0:00

alright, so now

0:03

another young gentleman 26 year old male right up

0:06

a quadrant pain. And this was interesting in that the patient got

0:09

a I'll just tell you the history got a CAT scan showing no real

0:12

abnormality that got an ultrasound where they couldn't find

0:15

the gallbladder. They got a Hiatus scan that showed no

0:18

uptake in the gallbladder. And so they were like

0:21

well, you know worried about cholecystitis potentially,

0:24

but because there's

0:27

no uptake in the gallbladder, but the or potentially,

0:30

you know, the gallbladder was just absent but

0:33

there's no history of Prior Kohl's hystectomy. So they got another Imaging modality

0:36

to sort of sort this out and that's what I'll share with a group.

0:39

Somebody's asking why renal Pharaoh in the right? Kidney is

0:42

working perfectly. I think that I miss

0:46

you. I'm not really sure to be honest. I think I was just a history that was provided.

0:49

I think oftentimes we get these generic histories, but they certainly

0:53

were not this is the second case. Yes, somebody's

0:56

asking but certainly perhaps a

0:59

left kidney was dysfunctional enough that it was affecting

1:02

the overall renal function in the patient.

1:04

So let me show the second case. It's an MR a few

1:07

more sequences to look at and I'm happy to you know, scroll through some selected sequences

1:10

and I'm happy to scroll through more

1:13

of the group once okay, so I'll start up with the t2fatsat sequence. Remember, this

1:16

is a young patient right upper quadrant pain HIDA scan

1:19

showed no uptake in the gallbladder, but, you know,

1:22

they weren't really worried about clinically about cholecystitis.

1:25

But person also never had a cholecystectomy. So they're

1:28

just wondering

1:29

What's going on with the gallbladder? What's going on in this patient? So here's

1:32

the

1:35

t2fatsat sequence

1:44

Right, you can see a bunch of organs here spleen kidneys

1:47

adrenal glands.

1:50

Probably just sort of hone your eyes to the

1:53

sorts of things that you may be worried about given this.

1:56

History is the coronal T2 image.

2:07

And I'll show you a myth of the MRCP that

2:10

helps at all.

2:14

These images didn't come out too. Great. I'd imagine so I'm not sure

2:17

this will help you but let's look at the

2:20

Excuse me, the T1 pre.

2:24

- let's give

2:29

you a post contrast sequence in the arterial phasers. Look gonna

2:32

be a little bit of motion here. So

2:37

I'll say that I not sure if the motion

2:40

will affect.

2:43

Don't think it should affect your interpretation of.

2:46

What's going on? There's no mass or anything that I'm asking

2:49

you to characterize. It's just this is probably the best sequence the

2:52

portalena's face.

2:54

Got some of the other organs again.

3:06

So the question they're really asking is you know, what what's going

3:09

all the gallbladder that inflamed. Is it

3:12

missing? He's had no prior history cholecystectomy.

3:20

I see a few.

3:24

People in the chat box. I'm just gonna address that in the second

3:27

while I go through the final set of sequences. I wanted to share with the group is the in and

3:30

out of phase out of face on this side and face on this side.

3:34

All right,

3:42

there you have it. So I'm just going to put up.

3:45

Let's see.

3:48

Go back

3:51

to this box here. Okay, let's see we have here. Yeah, so

3:55

somebody describe that there are multiple pancreatic

3:58

system. So that is a good observation. It's a

4:01

correct observation as well. It's a maybe useful

4:04

observation scleros and colonitis. Okay can

4:07

generally absent golf better. You know, I suppose that can happen.

4:11

I yeah anything can be continually absent. I

4:14

haven't really seen a case of that but I'm sure

4:17

if I go to radiopedia, it's there fatty liver. That's another correct

4:20

observation. I don't see a call platter. Yeah, that's that's that's

4:24

absolutely correct David. That's that's the tough part here.

4:27

Is it there is it really really small app since missing gallbladder? Yeah

4:30

cystic duct obstructive Stone.

4:32

Okay. So a lot of good thoughts portal means a

4:35

little dilated. Let's look at that observation day. Do you

4:38

remember being a little bit big?

4:40

Yeah, it looks a little bit big. I don't know if it's

4:44

maybe a little bit bigger than normal. I agree with you. I'm not

4:47

sure if it's pathologically big but the

4:50

question I have for group is is that the one thing I'm sort

4:53

of emitting obviously here is that

4:56

MRP again? I'll show that the one thing I'm admitting from

4:59

the group.

5:00

is that

5:03

The patient has some underlying history. There's an underlying.

5:07

History that this patient has that I haven't given the group.

