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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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Today we are honored to welcome Dr. Daniel Souza

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for a lecture about the multimodality

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imaging of the gallbladder.

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Dr. Souza is the program director of the Abdominal Imaging

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and Intervention Fellowship at Brigham

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and Women's Hospital, an assistant professor

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at Harvard Medical School.

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His main interests are GI

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and GU radiology, cross-sectional, interventional radiology,

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and advancing medical education through innovation

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and me mentorship.

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His career and medical training have spanned Brazil,

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France, and the United States.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you

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may have on today's topic.

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Please remember to use that q

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

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as many as we can before our time is up.

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

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Susa, please take it from here.

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Perfect. Thank you so much, Ashley.

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Thank you modality for the opportunity.

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I'm really excited to be talking about

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this exciting topic today.

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I hope, uh, you will learn, um, as much

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as I will enjoy this session.

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So in the next, um, about 45 minutes, I'll be discussing

1:15

and showing you a large, uh, collection of cases

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and the multimodality imaging approach to not just cosis,

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but its many complications, cholecystectomy, uh, normal

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and abnormal, uh, postop postoperative appearance,

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and also multiple complications

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that can result from chole cystectomy.

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Um, I wanna invite you all, um, to click

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and subscribe to my Twitter account where I post, uh,

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cases on almost a daily basis on Twitter,

1:44

a former Twitter now X

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and this is my contact information,

1:47

my email in case you wanna reach out with any questions

1:50

or any comments about the lecture topic

1:53

or any other related radiology topics.

1:56

So, let's, uh, get started.

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I have, uh, no disclosures,

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and I do have, uh, four main learning objectives

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for this next 45 minutes.

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I want you to be able, at the end of this discussion

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to describe the composition of gallstones, the risk factors

2:11

for its developments

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and its appearance on multiple imaging modalities.

2:16

Recognize the wide range of complications associated with

2:19

cosis diagnosed early

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and late complications of cholecystectomy,

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and then finally discuss, uh,

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the management recommendations based on its clinical

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presentation and imaging findings.

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So, let's get started with a little setting the stage here

2:34

in, uh, simple facts about the development

2:36

of gallstones and risk factors.

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As you may know, uh, there is a three to one ratio of female

2:42

to male ratio in its, uh, incidents.

2:45

Typically, patients

2:46

that have gallstones are middle age women.

2:49

One fourth of women actually over 50 years

2:51

of age will have gallstones.

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And that's why when you're studying for step one, uh,

2:57

we will try to remember the mnemonic 40 fat female patients

3:01

because these are the risk factors for its development.

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The gallstones, they usually come in two different flavors.

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They can be cholesterol based,

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they can be pure cholesterol gallstones,

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or they can be cholesterol mixed

3:12

with calcium variable amounts of calcium.

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But the development of those types of gallstones,

3:18

the risk factors are, as you could imp

3:20

as you could suspect based on the incidences,

3:22

larger incidences in female patients, is, uh, the presence

3:26

of estrogen obesity, advanced age

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hypertriglyceridemia and clo clo fibrate use can all

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increase the incidences in development

3:35

of cholesterol gallstones.

3:38

The other type of gallstones that can develop in a minority

3:40

of patients are pigment, gallstones

3:42

or calcium bilirubin eight calcium, uh, gallstones.

3:45

They develop in patients

3:46

that are undergoing hemolytic states, uh, such as patients

3:49

with s spherocytosis, prostatic valve cirrhosis, patients

3:54

advanced age, especially patients that have biliary disease

3:57

and longstanding stenosis and longstanding biliary stasis.

4:00

Those are patients that can develop calcium bilirubin

4:03

or pigment gallstones.

4:06

So, um, this is what they look like.

4:08

They, they, they can be pigment stones.

4:10

A minority of them are gonna be pigment stones.

4:12

About 20% of them are gonna be pigment stones.

4:15

About 10% are gonna be pure cholesterol,

4:17

and about 70% are gonna be a

4:19

mixture of cholesterol and calcium.

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And depending on the, the amount of calcium, they may

4:24

or may not be visible on x-ray.

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And as, as you may know, only about 10 to 20%

4:28

of gallstones are gonna be visible by x-ray.

4:31

And this is an example

4:32

of a spot radiograph demonstrating multiple partially

4:35

calcified gallstones in the right upper quadrant.

4:38

When you are able to vi visualize them on x-ray,

4:40

you may be able to make a very elegant diagnosis

4:43

of acute cholecystitis.

4:44

Like in this example here, as you can see, uh,

4:47

there are two images spot radiographs

4:49

of the right upper quadrant on A KOB, the patient is supine.

4:52

On the left hand side,

4:54

the patient is upright on the right hand side,

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and you can see that there's one of the gallstones

4:59

that is actually stuck in the,

5:00

at the level of the cystic duct.

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So the, in a, in the right, in the proper clinical setting.

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This is a very nice way of, uh, make maybe being able

5:08

to make it the diagnosis

5:09

of an acute cholecystitis in a patient with, uh, just KOB,

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but unfortunately, we're not that lucky

5:17

and most gallstones are not calcified

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and not visible by KOB.

5:21

And why is it important to understand

5:22

the composition of gallstones?

5:23

I mean, this is something that is somewhat controversial,

5:26

but this is an algorithm for a, for a,

5:28

for a paper from a few years ago, demonstrating

5:30

that in patients that are symptomatic, um,

5:34

and they are not operative candidates, uh, if you are able

5:38

to establish that the composition

5:40

of the gallstones are mainly cholesterol gallstones

5:42

and not calcified, they may, they may be, um, eligible

5:46

for treatment with oral bile acids.

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That's one of the reasons why non radiologists really wanna

5:51

know what the composition of gallstones are,

5:53

although we as radiologists are limited

5:55

in making that assessment.

5:59

So now I'm gonna show you, uh,

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the imaging appearance in multiple different

6:02

modalities of gallstones.

6:03

As I said, only 10%, 10 to 20% are gonna be visible by KOB

6:08

On ultrasound, they're pretty straightforward to diagnose.

6:10

They're echogenic, they're, they're multiple, uh,

6:13

usually echogenic structures

6:16

demonstrating acoustic shadowing.

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And that's why how you're able to make

6:19

that diagnosis is large.

6:21

On the other hand, is gonna be mobile,

6:23

they're gonna be layering,

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and they're typically not gonna have acoustic shadowing.

6:27

But very often you can have a combination of both.

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You can have mobile echogenic debris and scattered on date.

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Echogenic foci demonstrated acoustic shadowing,

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which is diagnostic of gallstones on ct.

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Uh, they're typically not well seen

6:43

as you can see in the example here.

6:44

Um, they're only gonna be well seen when one,

6:47

they have a lot of calcium in it when they're partially

6:50

calcified at the very least.

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Or if they have a lot of cholesterol,

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they may be actually hypodense and appear floating in bile.

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As you can see in the example on the top left, um,

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this is something that we're obviously not gonna be doing

7:03

with ct, which is changing the patient's, um, position

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and re-scanning the patient to assess whether

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or not the stones are mobile or non-mobile.

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This is something that we limit to ultrasound

7:14

and that ability to evaluate dynamically the, the location

7:18

and whether or not they're impacted.

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Uh, and this is an example on the right side

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of the differences in sensitivity and modality between MR

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and CT and diagnosing gallstones.

7:29

I guess the major teaching point here,

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the learning point here is that CT is very,

7:33

very limited in the detection of gallstones.

7:37

MR is much far superior modality for detection.

7:42

This is a, occasionally you can see this appearance on MR

7:45

or CT of a Mercedes-Benz sign,

7:47

which is this star shaped pattern

7:49

of gas fishering within the gallstone,

7:52

which is also referred to as the Mercedes-Benz sign.

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And why is that helpful? It may be occasionally helpful,

7:58

and I'll show you an example where this was helpful.

8:01

This is a 38-year-old male patient that had a pelvic mass,

8:04

uh, diagnosed, uh, uh, on CTU

8:08

and had a subsequent MRI for further characterization of

8:11

that midline structure.

8:13

And you can see clearly on the MRI that actually,

8:15

this is a dropped gallstone with this Mercedes-Benz sign or,

8:20

or gas, uh, gas fissure of the gallstone.

8:24

It was, this was just simply a dropped gallstone in the

8:26

pelvic called the sac that was mimicking as a mass on ct.

8:30

So recognizing the Mercedes-Benz

8:32

sign can be helpful at times.

8:36

And again, just showing the differences in limitations

8:39

between the different modalities.

8:41

In diagnosing gallstones, we have, uh, an example of a ct.

