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Today we are honored to welcome

0:42

Dr. Douglas Katz for a lecture on

0:44

gallbladder ultrasound pitfalls on call.

0:46

Dr. Katz is the Vice Chair for Research in the

0:48

Radiology Department of NYU Long Island, and is

0:51

Professor of Radiology. In 2023, he was awarded

0:55

the NYU Long Island School of Medicine Dean's

0:58

Award for Excellence in Clinical Research and

1:00

Scholarship, and has been an honored educator

1:02

of the RSNA four times, most recently in 2022.

1:06

He's co-authored numerous publications and

1:08

abstracts, books, exhibits, and posters, and

1:11

serves on the editorial boards of Radiology,

1:13

AJR, Emergency Radiology, and Radiographics.

1:17

Dr. Katz is passionate about radiology in general,

1:19

resident medical education, and has mentored

1:22

numerous undergraduate and medical students,

1:25

residents, and faculty, and we're thrilled

1:27

he's here today to share his expertise.

1:29

At the end of the lecture, please join

1:31

Dr. Katz in a Q and A session where he will address

1:33

questions you may have on today's topic.

1:36

Please remember to use the Q and A

1:37

feature to submit your questions so we

1:39

can get to as many before our time is up.

1:41

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

1:43

Dr. Katz, please take it from here.

1:46

Thank you very much.

1:47

It's an honor and a pleasure to be back.

1:49

It's been about, maybe about two and a half, three

1:51

years since I did my initial presentation

1:54

for MRI Online, and I appreciate that

1:57

invitation from Dr. Collins herself a few years ago.

2:00

And, uh, pleasure to be back.

2:02

So welcome to those joining us live online,

2:05

this afternoon if you're in the Eastern

2:09

time zone or other time zones that it's the

2:11

afternoon, and those watching this down the road.

2:14

So, you know, I joke, I do a lot of academic

2:17

stuff, but I also do a lot of clinical work,

2:19

and I joke that I have an ivory basement.

2:22

You know, I'm not an ivory tower academician.

2:25

I live in the real

2:26

world, like most of us.

2:28

And, increasingly in the last—

2:31

I'd say four or five years, I've been

2:33

doing abdominal and other parts

2:36

of the body ultrasound, sonography.

2:39

And so sonography has become an

2:42

increasing emphasis and interest

2:44

in my academic work as well.

2:47

And, you know, gallbladder ultrasound is part,

2:51

of course, of right upper quadrant sonography,

2:53

done often in the emergency setting, which

2:56

is where we're gonna focus our emphasis

2:58

today, but also in the outpatient setting,

3:01

as well, where there can be pitfalls as well.

3:04

Although as bread and butter as it gets, it really

3:07

leads to a host of potential pitfalls and

3:10

quality assurance peer learning-type problems.

3:13

And I'm going to show some of the cases

3:17

that I've encountered that raise a variety

3:20

of teaching points and peer learning and quality

3:22

assurance points that I've encountered.

3:26

I'll note that I very recently updated this

3:28

lecture, and in my logbook—I have a logbook

3:31

that I keep with me when I do clinical work—

3:34

over the past year or so, I would say on average

3:38

I see about one or two of these types of cases a week.

3:42

And we just—you know, my hospital is a 600-bed—

3:46

I call it a community-university hybrid.

3:48

We're in suburban Long Island,

3:50

as part of the NYU system.

3:53

So we're just one, you know,

3:55

medium-sized institution, and—

3:59

so I imagine this is really quite a common

4:01

scenario that you're gonna encounter, no

4:04

matter what your practice-type situation is.

4:07

So I have no disclosures related to this presentation,

4:10

other than to disclose that, as with many aspects

4:13

of the acute abdomen and pelvis, although this has, as I

4:17

note, not been the main focus of my clinical work,

4:19

clinical research has been an increasing focus.

4:23

I'm a generalist, body imager, emergency

4:26

radiologist, and as we know, with any type of

4:30

ultrasound or sonographic examinations, it's

4:34

a different sort of animal than with other

4:37

cross-sectional imaging, in that, at least in the

4:40

U.S. and in other parts of the world, we rely heavily

4:46

initially on the technologist's preliminary notes.

4:50

I'll talk about that.

4:51

We depend on the equipment, of course, with any

4:54

modality, but very much on the particular patient.

4:59

And it's not even so much the specific

5:01

body habitus, it's the sort of—

5:03

image that we get.

5:05

It isn't directly correlative necessarily

5:08

with a, you know, lack or presence of fat.

5:11

It's just the particular characteristics of

5:13

the patient, their ability to cooperate or

5:16

inability to cooperate in the emergency setting.

5:19

All these factors are going to determine

5:23

what kind of image quality we get.

5:25

In general, our sonographers are excellent.

5:29

But again, there's a lot of variability,

5:32

and particularly after hours on call, we

5:35

run into some potential problems with this.

5:37

So this is not, you know,

5:40

renal transplant ultrasound.

5:43

This is not small parts tendon imaging.

5:47

And you can get lulled into deceiving yourself

5:50

that, yeah, it's, you know, it's the gallbladder.

