0:00

Okay.

0:01

Here we have another right upper quadrant

0:03

ultrasound, and here at the level of the liver,

0:05

we can see a lot of echogenic structures here.

0:07

Those little tiny tubular anechoic

0:09

structures with echogenic borders

0:10

within the liver parenchyma themselves.

0:12

The question is, is that a portal vein that

0:15

usually has echogenic walls, or is it a dilated

0:18

bile duct that would also have echogenic walls?

0:20

And here on the color flow image, you can see that

0:22

these little anechoic regions do not have blood flow.

0:25

So indeed these are.

0:28

Dilated intrahepatic ducts.

0:30

Going on to look at the gallbladder, you can see that

0:32

the gallbladder is quite distended, and there are very

0:35

echogenic shadowing gallstones at the gallbladder neck.

0:37

So this is an unusual case in that this patient has

0:40

dilated gallbladder and gallstones within the neck of

0:44

the gallbladder, compressing the common hepatic duct,

0:47

resulting in intrahepatic biliary ductal dilatation.

0:51

Let's go on to see this patient's CT

0:53

scan so that I can convince those of

0:55

you who are questioning the diagnosis.

0:57

Here you can see that there are dilated bile ducts.

0:59

These parallel the portal veins.

1:01

There's a little tiny circles adjacent to the

1:03

portal veins, and as we come down, we'll see

1:05

those dilated bile ducts all the way to the portal

1:08

hilus into the central region of the gallbladder.

1:10

And here we can see a calcified gallstone just

1:13

compressing on that common hepatic duct resulting in.

1:18

Hepatic ductal dilatation and jaundice.

1:19

This is referred to as Mirizzi Syndrome,

1:22

and this is a higher level problem

1:25

in patients who have cholecystitis.

1:27

In this case, you can also see

1:28

that the gallbladder is distended.

1:31

There is some, um, pericholecystic fluid, which

1:33

I may be able to convince you on the coronal

1:36

as well, consistent with cholecystitis.

1:39

With secondary compression of the common bile duct.

1:42

Now, this patient also received an MR MRCP, and I'm

1:44

not saying that this patient needed an MR MRCP, 'cause

1:47

you know I can't always control all that's done.

1:49

But I really wanted you to have a

1:50

chance to take a look at this MR MRCP.

1:52

I think as residents, frequently our

1:54

residents are kind of intimidated by MR

1:56

MRCPs, but they're really not something

1:58

that you should be intimidated by.

2:00

Here is a coronal fluid-sensitive sequence.

2:03

If you repeat after me, I would like

2:05

coronal single-shot T2 images.

2:08

That's what you want to tell your technologist.

2:09

If you ever have a case that you don't really know

2:12

what you're looking at, ask for more coronal T2s.

2:14

These are the money shot.

2:15

These are anatomical images.

2:17

They are beautiful, but they can

2:19

be read similar to a CT scan.

2:21

We're not doing functional voxel suppression images.

2:26

When we're looking at MRCPs.

2:28

We're just looking for stones that may not

2:30

be visible on ultrasound or on a CT scan.

2:34

Here you can see that there are dilated bile ducts

2:36

that are paralleling the portal vein, just like we

2:39

saw on the CT scan, and here we see that large dark

2:42

stone causing compression of the cystic duct there

2:44

and the common duct as well, posteriorly, and

2:48

that is a beautiful view of Mirizzi syndrome.

2:50

You can see the other large rock

2:52

chunks in that gallbladder as well.

2:54

You can see that the distal common bile duct is

2:56

completely decompressed down to the duodenal sphincter.

3:00

Here is a beautiful view of

3:02

the pancreatic duct as well.

3:04

So MRCPs, they can be helpful.

3:07

This one is probably not

3:08

necessary to make the diagnosis.

3:09

We had made it on other entities, but comfort

3:12

with MRCPs can only bring you farther down

3:16

the road of mastery of our profession.

3:19

This is a gorgeous slab image showing that intrahepatic

3:23

biliary ductal dilatation being caught to the level of

3:26

that gallbladder neck, consistent with Mirizzi syndrome.