8:43

I don't think anyone would proactively make the diagnosis

8:46

of gallstones in this patient.

8:49

Same patient had an ultrasound, a prior ultrasound,

8:51

and the ultrasound shows a gallstone completely filled with,

8:55

uh, a gallbladder completely filled with gallstones.

8:58

And then finally, an MRI confirming the presence

9:01

of multiple tiny gallstones completely

9:03

filling the gallbladder lumen.

9:05

And you can see how limited CT is in the diagnosis

9:08

of gallstones.

9:11

If you are lucky to have dual energy ct,

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then you may be able

9:14

to increase a little bit your sensitivity in detecting those

9:17

gallstones by assessing the contents

9:20

of the gallbladder in different energies.

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And you can see how looking at the gallstone contents in a

9:25

lower energy and the 40 KEV images, you're actually able

9:28

to better assess

9:29

or detect the presence of those layering gallstones.

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But the bottom line is CT is very limited.

9:35

Ultrasound is and r are far superior in the

9:38

detection of gallstones.

9:40

Another reason why MRI can be helpful is

9:42

that not only are able to detect the presence of gallstones,

9:45

you can very nicely assess the biliary tree, the presence

9:48

or absence of intra or extrahepatic,

9:50

biliary ductal dilation,

9:52

and also diagnose the presence of colido,

9:54

which may be an indication,

9:56

especially in a symptomatic patient of ERCP

9:59

and stone retrieval.

10:02

This is an example of a patient that had, um, elevated LFTs,

10:07

um, had an ultrasound showing sludge in multiple gallstones,

10:11

had a subsequent MRI done about three days later to detect

10:15

for the press of cosis.

10:17

But at that time, um,

10:19

the biliary ductal dilation had resolved the trends, the,

10:23

the enzymes were trending down,

10:25

and we felt that there was a little bit of, uh,

10:27

of enhancement and prominent enhancement

10:30

and some prominence of the papilla suggestion

10:33

that maybe the stone may have passed.

10:35

So in the appropriate clinical setting,

10:37

you may be even be able to assess, uh, the presence

10:40

of a PE stone by using MRI and a combination of clinical

10:44

and laboratory findings.

10:47

And this is what we suggested, that there was some mild

10:51

residual biliary ductal dilation, uh,

10:53

and some mild enhancement at the prominent papilla,

10:55

which could have represented a PEs to stone in this context.

11:01

Now, I'm gonna use one

11:02

of my favorite cartoons from my childhood to make a little,

11:06

a little bit of an analogy of, uh,

11:09

why diagnosing gallstones can be important,

11:11

and what are the types of complications that can happen.

11:16

This is, um, this is the coyote, as you can see here,

11:20

when you have gallstones in the gallbladder

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and they're just there and not causing much trouble, uh,

11:27

they're really patient is really asymptomatic,

11:29

and there's really no real complications that can ensue.

11:33

The problem is when the stones move, right?

11:35

Like in the example here,

11:37

whenever the stones move from the gallbladder lumen,

11:40

that's when you're gonna gonna have a,

11:42

a multiple different complications.

11:44

The complications will range depending on

11:47

where the stones get stuck, how big the stones are,

11:50

and if there are any associated findings.

11:53

So it's very helpful to go back to the anatomy

11:58

and try to understand the,

12:00

or relate the anatomical structure that has been impaired

12:03

with the complications.

12:05

So let's go over that in detail now.

12:08

So now that we were able to diagnose gallstones,

12:10

we're gonna try to figure out what types

12:12

of complications that can ensue.

12:14

So if the gallstones are within the lumen,

12:17

they're typically not gonna cause much trouble,

12:19

and patients are typically asymptomatic.

12:21

If they stay there for a long time, uh,

12:24

they may cause overtime chronic cholecystitis,

12:26

and typically it takes decades

12:28

for chronic cholecystitis to happen.

12:29

And that's why chronic cystitis is typically diagnosed in

12:33

patients that are older, 60, 70, 80 years old.

12:37

On the other hand, if the gallstones, they move

12:39

and they get stuck in the cystic duct

12:41

or the gallbladder neck, they can cause biliary colic.

12:44

If they, if that, uh, retention

12:47

or if that impaction is transient, or if it's permanent

12:51

and irreversible,

12:52

they can cause acute calculus, sc cystitis.

12:54

And we're gonna see a lot of different examples of that.

12:57

If the stone on the other hand moves a little further, it,

13:01

it can cause inflammatory changes there.

13:02

It can block not only the cystic duct,

13:04

but also the hepatic duct.

13:06

In that context, the patient is not only gonna have acute co

13:09

cystitis, but also gonna have biliary ductal dilation

13:12

and oftentimes present with abnormal LFTs.

13:15

And that's what we called Mei syndrome,

13:17

which is the compression, dual compression

13:20

of the cystic duct and the hepatic duct.

13:22

It can be hard to differentiate from

13:24

other inflammatory conditions.

13:25

And we're gonna show some examples in the next slides.

13:29

What about when the stone actually is small enough

13:31

to actually progress

13:32

and migrate down this co the common bile duct that can lead

13:36

to symptomatic ocli?

13:38

If it's not entirely obstructive,

13:41

if it is entirely obstructive,

13:42

it can cause acute cholangitis

13:44

and even occasionally gallstone pancreatitis,

13:46

which is a not uncommon complication of gallstones.

13:51

If they're big and they get, get,

13:53

they can occasionally get into the, into the bowel

13:55

and cause small bowel obstruction most often

13:58

because the narrowest segment

14:00

of the bowel is the ileocecal valve

14:02

that's gonna happen down in the distal ileum or ileum,

14:06

and that we call gallstone ileus.

14:09

If the stone, on the other hand is so large

14:11

that it gets stuck in the duodenum, that can cause a subtype

14:15

of complication or subtype of gallstone ileus called

14:19

bu ray syndrome, which is essentially a gastric outlet

14:22

obstruction caused by a blocked gallstone.

14:24

Again, those are big stones.

14:26

Those, you know, stones that are big enough to cause

14:29

bowel obstruction and for stones should be that big.

14:32

Typically, patients will have associated chronic

14:34

cholecystitis and they're gonna be older.

14:36

And then finally, this is a more uncommon complication,

14:39

is peritonitis.

14:40

Um, when the, the gallbladder perforates, it can cause, uh,

14:45

peritonitis and gallbladder perforation in the presence

14:49

of a prior cholecystectomy, we can have dropped gallstones

14:51

and the development of flag monitor inflammatory masses

14:55

adjacent to the surgical site.

14:58

So how do we suggest, how do we suspect the presence

15:01

of gallstones, or how do we suspect the presence

15:03

of biliary obstruction

15:04

or one of the complications we just talked about?

15:06

And it's important to take a step back

15:08

and think to ourselves, does biliary obstruction always lead

15:12

to biliary ductile dilation?

15:15

Does dilation always reflect biliary obstruction?

15:19

What is the exact imaging criteria that we radiologists use

15:23

for diagnosis of biliary ductile dilation?

15:26

And the next question as radiologists, once we are able

15:28

to establish the presence of, of biliary ductal dilation, is

15:33

to assess where the transition point is.

15:35

Because depending where the transition point, the etiology

15:38

of the biliary obstruction will be different.

15:40

So let's answer some of these questions.

15:45

So does obstruction always lead to dilation?

15:47

Not necessarily. And

15:49

that's something we need to keep in mind.

15:50

You know, it may take two to three days

15:52

for the extra biliary ducts

15:54

to dilate the extra hepatic ducts to dilate.

15:56

It may take up to a week for the obstruction

15:59

to express itself with dilation.

16:02

So it really depends on the level of the severity

16:05

of the obstruction, how much time's been happening.

16:08

So it may take some time in other conditions like PSC

16:12

or primary S sclerosis cholangitis, we have

16:14

so much per ductal fibrosis

16:16

that the bile ducts will not dilate.

16:17

In fact, when you see dilation,

16:19

biliary ductal dilation in a patient

16:21

with primary sclerosis cholangitis, you should suspect

16:24

mal obstruction development of cholangiocarcinoma.

16:27

What about dilation? Does it always reflect obstruction?

16:31

Well, not necessarily.

16:32

As you know, uh, there may be over time,

16:35

irreversible distension of the elastic fibers

16:38

of the bile duct, which can be physiologic,

16:40

or it can happen post cholecystectomy.

16:43

Patients that have had echo cystectomy,

16:45

usually they have a more dilated system

16:47

because you don't have the gallbladder

16:49

acting as a reservoir.

