickle down the CBD.

51:43

So understanding, uh, of the,

51:47

if there is a large calculus

51:48

and if it's impacted in a particular location,

51:51

it'll really irritate the muy that point

51:54

and it may lead to, uh, carcinoma neoplastic changes.

51:57

So again, that needs to be mentioned that it's an impacted

52:01

and this is the size of the calculus in

52:03

the largest field of you.

52:04

And especially when you have those gravel like which are

52:07

photo six millimeters, they're very vulnerable

52:10

to drop down into the duct

52:12

and lead to pancreatitis, lead to various other scenarios

52:16

and uh, the clinical medical emergency and other scenarios.

52:22

I do give a range.

52:24

I do give, I do not give the number more so than the sizes.

52:29

I do give few calculi because you couldn't,

52:32

unless there is a really sure that there's a single calculus

52:35

or then I would say a few calculi or a single calculi.

52:39

So I wouldn't go about the numbers,

52:41

but I would say, uh, they measure approximately

52:45

or between four to eight mm or between uh, eight to 12 mm

52:50

or between 15 to th 30.

52:53

So whatever is my uh, uh, I measure and the largest

52:58

and or the smallest and then I give a range.

53:02

I try and give some clinical picture to the clinician

53:06

and to the patient so that they have some answer,

53:09

but mainly to the clinician to understand

53:11

that if they're very small they need to watch out

53:13

for them trickling down.

53:15

If they're very large and irritating there, they could lead

53:18

to new changes because they're not moving around.

53:21

So like, you know, if some fixed

53:23

and irritating there if you need to mucosal changes.

53:27

Thank you. Thank you for your question.

53:32

Do you make a disclaimer in the report for the patients

53:34

who are difficult to reposition?

53:38

Um, technically we don't do that.

53:42

So it's up to you

53:44

or whichever way your practice is working smoothly,

53:48

whatever is the law of the land,

53:50

whatever, whatever works for you.

53:52

If there's a practice for disclaimer,

53:54

so we do it if they're difficult to reposition,

53:57

so we just uh, I mean you would just say limited scan,

54:00

you do inate patient positioning.

54:03

So this is not evaluated.

54:05

You would, uh, you would I would say yeah,

54:07

patient is non fasting so you've not evaluated that area.

54:11

You would add that and

54:13

because many times the patients would come

54:15

for a whole abdominal scan, they're coming

54:17

for a renal colleague and uh, patient is non fasting.

54:19

So the intention is not for that area,

54:22

but it's just for the kidney stone.

54:24

But you are still doing the whole abdomen

54:26

so you would make a note for that.

54:27

Right. Okay.

54:30

So where, so disclaimer. Yeah, it's up to you.

54:34

Right. So the next thanks

54:36

for the great talk, thank you so much.

54:38

Do you have any experience, uh, using point

54:40

of service pocket your scanners for evaluation of the gp?

54:44

Uh, in our country point of uh, uh, US scanners are not, uh,

54:49

authorized, uh, to be used.

54:50

So we use the, the, the big,

54:56

big state of art equipment.

54:58

We are blessed to use that. So thank you so much.

55:02

And what's the prevalence of pseu? Lithia?

55:05

I dunno, that's a term that I'm actually seeing it now.

55:08

So you mean soft calculi without any acoustic shadowing?

55:12

I I actually use that same descriptor.

55:15

I see genic archive which are mobile

55:17

but I do not see an acoustic shadowing.

55:20

So they could be in the, along the pathophysiology

55:25

but they're not casting the test acoustic shadowing.

55:27

They may resolve over a period of time

55:29

or they may lead to dense.

55:32

I use that terminology.

55:34

Could you tell the standard views

55:35

and positions of the call value evaluation?

55:37

Very information lecture.

55:39

Thank you so much for the compliment.

55:42

Standard views are longitudinal and transfer.

55:44

So for any organ in ultrasound imaging we get the

55:48

longitudinal span of the organ

55:50

and we get the appendicular scan and so, but

55:53

however it's a three dimensional scan

55:55

so people scan the organ from top to the bottom left

55:59

to right in all different sleeves.

56:01

So assuming that we've covered the 360 degree in all volume

56:05

of the tissue, thank you.