5:10

but that

5:13

disease into that rare disease entity as it were.

5:16

all sort of put together

5:18

Couple of observations that the group is made. Somebody asked us

5:21

closingitis. I think it's a good thought my own experience

5:24

perhaps it's just with some of the mrtps that we get. It's a little bit tough on

5:27

the mrsp to look for that. I like to look at those on the post contrast sequences.

5:30

And what I'm looking for is areas of

5:33

ductal dilatation and narrowing which

5:36

is strictures and on the post Contour sequences bile will

5:39

be dark as it contains fluid. And so you'll see areas of biliary

5:42

reductibilitation and then you won't see that bile duct and then you'll see it

5:45

again as it dilates and you won't see that bottled up and so you sort of have these alternating areas

5:48

or multifocal and so if you

5:51

just look at you know that, you know, the the post Contra

5:54

sequences which are thinner slices you really don't

5:57

see any ducks that are dilated nor do you see a CBD that's dramatically affected

6:00

and so I was one of the thoughts of somebody in

6:03

the group had but

6:05

You know, I don't know if I see convincing evidence of that based on

6:08

these images. And so

6:11

let me see the chat feature. Where is the group going?

6:15

Okay, here we go. Here we go congenital absence

6:18

missing gallbladder bronze diabetes.

6:21

Oh, I haven't heard that term in

6:24

a long time. Thank you for igniting some

6:27

some memories there. Some Ron

6:30

is asking about cystic fibrosis which seems to be out there. But I appreciate them

6:34

putting themselves

6:37

with that diagnosis a true

6:40

eight. Try to get topic gallbladder. Okay PSC static

6:43

fibrosis Colonial position gallbladder

6:46

over long CBD PSC also going

6:49

to be pancreasics CFT are okay. Okay. So

6:52

yeah, this is nice. I I like that

6:55

people are starting to not only

6:59

get warmer trying to figure

7:02

out the disease is that they've absolutely nailed it

7:05

and so I won't torture the group anymore. Thank you for your

7:08

engagement. Ladies and gentlemen, this is

7:11

a case of cystic fibrosis is what the patient had and the reason

7:14

I wanted to

7:15

With the group is you know, listen, you know, you

7:18

know in our in our patient population, you know, we we do see cystic fibrosive time

7:21

in the classic case that we all see that we all

7:24

show in sort of case conferences of that fatty atrophic, you

7:27

know, the fatty pancreas the absence of the pancreas and I'm sure

7:30

if I showed you that case you guys would be you know, why why did

7:33

I even tune into the seminar?

7:35

I know that I know that day in and out

7:38

one thing that

7:40

that I learned a little bit later on in my training was the

7:43

you know, the other manifestations of

7:46

cystic fibrosis in the abdomen and pulse and that

7:49

sort of is always interesting and it's almost now I look for those

7:52

manifestations because the ones that we see all the time are so

7:55

burned in my memory and one of the things you can see is

7:58

multiple multiple pancreatic cysts. They're diffused

8:01

just like here and it's thought to beat

8:04

you to inspipated secretions, which dilate the Ducks these are not

8:07

neoplastic. This person will not develop cancer as

8:10

a result of these cysts, but you can see it best on the t2 aided

8:13

sequence multiple multiple systems the first comment that I think somebody

8:16

made which is good for you to recognize that and you

8:19

know, you can certainly see cysts like

8:22

this, you know in other conditions but you know,

8:25

maybe in chronic pancreatitis you can multiple times but the

8:28

pancreas there is very very trophy in those instances. And so

8:31

that's one of the manifestation to cystic fibrosis is

8:34

something called pancreatic cystosis, and you can

8:37

also sometimes get some calcifications so it can

8:40

look like

8:40

Pancreatitis so that sometimes gets confusing that's even

8:43

rare. But when you see these cyst, that's what you

8:46

have to think about. Well, the other things that patients with cystic fibrosis can

8:49

get in the abdomen is hepatocytosis, but that

8:52

itself is not

8:54

You know, is that an important finding because

8:57

we see that in our patient population all the time, but certainly this

9:00

patient has hepatic stytosis. So that's that's not subtle and

9:03

then the final question which I think is the most

9:06

unfair question. But but there

9:10

it is is where is the gallbladder? Right

9:13

and so I think a few people say can generally absent Gall better. I'm sure

9:17

that exists and and certainly that's

9:20

something that I would have thought about if I'm scrolling in the setting but if

9:23

you know a little bit about cystic fibrosis, you'll

9:26

know that there are some call that automatic stations of cystic

9:29

fibrosis one of which is for some reason this really one

9:32

of my favorite entities is micro micro gallbladder.