16:51

So to that end, what is the criteria that we use

16:54

for biliary ductal dilation?

16:56

Typically, when you see intra hepatic ducts,

16:59

that means they're dilated.

17:00

If you want to use a d uh, an absolute value,

17:02

you can use two millimeters.

17:04

But most importantly, it's helpful to compare

17:07

with the adjacent portal branch

17:08

that is running parallel to it.

17:10

Typically, the bile duct needs to be about 50% the size

17:14

or the caliber of the adjacent portal branch.

17:17

If it's more than 50%

17:18

or it's similar to the caliber of that portal branch,

17:21

that means that that segment is dilated.

17:24

The other option, if you're equivocal,

17:26

if you're not sure there's real dilation,

17:29

you can potentially give a patient a fatty meal

17:32

and evaluate for a change in the caliber of the bile ducts.

17:35

If a fatty meal does change the, the dilation

17:38

and it makes it more pronounced, that means

17:40

that there may be obstruction.

17:42

And in terms of extra hepatic bile ducts, uh,

17:44

six millimeters is the normal caliber for most patients

17:48

until the age of 60,

17:49

and then you add one millimeter per decade.

17:51

So if a patient is 80 years old, for example,

17:54

the normal caliber glaucoma bowel duct

17:55

will be eight millimeters.

17:57

The patient is 99 millimeters would be a normal.

18:00

If the patient has had cystectomy,

18:02

10 millimeters would be a normal, normal caliber.

18:05

Okay, and then, uh, once you've established the diagnosis,

18:08

it's very helpful to assess where the obstruction is,

18:11

depending on where the obstruction is,

18:13

there are different causes for the biliary obstruction.

18:16

Here in our, in our lecture, we're discussing

18:19

cosis as the main etiology.

18:22

Now let's talk about acute calculus co cystitis, which is,

18:26

uh, one of the most common complications of COIs.

18:29

Uh, I put calculus in parenthesis

18:32

because when we say acute cholecystitis, we're almost always

18:35

assuming that there are gallstones associated with it,

18:38

because the vast majority

18:39

of acute cholecystitis are associated

18:41

with gallstones greater than 90% of them.

18:44

And the cause of the colo cystitis is essentially similar

18:48

to the pathophysiology of acute appendicitis.

18:51

You have a, an appendicular, an appendix,

18:54

or a cosis in a gallbladder that gets blocked.

18:58

It blocks the cystic duct.

19:00

That blockade may cause, uh, retention of bile,

19:04

progressive retention of bile gallbladder over distension

19:06

that can cause pain.

19:08

That causes bacterial proliferation.

19:10

You can have translocation of bacteria into the wall.

19:13

The wall becomes thickened, the patient becomes symptomatic

19:16

with right upper quadrant pain.

19:18

Uh, the gallbladder is again over distended.

19:20

We use typically four centimeters in transverse diameter

19:23

to assess whether or not the gallbladder is over distended.

19:26

And I do find his finding, uh, very,

19:29

very helpful in the diagnosis of cuticular sitis.

19:31

Whenever you're suspecting acute sitis.

19:33

And the gallbladder is not that distended, it tells me

19:36

that the gallbladder is not obstructed.

19:37

So looking at the degree

19:39

of distension can be a very helpful feature.

19:43

Gallbladder wall thickening is not

19:44

as helpful as people think.

19:46

Uh, three millimeters would be a normal cutoff greater than

19:49

three millimeters being abnormal wall thickening.

19:52

There are so many different things

19:53

that can cause gallbladder wall thickening

19:54

that are not acute chole societies,

19:56

and I find this a very insensitive, uh, a sign

20:00

of acute chole cholecystitis, which people tend to overvalue

20:04

sonographic morphine is something

20:07

that is super helpful when present,

20:09

but it's oftentimes not present

20:10

because these patients come to the ER very symptomatic,

20:13

they get treated very early,

20:14

and by the time they get to radiology

20:16

and get to the ultrasound, they have zero pain.

20:19

I, I have to say, I have to count in my hand the fingers

20:22

of my hand, how many cases

20:23

of product positive sonographic morphosa I have seen.

20:26

And I can tell you I've seen dozens

20:28

and dozens of cases of acute cholecystitis.

20:33

If the infection or the inflammation persists

20:35

and it becomes transmural,

20:37

then you're gonna see peric cystic fluid per peric cystic

20:40

strain, the pain becomes more severe,

20:42

it can involve adjacent organs,

20:44

and then at that time, it's much easier

20:46

to make that diagnosis.

20:48

So in terms of all the findings

20:49

that we discussed in ultrasound, I think the ones

20:51

that are more specific and more helpful in establishing the

20:54

diagnosis of acute cholecystitis are the presence

20:57

of Sonographic Murphy sign

20:59

and the unimpacted stone at the infant giblin.

21:01

And for to, to that end is very helpful to assess whether

21:05

or not the stone is really impacted, move the patient

21:07

around, check for the position

21:09

of the stone in multiple different patient positions

21:12

to make sure it's truly impacted and not just lying there.

21:16

Mobile within the lumen.

21:18

All the other findings can be helpful, uh, in, in, you know,

21:21

increasing your confidence in the diagnosis.

21:24

As I said, over distension is super helpful.

21:26

I like to use four centimeters in maximum

21:29

transverse diameter.

21:30

Um, the, some people have gallbladders that are very long,

21:34

so using the long axis is not that helpful in my opinion.

21:37

Gallbladder wall thickening again, uh, can be helpful,

21:40

but not always present.

21:41

And then obviously if you see peric cystic fluid abscesses,

21:45

hyperemia, especially in CT NMR adjacent

21:48

or surrounding the gallbladder,

21:49

that can be also a very helpful sign in

21:51

establishing this diagnosis.

21:54

Again, the presence

21:56

of gallbladder wall ticking is not super helpful.

21:58

There are so many things that can cause

21:59

gallbladder wall thickening.

22:01

All these are examples of gallbladder wall thickenings

22:04

that are not related to acute cholecystitis.

22:06

So in the first example, the patient just had a recent meal,

22:10

so the gallbladder was contracted

22:11

and the gallbladder was thickened

22:13

because simply it wasn't extended enough.

22:15

Second example, the patient has cited had AEs,

22:18

cirrhosis hypoalbuminemia.

22:20

So this is all, uh,

22:22

third spacing causing gallbladder wall thickening.

22:25

The third case is a case

22:26

of severe acute hepatitis causing reactive

22:29

gallbladder wall thickening.

22:31

And finally, the fourth case, I hope you're making

22:33

to be able to make this diagnosis is just focal thickening.

22:36

That is cystic thickening at the gallbladder fundus.

22:38

This is just an example

22:39

of benign focal adeno mytosis of the gallbladder.

22:44

There are other signs. This is a slide from, uh, uh, Dr.

22:48

Aya Kamaya that she gave grand rounds here at the Brigham,

22:51

showing that there are other one findings

22:53

of acute cause studies that could help you increase your

22:55

confidence in establishing this diagnosis

22:57

of presence sludge.

22:58

As an example, the bulging of the gallbladder fundus.

23:01

Sometimes the gallbladder is so standard, it can bulge

23:04

and can cause a little bulging in the abdominal wall.

23:07

At that point, when you see mucosal discontinuity,

23:10

that is a sign of gangs, sc cystitis

23:11

that can be super helpful.

23:13

The echogenic fat is simply the ultrasound, uh,

23:17

manifestation of the peric cystic inflammation

23:20

co bladder wall hyperemia,

23:23

and even using doppler can be helpful.

23:25

Uh, now in patients that have suspected, uh,

23:28

acute cholecystitis in our division,

23:30

we are now using doppler in using the hepatic artery

23:33

velocity to make the diagnosis

23:34

and increase our confidence in diagnosing acute

23:37

cholecystitis by ultrasound.

23:40

This is an example of a patient

23:41

that evolved three days later, um,

23:44

with gang gangs, scoliosis.

23:46

And by the time you're able to seal it,

23:47

there's mucosal discontinuity and the ling of the mucosa.

23:51

It's a much more straightforward diagnosis of gangs,

23:54

scoliosis, which is one of the complications

23:56

of acute cholecystitis.

23:59

Once you know, uh, what happens in the gallbladder when, uh,

24:03

in this continuum of development of acute cholecystitis,

24:07

it's very easy to make the diagnosis regardless

24:09

of the modality that you're looking at.

24:11

So this is another example of acute cholecystitis.

24:13

Now on ct, same findings we saw on ultrasound are present.

24:17

Here you have an impacted stone.

24:18

Luckily, we're able to see on CT

24:19

because it's heavily calcified.