56:08

How to differentiate a small polyp

56:11

and stones in the reta mobility DY scan, as simple as that.

56:16

Polyps could not what to do if TB does not distend

56:20

after overnight fast tb.

56:22

While thickness is normal, she is not standing.

56:25

Is that for a pediatric population

56:27

or is that for an adult population?

56:29

If you're looking at raia, which should not distant

56:32

after overnight fasting, pediatric will not do.

56:36

But if an adult, if it's not dis descending

56:38

after overnight fast, probably due to chronic ly cystitis,

56:41

it's inflamed contrast and you may need to do a ct.

56:46

Lets exclude any other pathology

56:49

to patients with fatty liver.

56:51

Uh uh, this patient with fatty liver.

56:54

A contributing factor for gallstones

56:55

or that's in pathophysiology.

56:58

Remember we reading that in a pet email of 40.

57:01

So I guess obesity is a factor.

57:05

Okay, so US guided drainage of tb.

57:08

Uh, drainage of tb you mean?

57:12

I'm not into uh, doing uh, any of those interventions?

57:16

No, the contribution

57:19

of contrast enhanced ultrasound.

57:22

Okay, it's there. It's developing, it's there.

57:25

We, we use it for the liver for focal hepatic lesions

57:29

to do the RFPAs

57:30

and to um, uh,

57:33

follow the lesions in CC post RFA

57:37

but uh, we use it for gall battle.

57:39

We haven't done that as at our you.

57:43

Thank you for the wonderful presentation.

57:45

Could you please do you know istic neck

57:48

of the gallbladder causing pain?

57:51

Oh you mean like aion of the gall bladder? I can wait.

57:55

Interesting to see a case. Thank you so much though.

58:00

Okay. How to frame sludge in a mouse in corporate, again,

58:03

mobility dynamic scan.

58:04

So sludge would move.

58:06

Uh, that's uh, I had a case where there was a sludge,

58:08

which I thought was a mouse and then uh, uh, it moved

58:12

or it all moved in the dynamic imaging.

58:15

Thank you for your question.

58:17

Do you give a diagnosis that says

58:19

considered entrusted stone versus partially calcified polyp?

58:24

I wouldn't give that. That's like, uh, uh,

58:30

I would give, if I think it's a polyp, I would give a polyp.

58:32

I would give a uh, echogenic.

58:35

I would no shadowing soft

58:37

or I would give cal lab, which for doing

58:42

how can I differentiate oline from sludge.

58:46

Oline is in the wall

58:47

and sludge is in the inside the contain.

58:50

They're both different things.

58:54

Hence ma'am, it was very informative.

58:56

I gained a lot of knowledge. Thank you Dr. Bhe.

58:59

And uh, I read somewhere normal

59:04

CND thickness is four.

59:05

Uh, you mean common bile duct?

59:07

Uh, I have four to six.

59:11

Mm like depends upon the age long ary

59:14

for GB and complication.

59:17

Uh, not no of that. Thank you so much.

59:21

Thank you for all your questions.

59:25

One more has just popped in how to differentiate

59:27

to mucosal and sludge.

59:29

So basically sludge is just a collection of the bile, right?

59:32

But over a period of time they say the sludge ites

59:35

and it becomes like a mucus collection.

59:38

So an ultrasound basis you cannot really say in MUE is when

59:42

you actually operate

59:44

and you pull it out that it's just a mucus, it's not bile,

59:47

that's when it's to pathologically on the table le

59:50

but on its can be impacted

59:52

and over a period of time it can become like

59:54

a MUE or dis standard.

59:55

That, thank you. That was your question answered.

59:59

Thank you so much. All done.

60:02

Alright. Thank you so much everyone for,

60:04

for participating today, uh, in our noon conference.

60:07

You can access the recording of today's conference

60:10

and all our previous noon conferences by creating a free

60:13

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60:15

Be sure to join us next week on Tuesday,

60:18

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60:21

where Dr. Dennis Beki will deliver,

60:23

deliver a lecture entitled Introduction

60:25

to Arthritis part two.

60:27

You can register for it@mrionline.com

60:30

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60:31

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60:34

Thanks again and have a great day.