9:35

So I think some people in the chat box had a

9:38

credit gallbladder and I think the term is micro gallbladder, but

9:41

I tried it is very reasonable. So my goal here is to find the

9:44

gallbladder and believe it or not. This is the only sequence which I could find it right over

9:48

here is your gallbladder.

9:50

It's small. There's nothing else. This is going to be it's not a loop

9:53

of bowel. It's not a bile duct. It's right with a gallbladder should

9:56

be and it's really small. It's micro. In fact, you know,

9:59

and I looked up the definition of micro gallbladder

10:02

because I'm sure there are people in the in the group that

10:06

They'll want to know about Michael. You

10:09

know, how do you define it? And you know, I think

10:12

a ballpark number that I looked at I think is easier

10:15

to remember is like two centimeters in width by one centimeter in in

10:18

transverse time it two centimeters in length

10:21

by one centimeters in transverse diameter to be honest.

10:24

I'm not going about measuring these call patterns, but we all have a sense of

10:27

what a normal gallbladder. Perhaps should look like even if

10:30

it's collapsed.

10:31

This is Tiny. And so this patientistic

10:34

so is in fact it's you know, knowing that

10:37

we're not surprised that we couldn't even see

10:40

any uptake in the gallbladder. Some of the inspected secretions. I think somebody's

10:43

talked about that the chat box will contribute to

10:47

to the micro gallbladder. Maybe that's the theory of why it's

10:50

very small but even it, you know, even if there was uptake in

10:53

this, you know, good luck perhaps finding that

10:56

in the context of the highest scan or even an ultrasound think it'd be very tough and it

10:59

was very tough on the CT. I happen to read the CT on

11:02

this patient. I do remember seeing it and and mentioning my report micro

11:05

gallbladder because it's just one of those manifestations that

11:08

you can see assistive and there are others in

11:11

the admin politics you get distill intestinal obstructive syndrome. They can

11:14

have also issues with the stamina vesicles and males and so this

11:17

was a case of cystic fibrosis to

11:20

the micro gallbladder.

11:21

And so let me share this this slide

11:24

with you to for a few

11:27

words about cystic fibrosis autosomal recessive and one of the things

11:30

that I think it's important for us to know about these other manifestations Beyond

11:33

say the chest and the nor in a

11:36

and the most common manifestations in other organs is that you know, we've

11:39

had better.

11:40

Treatment algorithms for patientistic fibrosis. And

11:43

so these patients are surviving longer and so you end

11:46

up seeing you know, you will in Time end up seeing more different

11:49

manifestations of that. We don't that we

11:52

haven't traditionally seen and in the pancreas of course

11:55

fatty replacement is the most common but you can see these cysts

11:58

for the reason that was that I mentioned they're

12:01

very small. They replace the pancreas the San

12:04

Diego pancreatic cystosis. You can sometimes also see califications

12:07

and that's thought to be some data abnormal physiological that

12:11

promotes calcium binding

12:13

and so these patients don't have chronic pancreatitis. It's

12:16

just calcifications a tiny calcification associated with

12:20

Cystic fibrosis stewtosis, you can see up to 50% of

12:23

patients. So that's pretty obvious. You look at the endophase images and

12:26

the micro golf. I look at that almost a third that's not

12:29

an uncommon amount. I suppose, you know, and so

12:32

and thought to be either Treaty of the cystic

12:35

doctor chronic stenosis and something to do with the way the

12:38

secretions are manifested in these patients. A lot

12:42

of people mentioned PSE they can get PSC type picture in

12:45

in their Ducks. This person did not have that but that's a

12:48

possibility. So I think it's a good thing to look for and of

12:51

course another organs in the battle. They can

12:54

get distal intestinal obstructions in your ass to look at that from time to

12:57

time. Would you this top? I'm not sure if this

13:00

helps even an impatience that's one of the questions that are being

13:03

asked I find that even with patients in normal gallbladders

13:06

is very seldom that I see the gold or filling up really nicely. It

13:09

might help in the sense that it you

13:12

have this will increase the background the signal

13:16

intensity of the liver prank. And so maybe you see a small

13:19

sort of

13:20

micro gallbladder the gallbladder fossa as

13:23

a dark signal amidst the variety of list

13:26

Haida. In fact was done in this case that one of the other panelists people

13:29

are asking about Ida it

13:32

was actually done in this case. They didn't see the gallbladder.

13:34

And so my end of one based on this case was suggest

13:37

that the height I would not help or at least it did not help in this case.