24:22

You have gallbladder wall thickening.

24:24

The gallbladder is not that distended,

24:25

but you do see mucosal irregularity in pretty prominent

24:29

peric cystic fat stranding.

24:31

When you see that level of fat str, when you see that level,

24:34

and I used to joke with the residents, when you see smoke,

24:37

there is fire, right?

24:38

So if you see that level of, of fat training, that means

24:43

you have inflammation associated with it.

24:46

Whenever you have acute pain, fat str will tell you

24:48

where the, where the fire is.

24:50

And in this case, the fire is in the gallbladder

24:53

because of acute cholecystitis.

24:55

Another example of mild uncomplicated acute cholecystitis.

24:58

Now on MRI, you can see gallbladder wall thickening,

25:01

some degree of gallbladder wall distension you have as well,

25:05

uh, multiple stones.

25:07

The wall is hyper enhancing,

25:08

and that's one of the major advantage

25:10

of MRI is really our sensitivity in

25:12

assessing for enhancement.

25:15

On DWI,

25:16

you can see also restricted diffusion within the wall,

25:19

which is a sign of, uh, gallbladder wall inflammation.

25:27

Now we're gonna see the evolution of gallbladder, um,

25:30

of acute cholecystitis,

25:32

and in a patient developing now peric cystic abscesses, once

25:35

that inflammatory process goes beyond the wall,

25:38

it becomes transmural.

25:40

Very often that inflammatory processes drain

25:43

into the liver, right?

25:44

So this is something we see with gallbladder carcinoma.

25:46

Because of the prominent drainage

25:49

of the gallbladder into the hepatic parenchyma,

25:51

it's very common that these epsis actually happen within the

25:53

liver and not outside of the liver.

25:55

And this is an example of multiple tine coalescing

25:58

peric cystic abscess abscesses happening in the patient

26:01

with untreated acute cholecystitis.

26:04

Another example of peric cystic abscesses.

26:07

Now on, now on a ct, you can see also

26:10

surrounding the gallbladder, some inflammatory, uh, changes

26:14

surrounding the overextended gallbladder.

26:17

And this is, now we're gonna moving on to some pitfalls

26:21

and some traps that I fell into during my training.

26:24

This was, uh, during my, uh, Dana-Farber, uh,

26:27

fellowship in pet, uh, where I saw this on a patient

26:31

that was a 41-year-old had a history lymphoma.

26:34

And on the, I was really alarmed by the level

26:37

of gallbladder wall thickening

26:39

and the level of FG taken the wall.

26:42

And I was able to convince my attending that this was

26:45

probably acute cholecystitis.

26:47

And, um, we actually added up, added that

26:50

to the differential in our PET CT report.

26:53

The patient was taken to surgery

26:54

and it wasn't very symptomatic, but he was taken to surgery

26:57

and this came back as just lymphoma of the gallbladder.

27:00

So keep in mind, lymphoma can be really the great mimicker

27:04

and the clinical context is really important.

27:06

When you're making a diagnosis of acute cholecystitis,

27:08

it's really, really difficult, uh,

27:10

to make a diagnosis solely on the basis

27:12

of the imaging findings.

27:16

Other pitfalls, I mean, the gallbladder, as you know,

27:18

may have a lot of different, uh, embryologic remnants

27:22

or, uh, different manifestations.

27:25

They can be duplicated, they can be septated.

27:28

This is an example of a septated

27:29

gallbladder detected by ultrasound.

27:31

This patient was asymptomatic, so it was easy

27:34

to rule out acute cholecystitis in this, in this case here.

27:38

Another pitfall, um, that can mimic as acute cholecystitis.

27:43

This is a patient with right upper quadrant pain, uh,

27:46

and doing, uh, the patient had a dual energy CT on ct.

27:51

We see, uh, in this study in the performing in 2018,

27:55

that there is wall thick at the mid to distal,

27:58

uh, gallbladder.

28:00

You can see the fundus

28:01

and the mid gallbladder wall is very thickened

28:03

and contains some stones.

28:05

Luckily, um, as you know, the radiologist's best friend is,

28:09

uh, the priors.

28:10

But we had a prior, looking at the prior in 2017,

28:14

so just one year before the gallbladder looked completely

28:16

normal, we also were lucky to that we had dual energy ct.

28:20

So using at the iodine overlay images, we could see

28:23

that the wall of the gallbladder was enhancing normally

28:26

proximally, and it was not enhancing distally.

28:30

But what do you guys think this is?

28:32

And patient had pain came as an outpatient.

28:35

We had pain discomfort in the right upper quadrant,

28:38

so we were able to actually suggest the diagnosis,

28:40

which is rare, of subacute portion of the gallbladder,

28:45

which was confirmed by surgery.

28:47

So this is an example of gallbladder wall thickening

28:50

that is secondmental that caused by torsion,

28:53

very unusual example, that was helpful to,

28:56

to have priors helpful to have the dual energy

28:58

to be able to make that diagnosis.

29:00

Prospectively another pitfall, I mean, you have to recognize

29:04

that this is a dynamic process.

29:06

So there is no, you know, the,

29:09

the imaging modalities can be actually complimentary

29:11

and not necessarily one better than the other.

29:14

I mean, ultrasound technically is better than CT

29:16

for making a diagnosis of acute cholecystitis.

29:19

But this is an example of a patient

29:20

that had right upper quadrant pain,

29:22

had an ultrasound December 19,

29:25

and the ultrasound, uh, did not see much in addition

29:28

to the co lip PIIs in the sludge, the gall bladder wall

29:31

that was not taken, the gall wasn't over the standard.

29:33

There wasn't a sonographic Murphy sign that was detected

29:35

by the tech, that the patient was, had persistent symptoms

29:39

and elevated, elevated white count.

29:41

I was training up, had a CT the next day.

29:43

And then now on ct we see

29:45

that the gall bladder is more distended.

29:47

And you see a ton of hyperemia.

29:49

You can see the, the parenchyma

29:50

of the liver surrounding the gall bladder is very hyperemic.

29:53

And there's a some peric cystic device training at this

29:56

point, making the diagnosis a lot more straightforward.

30:00

So it's really, it's really important

30:02

to monitor these patients closely

30:03

because, you know, it may not be, uh,

30:06

diagno diagnosable at first,

30:08

but the patient may evolve with findings, uh,

30:12

that are prominent enough that they're now, uh, detectable

30:15

by imaging, different imaging modalities.

30:18

Now we're gonna move, moving up

30:20

to a more difficult diagnosis, right?

30:22

We talked about acute calculus, sc cystitis,

30:25

and acute acute, a calculus SC cystitis,

30:27

it is a much more challenging diagnosis

30:29

'cause it's not, uh, not infrequently, not suspected.

30:33

So a lot of people forget about the potential, uh, presence

30:37

of acute acal cystitis once you roll out

30:40

the presence of gallstones.

30:42

So keep in mind that there are certain populations,

30:44

especially severely ill patients, diabetics patients

30:47

that are septic in the ICU had a major surgery.

30:50

These are patients that are particularly prone

30:52

to developing acute acal SC cystitis.

30:54

So think about this diagnosis.

30:57

Even if the patient does not have gallstones, you need

31:01

to have really a high index of suspicion.

31:03

I, I showed Dr. House here,

31:04

but I know also that the Good doctor

31:06

is another popular TV show that only these people are make,

31:11

are able to make this diagnosis.

31:12

And a hightest can can actually be required for diagnosis.

31:16

And, uh, the pathophysiology is slightly different.

31:19

A acute acal sc cystitis, we talked about blockade

31:23

of the cystic duct by stones in acute calculus,

31:25

sc cystitis in acute acal sc cystitis.

31:29

What we have instead, typically ischemic changes

31:31

to the cystic artery,

31:32

and that can lead to inflammatory

31:34

changes in the gallbladder.

31:36

Luckily, HIDA can be helpful to make that diagnosis

31:40

even in the absence of gallstones.

31:42

So I'll show you one example.

31:45

Uh, patient with right upper quadrant

31:47

pain had an ultrasound.

31:48

Ultrasound was unremarkable, gallbladder looked normal.

31:50

There was no gallbladder wall thickening, no gallstones.

31:54

The patient had a Haida.

31:56

And the Haida show actually no, uh,

31:59

radiotracer accumulation in the gallbladder lumen suggesting

32:02

cystic duct obstruction in the right context,

32:04

suggesting acute cholecystitis.

32:07

Um, the clinical team decided not to treat

32:10

and just monitor, uh, after antibiotics.

32:13

And then a couple of days later, patient had an MRI.

32:15

And at that point, you can see gallbladder over distension.

32:18

You can see gallbladder wall irregularity,

32:21

some discontinuity of the wall,

32:23

suggesting some early gang changes of the gallbladder,

32:26

which is a more, uh, advanced stage

32:28

of acute cholecystitis at that point.

32:30

And you can see on the wi also

32:32

that there was some restriction in the wall.

32:35

Another complication of acute cholecystitis is development

32:38

of gangrenous changes and sems changes.

32:41

These are typically happening in diabetic patients.

32:43

And this is an example I have

32:45

actually from Brazil when I worked there, uh, in Rio,

32:48

a patient had a 70-year-old diabetic,

32:51

was in the ICU, had right upper quadrant pain.

32:53

We did a full pan scan, chest, abdomen, and pelvis.

32:56

And we saw, uh, the patient had a prior ultrasound screen

32:59

that there were no gallstones.

33:00

So gallstone, the Citis was not high in the differential.

33:04

We did suggest the diagnosis

33:06

because there was some hyperemia around the gallbladder.

33:08

Uh, but the, uh, referring physician did not really, uh,

33:12

believe in the diagnosis, was feeding this

33:13

as a presumed pneumonia.

33:15

And then four days later, patient came back

33:17

and at that time had already

33:19

ous changes in the wall confirming

33:21

that this was actually complicated acute cholecystitis.

33:25

And this was a little nice c need that we did just

33:28

to show some gasp accumulation within the gallbladder wall

33:32

going to a greater extent.

33:34

Uh, the exchange, the, the, the extent

33:36

of in semus changes pre perforation.

33:41

This is a case courtesy of one of my colleagues here,

33:44

not something you typically see, uh,

33:46

but that's a, a, you know, a, a potential complication

33:49

of acute cholecystitis.

33:50

You can see some dropped gallstone,

33:52

some dropped sludge in the, uh, uh, per hepatic space

33:56

and a lot of bile leaking from the gallbladder.

33:58

In this patients, uh, they're gonna be very symptomatic

34:01

as bile is very toxic

34:02

and can cause pretty severe peritonitis.

34:06

Another complication

34:07

that really is a clinical diagnosis is acute.

34:10

A anti cholangitis.

34:11

Typically these patients are gonna present

34:13

with a charco triad of right upper quadrant pain,

34:17

fever, and jaundice.

34:18

When we see changes in, uh, on imaging, uh, the changes

34:22

that we typically will see on MRI are

34:24

biliary ductal obstruction.

34:25

So you're gonna see biliary ductal dilation.

34:28

You can see occasionally biliary wall thickening

34:31

and biliary wall hyper enhancement,

34:33

like in the example here.

34:35

And if you do multiphasic imaging, it's not uncommon

34:38

to see these wedge-shaped profusion changes within the

34:41

hepatic parenchyma, which are typically reactive changes

34:44

to the acute ascetic cholangitis.

34:46

If leftin treated, that can lead

34:48

to development of ABS disease.

34:50

But again, this is a clinical diagnosis that really needs

34:53

to have a high index of suspicion and,

34:55

and normal imaging does not rule out this diagnosis.

35:00

Now moving on to a more, uh, late complication of cosis,

35:05

and we're talking now about chronic colo cystitis.

35:07

These are typically seen in older patients, 16,

35:10

70 years old, years of age.

35:13

Uh, what you see on imaging is very different from

35:16

acute cholecystitis.

35:17

Instead of a dilated over tend gallbladder,

35:19

you're gonna see a shrunken gallbladder with, you know,

35:22

asymmetric occasionally gallbladder wall thickening.

35:25

Um, these, the wall could develop calcifications over time,

35:28

which we call percel and gall bladder.

35:30

And that chronic cholecystitis, especially associated

35:33

with large stones, can lead to development

35:35

of other complications like gallstone,

35:37

ileus, resis syndrome.

35:39

And occasionally over time

35:41

that persistent inflammatory change can lead even

35:44

to development of cancer gallbladder carcinoma.

35:47

And in some severe cases of chronicle cystitis.

35:50

It's really very hard for us as radiologists to distinguish

35:53

that from gallbladder carcinoma in These patients will need

35:56

to get surgery for a definitive diagnosis.

36:01

This is an example of a patient that actually was admitted

36:04

to our hospital with a presumed diagnosis

36:06

of complicated cholecystitis with the liver abscess.

36:09

Uh, by looking at the CT

36:11

and reviewing the outside imaging, we felt

36:12

that the mass in the, in the,

36:15

in the liver was very abnormal looking, uh,

36:18

did not quite look like a complicated acute cholecystitis.

36:21

It had its mass like appearance, very heterogeneous.

36:24

And we suspected malignancy.

36:26

We ended up doing an MRI, which confirmed that the bulk

36:29

of the abnormality in the liver was actually hypo enhancing

36:32

and ill-defined it looked pretty, pretty suspicious.

36:35

We performed an image guided biopsy,

36:37

and this came back as an adenocarcinoma,

36:39

likely gallbladder carcinoma, uh, extending into the liver.

36:44

Not complicated, uh, chronic cholecystitis

36:46

as initially thought, uh, porcelain gallbladder,

36:50

another complication of cortico chronic cholecystitis.

36:53

It's the presence of these calcifications

36:55

within the gallbladder wall.

36:57

Um, traditionally, you know, historically it's been thought

37:00

to be a very important risk factor for the development

37:03

of gallbladder carcinoma.

37:05

And a lot of people still recommend,

37:07

even in asymptomatic patients cholecystectomy as a, uh,

37:11

prophylactic measure to avoid, uh, gallbladder carcinoma.

37:15

This is a little bit more controversial

37:17

and a lot of people think that, uh,

37:19

the risk is overestimated

37:21

and, uh, it is not no longer an indication for, uh,

37:25

elective cholecystectomy.

37:29

What about this case? This is a combination of findings,

37:32

your, uh, acute and chronic cholecystitis, right?

37:35

We see an overextended gallbladder on ct.

37:38

We also have MR images showing, um, the represented finding.

37:43

Um, you do see some inflammatory

37:45

changes surrounding the gallbladder.

37:46

The gallbladder wall is thickened.

37:48

You have stones for sure,

37:50

but it's, it's, it's kind of an odd looking gallbladder

37:53

with multiple intramural abscesses.

37:57

Um, this is not a hundred percent specific

37:59

of this condition, but

38:00

whenever you see a cage like this,

38:02

when you see this intramural lakes of pus in the wall,

38:05

you have to suspect the diagnosis of exometer sc cystitis.

38:10

That's the typical image manifestation of this condition.

38:13

This is essentially a chronic inflammation

38:16

with lipid lead macrophages,

38:18

and that can lead to the development

38:20

of these intramural bile extravasations.

38:22

And on imaging. The hallmark is again,

38:24

gallbladder wall thickening.

38:26

These tissue, um, hyperintense, uh, neural nodules,

38:31

these tiny little intramural abscesses.

38:33

And that can really mimic the presence

38:35

of gallbladder carcinoma.

38:37

So suspect this diagnosis whenever you see this appearance.

38:43

Now moving on to other complications,

38:44

we're gonna talk about gallstone pancreatitis.

38:47

This is a nice example of a gallstone pancreatitis.

38:49

You can see, um,

38:50

inflammatory changes surrounding the entire pancreas.

38:53

The pancreas is edematous.

38:54

There's a lot of para pancreatic fluid.

38:56

You can see multiple, uh,

38:58

stones within the dilated common bile duct,

39:01

which are actually nicely seen by ct.

39:04

And whenever you see this,

39:06

a pretty straightforward diagnosis

39:07

of gall gallstone pancreatitis.

39:12

I wanna just show you this case as well,

39:14

because it really highlights that gallstones don't have

39:18

to be big to cause a lot of trouble, right?

39:20

This is a patient that was 28 years old, uh,

39:23

females was just postpartum

39:25

and had right upper, upper quad pain

39:27

because of the discomfort.

39:28

She ended up getting an MRI.

39:30

Uh, on MRI, you don't see a lot

39:31

of biliary ductal obstruction, uh, dilation.

39:34

There's a, there wasn't a lot

39:35

of no suspicion for obstruction.

39:37

There was some mild abnormal LFTs,

39:40

but we were able to assess or diagnose the presence of it.

39:43

Little, little tiny, I dunno if you can see

39:45

with the arrow here, but a little tiny layering stone, uh,

39:48

within the mid CBD.

39:50

So we established that, that the patient had choli cosis.

39:53

And because of that and

39:54

because of the symptoms, the patient had an ERCP,

39:58

but the R-C-P-E-R-C-P was performed a few days later

40:02

and the stone was removed.

40:04

Can you guess the outcome?

40:07

So because of the RCP, a few days later,

40:09

the patient was admitted to the ER with acute cholecystitis.

40:13

You can see the emus, uh, pancreas, uh,

40:16

and the, the, the contrast within the, the, the gallbladder.

40:20

And then over time, the patient developed

40:22

necrotizing pancreatitis.

40:23

That was a complication of, uh, the ERCP that was performed

40:27

to retrieve the choli dosis.

40:31

Those collections became more organized.

40:34

The patient was extremely symptomatic

40:36

and for that reason was referred again

40:38

for endoscopy for treatment.

40:40

They tried to drain this transgastric,

40:42

but unfortunately the collections were not mature enough

40:44

and they were not very nicely encapsulated.

40:47

And all the contrast was peeled into the peritoneal cavity.

40:50

And we are now, uh, asked

40:52

to perform a percutaneous drainage of those collections.

40:55

So you can see how a really tiny two millimeter stone can

40:58

cause a ton of trouble.

40:59

This patient was admitted to the hospital, stayed many,

41:02

many weeks to recover from this episode

41:04

of acute pancreatitis.

41:06

So don't, do not underestimate, uh, gallstones,

41:10

they can cause a lot of trouble even when they're very tiny.

41:13

Now we're gonna talk about large gallstones

41:15

and complications associated with the larger gallstones.

41:19

Again, this is one of my favorite episodes

41:23

when the coyotes try to use large gallstones.

41:27

And, uh, unfortunately, some complications ensued.

41:31

And I think this is very representative

41:33

of the next complication that I'm gonna,

41:35

that I'm gonna be sharing with you guys,

41:38

which is gallstone ileus.

41:40

So gallstone ileus, this is a very common boards question.

41:43

So if you are a resident

41:44

and you're taking the boards, pay attention to this slide.

41:47

What is the regular triad? What are the imaging findings?

41:51

And the regular triad that we make will allow us

41:53

to make the diagnosis of gallstone ileus.

41:56

They're all seen on this, um, scout or KOB or localizer.

42:00

So the three imaging findings, uh, of the regular triad

42:04

that are diagnostic of gallstone ileus are pne mobilia,

42:08

which is, we can see here nicely the bil, so the air

42:11

and the biliary tree, and the,

42:13

and the gallbladder lumen, the SBO.

42:15

So you can see multiple dilated stone, uh, sorry,

42:18

multiple dilated small bowels,

42:20

can see the stack of screens here.

42:23

And then the third finding is an obstructed, uh, obstructing

42:27

ectopic gallstone, which in this case we're calcified

42:30

and very easily seen by x-ray.

42:33

So whenever you see these three things, uh,

42:35

you have a regular trial

42:36

and the diagnosis is pretty straightforward

42:37

of gallstone ileus.

42:41

As I said, there's a specific subtype

42:43

of gallstone ileus called var ray syndrome.

42:46

Uh, this is a, a patient that developed this complication,

42:50

um, when I was doing my fellowship in the er.

42:52

So this was a 90-year-old female patient presenting

42:55

with longstanding right upper quadrant pain.

42:57

And, uh, chole cosis, you can see a thickened gallbladder

43:01

with a large stone, uh, causing the symptoms.

43:04

At that point, the patient was medicated and sent back home.

43:07

At that point, we saw also there was some loss of fat pain

43:09

between the gallbladder and the dudu,

43:12

but not much was made out of it.

43:14

Three months later, the patient comes

43:16

back with different symptoms.

43:18

Now she has early satiety, nausea, vomiting,

43:22

but the right upper quadrant pain is much, much better.

43:24

What happened in the interim?

43:26

So the patient actually had the stone migrated

43:29

into the dudu, and now it's causing

43:31

gastric outlet obstruction.

43:33

So this is an example of boray syndrome,

43:36

which is caused essentially by the presence

43:39

of e cocy duodenal fistula.

43:42

Another example, when you see one,

43:43

you start seeing many, right?

43:45

Another example of an older patient

43:47

with a multi laminated stone that was actually,

43:50

they migrated, uh,

43:51

from the gallbladder fossa into the

43:54

duodenum causing obstruction.

43:55

You can see the fistula very nicely on the second image on

43:58

the top coronal image, also showing, uh,

44:01

a large calcified gallstone causing obstruction.

44:04

And you can see the cyto two adenal fistula nicely

44:08

on multiple planes.

44:10

This patient was referred for endoscopic retrieval

44:13

of the stone to try to relieve that obstruction.

44:15

She was not a surgical candidate,

44:17

and this is one of the reasons why I love radiology.

44:19

And the stone looks beautiful on ct.

44:21

Look how gross it looks.

44:22

I'm sorry if you're having lunch right now,

44:24

but this is how gross it looks on endoscopy.

44:28

This was a five hour procedure where we try

44:31

to remove, uh, the stone.

44:32

You can see the big hole that was left behind at the area

44:35

of the cyto duodenal fistula.

44:39

If this stone was able to move into the small bowel,

44:42

it would probably get lodged in the terminal ileum,

44:45

and it would cause a classic gallstone ileus since it

44:48

got stuck in the dudu.

44:50

We call that ovary syndrome.

44:52

Okay, moving on to another complication,

44:55

which is a common complication in boards question,

44:58

which is Mei syndrome.

44:59

So what is Mei syndrome?

45:01

Essentially, it is an extrinsic compression of the CBD

45:06

by stones or chronic inflammatory changes caused by a stone.

45:10

So what happens is the stone gets lodged

45:15

in the confluence of the cystic duct

45:17

and a common hepatic duct.

45:19

And that can cause not only symptoms related

45:21

to the gallbladder obstruction,

45:23

but also biliary ductal obstruction causing abnormal LFTs.

45:27

And this is what rizzi looks like.

45:29

You can see on the CT image a large stone

45:32

in the porta haps causing obstruction not only on the cystic

45:35

duct, but also the common hepatic duct.

45:37

And up and upstream biliary ductal, um,

45:40

dilation on mr the stones are typically gonna

45:42

be T two hyperintense.

45:44

And on RCP you can see the nice mass effect caused

45:48

by the stone into the common hepatic duct with the upstream

45:52

biliary ductal dilation.

45:54

And this is something actually, clinicians will come to us

45:56

and say, you know, I'm suspecting mui.

45:59

Um, this is a very well known diagnosis in, in, uh, by,

46:03

by gastroenterologists.

46:05

Um, and they suspect Mei when the patients have symptoms

46:08

of acute cholecystitis,

46:09

but also abnormal LFTs that are actually disproportionate to

46:13

what is often seen in, in simple, um, acute cholecystitis.

46:18

So, uh, using imaging,

46:20

cross-section imaging can be very helpful in

46:21

making this diagnosis.

46:23

The one thing though, uh,

46:25

if the inflammatory changes at the level

46:27

of the porta heide are very prominent, um,

46:30

and you have a lot of enhancing soft tissue there,

46:32

it may be difficult to differentiate Meza syndrome,

46:35

which is benign from a cholangiocarcinoma like a classic

46:39

tumor because they can look the same.

46:42

And that chronic inflammatory change can be very

46:44

indistinguishable from, um, an enhancing tumor

46:48

or enhancing cholangiocarcinoma at that level.

46:50

So it may be very difficult to make

46:52

that distinction by imaging alone.

46:56

Okay, now we're approaching the end of the presentation.

46:59

Uh, we're gonna talk about post

47:00

cholecystectomy complications.

47:01

So what does, and now the coyote is acting like the surgeon

47:05

here and try to get the, get rid of those stones.

47:09

And, uh, there are a lot of things that can happen

47:11

that can go wrong after, uh, an attempt

47:15

to remove those stones.

47:16

And you, you're gonna see what can happen to surgeons

47:19

when they're trying to do their best.

47:22

Um, and this is also one of my favorite episodes

47:26

where coyote was really not having a good day.

47:35

There you go. So a lot

47:37

of things can go wrong when we're trying

47:38

to remove the gallbladder and we're trying to remove stones.

47:41

Um, and the most common of them is a bile leak, right?

47:45

We, this is a, a nerdy complication we see all the time.

47:48

Um, there are,

47:50

the gallbladder can drain directly into the liver

47:53

by the ducts of Luka, and that can leak over time, um,

47:57

after surgery and can cause development of myelomas.

48:00

Uh, if the patient, if the surgeon is not able

48:02

to identify some anatomical variants that can also lead to,

48:06

um, leakage and development of myelomas.

48:09

The myelomas will look like a simple fluid,

48:12

and they're usually not very well circumscribed.

48:15

They happen, um, typically at around, uh, the,

48:19

the gallbladder fossa,

48:20

but they can be also happening away from the gallbladder

48:22

foa, like in this example here where you can see a lot

48:24

of bile leak happening in the pelvis.

48:28

Uh, it is a straightforward diagnosis in the postoperative

48:31

set setting, uh, especially if it's happening in the,

48:33

in the, you know, first three to five days.

48:36

But Hida can be used to,

48:38

to really establish the diagnosis with certainty.

48:41

And you can see the hida showing accumulation

48:43

of the radiotracer in the pelvis confirming leak.

48:48

Uh, um, when you have large myelomas patients can

48:50

become very symptomatic.

48:52

The bile can be very toxic

48:53

and cause pretty severe peritonitis and pain.

48:56

And when that happens, uh, we are often asked

48:59

to drain this, uh, percutaneously.

49:01

Uh, oftentimes patients will have, uh, epitomy to kind

49:04

of relieve the pressure in the bile ducts,

49:07

and that can lead to resolution without need

49:09

to a repeat surgery.

49:13

We can also use MRI to diagnose B leaks by using EO vista

49:17

or primo vista MRI, which is a contrast agent

49:19

that gets excreted to the biliary tree.

49:21

And this is an example from a few weeks ago

49:24

where we were able to actually establish

49:26

an active leak happening in the gallbladder fossa

49:29

by using vis MRI.

49:31

This is an acquisition at 20 minutes showing

49:33

that there is accumulation of contrast at around, uh,

49:37

the gallbladder fossum confirming, uh, the leak,

49:41

you may need to wait longer.

49:42

I mean, a typical protocol with VIS

49:45

or primo vista MRI takes about 20 minutes post contrast,

49:48

you may need to scan actually the patient, you know,

49:51

even two hours

49:52

after to make sure that they're, that you're able to detect,

49:55

uh, the presence of the, of the contrast.

49:59

Um, other complications which take a little longer.

50:01

So if the myeloma is left untreated,

50:03

it can become infected over time.

50:06

And signs of infection in addition to leukocytosis

50:09

and worsening symptoms are the presence

50:11

of hyperemia surround data collection, uh, debris, presence

50:15

of gas, particularly if you see a lot

50:17

of gas in the collection, you have to suspect development

50:19

of gas forming microorganisms

50:21

or connecting connection to, to bowel, right?

50:24

Like in the example here, this was an infected

50:26

by Loma abscess as a complication

50:28

of a prior cholecystectomy,

50:29

despite the benign looking heart-shaped shape.

50:33

Um, this was actually a, an infected myeloma

50:36

that was treated with percutaneous drainage.

50:38

Another example of an abscess formation

50:40

in the gallbladder fossa.

50:41

You can see now the development of a very thick wall, uh,

50:46

and very important debris within the, the,

50:49

the within the collection.

50:50

Uh, CT is really not a great modality to assess the contents

50:54

of a collection, but

50:55

whenever you see complex, uh,

50:57

contents within a collection on ct,

50:59

that really raises your suspicion,

51:01

especially if you see gas when it within it.

51:03

As you can see in the third image on the top,

51:07

a rare complication of cholecystectomy here is a left portal

51:10

vein thrombosis, which is also easier

51:12

to diagnose when you have, uh, a portal venous phase imaging

51:19

patients can develop recurrent CPD stones.

51:21

This is a patient that had, had,

51:22

had a cholecystectomy many years before,

51:25

but developed recurrent CHODOs despite the absence

51:29

of the gallbladder.

51:30

So you don't necess, you don't need

51:32

to have a gallbladder in order to develop CHODOs.

51:36

There's something to keep in mind,

51:37

and this is a very common complication

51:39

that is often left underdiagnosed, uh,

51:42

which is dropped gallstones with inflammatory mass

51:45

or flag malformation.

51:47

Why is it underdiagnosed?

51:49

Because surgeons typically are not very happy, uh,

51:52

or will not be very vocal about, uh, complicating, uh,

51:57

issues that happen during surgery.

51:59

Uh, and they're typically gonna, they're not gonna reveal

52:02

that, uh, they spilled some sludge

52:04

or gallstones in the Morrison pouch.

52:07

And if patients come to you

52:09

and you see this inflammatory mass, especially if you have,

52:12

you know, calcific foci

52:14

or evidence of calls of, of, of gallstones in that location,

52:18

that is a very common location of dropped gallstones.

52:22

And those dropped gallstones are gonna act

52:25

as a NIUs for infection.

52:26

It can cause, you know, repeat bouts of abscess formation,

52:30

inflammatory mass, a lot of symptoms

52:32

and it will only resolve with removal

52:35

of those dropped gallstones surgically.

52:37

Um, you can treat them temporarily with, uh,

52:40

catheter drainage, but as long

52:42

as those gallstones are dropped

52:44

and left there, um, there is a risk of developing infection.

52:48

And I'll show you an example of a patient

52:49

that had a very symptomatic car, uh,

52:51

course of dropped gallstones.

52:53

So May, 2017,

52:54

you can see the inflammatory mass inflammatory, uh,

52:58

soft tissue in the Morrison pouch, uh,

53:00

peripheral enhancement, uh, very symptomatic at that point.

53:04

Uh, it was left untreated.

53:05

Uh, we didn't feel there was enough fluid

53:07

for catheter drainage.

53:08

Patient comes back in August to the er,

53:11

uh, repeated symptoms.

53:13

The, the, the abnormal is still there.

53:15

In may they get a little better, but he's still symptomatic.

53:19

June, uh, almost resolved, but still there.

53:21

October, he develops a very large abscess,

53:24

which we drain, uh, percutaneously.

53:28

As you can see here on the coronal images.

53:30

The abscess is very, very large.

53:31

The patient is super symptomatic.

53:33

We end up doing a, a drainage percutaneously.

53:35

It's hard because the location often requires pleural, um,

53:39

approach, which can lead to the development of empyema.

53:42

So there's a lot of complications that can actually,

53:44

can happen as a consequence, as a result of, um,

53:48

dropped gallstones.

53:50

So you have to really raise the, the, the possibility

53:52

of dropped gallstones and the radiologist has a really

53:55

important role in, in raising this, uh, suspicion

53:59

and raising this, the possibility of this diagnosis.

54:03

Uh, another complication, um, post SC cystectomy, uh,

54:07

can be the development of these cystic duct remnants

54:09

that are very long, especially in patients

54:11

that have a low insertion of the cystic duct.

54:14

That cystic duct remnant can, can, can dilate over time

54:17

and really create a neo gallbladder.

54:19

Um, because this neo gallbladder will not contract

54:23

and you have a lot of biliary stasis in there,

54:25

they can develop, you know, a repeat bout

54:28

of acute cholecystitis.

54:29

And it's patients are usually puzzled, like,

54:31

why am I having right upper quadrant pain again if

54:33

I had my gallbladder removed?

54:34

That's because a long cystic duct remnants was left behind

54:37

that can dilate over time

54:40

and can cause a repeat, uh, bout of acute cholecystitis.

54:44

The inflammatory changes of the cystic duct remnant

54:48

another example of a cystic duct remnant.

54:51

It looks like a gallbladder,

54:52

but you will be able to elicit a history

54:54

of a prior cholecystectomy

54:56

and avoid making the wrong diagnosis.

54:57

Here again, this is

55:00

what happens if a cystic long cystic duct remnant is left

55:03

behind typically greater than than two centimeters.

55:06

You may dilate over time and cause trouble.

55:11

A drop clips are very common and they're typically inert

55:14

and they're not gonna cause much drop trouble.

55:17

The problem is really when you have dropped gallstones,

55:20

that's when you're really gonna have anus

55:22

for developing infection.

55:24

That being said, I have an anecdotal, uh,

55:26

thing to share here.

55:27

I mean, whenever I see too many cholecystectomy ec clips in

55:30

the gallbladder foa, I have a high index

55:32

of suspicion for complications.

55:34

And this is an example of a patient that we saw 13 years

55:38

after the patient had a cholecystectomy.

55:40

He had eight clips,

55:41

at least eight clips in the gall bladder pulse.

55:43

That tells me, honestly,

55:44

that either the surgery was very difficult

55:47

or it was performed by someone that is not very experienced,

55:50

like for a first, first year resident,

55:52

that too many clips in there.

55:54

Uh, that tells you that something probably did not go quite

55:57

right during surgery.

55:58

And this patient developed actually a myeloma 13 years

56:01

after, um, the surgery was performed,

56:04

which is an interesting, um, rare complication.

56:07

Another rare complication, uh, that we saw, uh, a couple

56:11

of years ago was a patient developing right upper quadrant

56:14

pain post cholecystectomy.

56:16

He had this linked fact that the dis OCPD

56:18

that was initially thought to be called a dosis,

56:21

but he had some magnetic susceptibility on mr.

56:24

So for that reason, we ended up doing a ct.

56:27

And on the CT we saw that actually, uh,

56:31

what we, what the feeling, the fact that

56:33

that this OCBD was not a stone.

56:36

This was actually a migrated chole cystectomy clip

56:39

that actually migrated from the gallbladder fossa each

56:42

of the biliary tree, and got lodged in the distal CBD

56:46

causing, uh, obstruction in right upper quadrant pain,

56:49

which is an uncommon complication,

56:50

but already widely reported in the literature

56:53

of a prior cholecystectomy.

56:55

And now to wrap up, I have a rare complication.

56:58

Uh, uh, you can have infection, uh,

57:01

in the laparoscopy sites, the port sites that can happen.

57:05

And this is an epidemic

57:06

that we had a few years ago in Brazil

57:07

of mycobacterium abscessus

57:09

because of improper sterilization technique

57:12

of the laparoscopy ports.

57:14

And this is what the, uh, microorganisms look like.

57:18

And you can also have hematomas, uh,

57:20

they can even develop in patients that have normal plates

57:22

as an INR if they're taking medications like JCO biloba,

57:25

which increase your bleeding risk.

57:28

So we covered a wide range of complications.

57:31

Uh, we, we, we talked about the composition of gallstones,

57:34

the risk risk factors for their development,

57:36

how they look in different image modalities, the wide range

57:39

of complications from uncomplicated acute cholecystitis

57:42

to widely complicated acute cholecystitis,

57:45

early late complications of cholecystectomy.

57:48

And I hope, uh, this was a helpful review of all

57:51

of these complications and I'm happy

57:53

to answer any questions.

57:55

I do leave a QR code here if you have, uh, any

57:59

feedback, uh, about the stock.

58:00

I really appreciate you using the QR code

58:03

to provide your, your input.

58:05

Thank you so much for that lecture, Dr. Caesar.

58:07

That was awesome. We are going

58:11

to open the floor now for questions.

58:12

There are a couple already in that q

58:14

and A box, if you can find it on your zoom screen.

58:20

So I, I do have a question that I see here when

58:22

to suspect bio par ct.

58:24

So, you know, typically patients do not get any imaging done

58:27

after cholecystectomy.

58:28

If it goes, uh, you know, if it goes well, so to speak.

58:32

So if you're getting a requi requisition for CT

58:37

early post-op, there's something probably already

58:39

suspected, at least clinically.

58:41

And if you see a collection, um, you know,

58:43

a fluid collection, uh, early on post called cystectomy.

58:47

You should, you should have a very, very high index

58:50

of suspicion for bio leak

58:52

regardless of where it's happening.

58:54

So if the patient had a recent chole cystectomy, um,

58:57

especially symptomatic,

58:58

and if you see a collection, um, it is a bio leak

59:01

through proven otherwise, it can resolve it spontaneously.

59:04

Uh, it may require treatment with percutaneous drainage,

59:06

as I said, but, um,

59:08

you should have a high index of suspicion.

59:12

So that's a great question.

59:13

So how to differ early post cholecystectomy myeloma

59:16

from other collections.

59:17

And as I said, CT is a very limited modality in assessing

59:22

the contents of a fluid collection.

59:23

I mean, oftentimes, uh, it looks simple on CT

59:27

and then into an ultrasound, and mr there's a ton of debris.

59:30

It's non drainable, non liquified.

59:32

So CT is limited in that, uh, assessment, uh,

59:35

especially if it's homogeneous.

59:37

Uh, that being said, when you see gas in it, you have

59:41

to suspect that there is gas micro microorganisms

59:43

there and the super infection.

59:45

So an abscess should be very high in their suspicion.

59:48

Um, if it's high density, you should suspect hematoma.

59:51

There's one caveat that I wanna, uh, really point out to,

59:54

which is, uh, especially in patients that bleed

59:57

during surgery, they can get hemostatic agents

59:59

added to the area.

60:01

And surgicel, which is the typical hemostatic agent

60:04

that is used, can look just like abscess.

60:07

They can look like an abscess,

60:08

and it's just hemostatic, uh, material

60:11

that will resolve over time,

60:13

typically takes about seven days for the hemo.

60:15

The surgicel, uh, get reabsorbed.

60:19

So if it's very heterogeneous suspect something more than

60:22

just a myeloma suspect, hematoma

60:24

or ansis, if it's homogeneous on ct,

60:27

you may need an ultrasound

60:28

or an MRI to better assess the contents of the collection.

60:34

Uh, other question, uh,

60:35

cholesterol stones in and out of phase imaging.

60:38

Not super helpful, to be honest, uh,

60:40

to distinguish between the two.

60:42

Uh, what I use sometimes is whether

60:44

or not the stones are floating bile that tells me

60:46

that they're a little bit lighter

60:48

and more cholesterol based.

60:50

Um, that can be helpful.

60:52

Pigment stones tend to be T one hyperintense, so

60:55

that can be helpful as well on fat on T

60:56

one fat suppressed images.

60:58

So the pigment stones can be, obviously the,

61:01

the context is gonna be very different like pigment stones.

61:03

They're only gonna be seen in those,

61:05

that population that I talked about.

61:08

Patients that have chronic biliary, uh, um, uh, states, uh,

61:12

they have, uh, hyper bilirubin, um,

61:16

you know, hemolytic states.

61:17

So these are the patients that are gonna suspect pigment

61:19

stones, but they tend to be E one hyper.

61:22

Um, MRI of the gallbladder ducts include MRCP automatically.

61:26

Yes, we do MRCP in all of our liver MRIs and pancreas MRIs.

61:29

So that's kind of added automatically.

61:31

We don't do non-contrast.

61:32

MRII know a lot of places will do non-contrast.

61:35

MRI we almost always will do, um, without, with

61:39

and without IV contrast.

61:42

And then top three locations of bio leak accumulation,

61:44

I think they're gonna de, they're gonna typically accumulate

61:47

where the dependent portions of the body, they're gonna be

61:50

closer to where the leak is.

61:52

So typically gallbladder, fossa, Morrison, pouch

61:55

and pelvis, these are like the most dependent parts

61:57

of the peritoneal cavity.

61:59

And then the dwi, I, uh,

62:01

the exometer cocita is not something

62:03

that is a hundred percent specific by imaging, um,

62:06

but that you do see a restricted diffusion in those

62:09

intramural nodules that can be helpful also as well.

62:12

And, and making your, uh, your, your, you know,

62:15

eliciting the, the diagnosis.

62:18

Uh, I have to say I have a 50 50, uh,

62:20

history in making this diagnosis prospectively.

62:23

Sometimes it's just chronic cystitis without vent

62:26

granulomatous changes.

62:27

Sometimes it can even be gallbladder carcinoma.

62:30

It's very hard to tell by imaging alone.

62:35

And then I think there's one more here.

62:37

Um, patients with acute, uh, pancreatitis do,

62:42

does, everybody does MRCP.

62:46

And then, uh, if the colitis can be seen by ultrasound, um,

62:51

we are very, uh, heavy on MRI here.

62:54

Um, but obviously if you're make able

62:55

to make the diagnosis confidently with ultrasound,

62:58

it can prove and show the images very nicely.

63:00

Then, uh, you could actually skip the MRI

63:03

and go straight to ERCP.

63:06

I do have to say our GI uh, docs here, uh,

63:09

really rely on free E-R-C-P-M RCPs.

63:12

They really like to see the biliary tree before they go in.

63:15

So oftentimes we do do, uh,

63:18

although it's a lot more expensive,

63:19

we we do end up doing MRCP even when

63:22

ultrasound is diagnostic.

63:24

Hey, I think you got through all the questions.

63:26

Thank you so much for being here

63:28

and giving that great lecture.

63:29

Thank you so much for everyone else

63:31

for participating in this NOOM conference.

63:32

Be sure to join us next week, Thursday,

63:34

November 13th at 12:00 PM Eastern, where Dr.

63:37

Anoop Shetti will deliver a lecture entitled PIRR,

63:41

standardizing prostate MRI, post-treatment reporting.

63:44

You can register for that@modality.com

63:46

and follow us on social media

63:48

for updates on future noon conferences.

63:50

Thanks again, and have a great day.