5:51

We do this every hour of every day, like, you

5:54

know, ultrasound of the lower extremity deep

5:56

veins, and you know, what's the big deal?

5:59

Why is this difficult or challenging?

6:01

But I would say very consistently we have

6:04

seen quality assurance issues and, again,

6:08

peer learning-type cases over and over

6:10

again in a non-trivial minority of patients.

6:13

So I would be very careful, especially in the after-

6:16

hours emergency setting. I would be meticulous

6:19

about things and really be alert and

6:22

careful to the series of potential pitfalls

6:25

and problems I'm gonna go over today with you.

6:28

Again, important is, with any imaging

6:30

exam, to correlate with the history.

6:33

And again, it can be difficult on call to do this,

6:35

but if possible, to discuss with the referring

6:38

clinician, whoever she or he may be. If there are

6:41

particular issues or questions, the exam is negative,

6:44

it's negative, but when there are equivocal findings,

6:47

when you're not sure how to interpret the findings,

6:50

when you need a clinical context, that's when

6:52

we should be picking up the phone and talking to

6:55

somebody. Correlate with any relevant imaging exams.

6:59

That's true with anything that we do, but particularly

7:01

as I'll show you, important when there are problematic

7:04

scenarios with the gallbladder and ultrasound.

7:07

And although, again, we have excellent

7:09

sonographers in general, and although in

7:12

general the ultrasound sonographer's report is

7:15

typically on the mark, it can be inaccurate.

7:19

There may be

7:20

inaccuracies with respect to the observations,

7:24

to the interpretation of the observations.

7:26

Do not take the report as gospel.

7:29

It's certainly a major starting point, but you need

7:31

to look at the images, and I would say the number one

7:34

major pitfall is not appreciating subtle gallbladder

7:39

wall thickening, whether anterior, posterior, or both.

7:43

And so the particular scenario that can occur here is

7:47

that you, you know, look at the sonographer's report.

7:50

It's called negative.

7:53

You then repeat the error and call it negative, and

7:56

it's not, and we've seen this over and over again.

8:00

Another error is you look at the static

8:02

images and there are subtleties that are

8:04

appreciable only on the cine images.

8:06

Now, in an ideal world, you're gonna go in the room

8:09

and look at every patient and examine them real-time.

8:11

That is simply not a possibility.

8:14

It's certainly not possible on call.

8:16

And in many practices, we're interpreting

8:19

exams even during the working day, coming

8:21

from multiple places within our system.

8:24

And it's just not an option.

8:26

But there are scenarios where we may be able to

8:29

request additional imaging or bring the patient

8:31

back when there are equivocal findings.

8:35

When there are findings that you're just not

8:36

sure what they are or what to do with them.

8:39

And again, ideally you should be discussing

8:42

these selected cases with your sonographers.

8:44

And I am, when I'm on the sonography service or when

8:47

there are imaging exams that are problematic, I am

8:51

constantly picking up the phone and talking to them.

8:53

That's how they learn, and that's how we

8:56

are ultimately giving better patient care.

8:58

Ideally.

8:59

Again, I'll show you multiple examples where

9:02

there is subsequent short-term imaging, and the

9:05

imaging can be a repeat short-term ultrasound, a CT,

9:10

MR, MRCP, or nuclear medicine. I'm not

9:12

gonna get too much into a HIDA scan.

9:14

There's still a role for that.

9:16

Less so, I would say nowadays, in the emergent

9:18

setting, more so in the more subacute

9:21

setting for things like biliary dyskinesia.

9:23

Again, I won't get into that so much in this setting.

9:26

Similarly, and I'll show examples of this,

9:28

there are situations where an initial CT

9:31

that may have subtle or equivocal findings

9:33

may benefit from correlation with ultrasound.

9:35

And I think the bottom line is, although we don't

9:37

want everybody to get the so-called triple play,

9:39

as I call it—a CT, an ultrasound, and MRI in

9:44

some order—for everybody with right upper quadrant

9:46

pain in the emergency setting, it's certainly

9:49

better to do one or more tests than to have

9:51

an unnecessary cholecystectomy, for example.

9:55

So we're gonna show some, uh, recent and

9:58

relatively recent problematic ultrasound,

10:00

gallbladder cases in patients from my

10:03

practice with an emphasis on emergency imaging.

10:05

We'll show correlation of imaging.

10:07

Some of these are fairly common

10:08

scenarios, and others are less common.

10:10

We'll go over some recent relevant papers

10:13

from the literature, provide some pearls as

10:15

to how to stay out of trouble, and I can't

10:18

cover everything in a 50-minute lecture.

10:20

There are some things like torsion and

10:22

postoperative complications, dropped

10:25

gallstones, and, you know, unusual things.

10:28

We can't get into all of these things,

10:29

but I'll try to hit some key points.

10:31

Now, just a couple of basic things

10:33

I'm not even gonna show examples of.

10:36

A gallbladder that isn't there.

10:38

Well, maybe you don't have the

10:40

history of a cholecystectomy, or you

10:42

don't have a reliable historian.

10:44

And one of my favorite sayings is,

10:46

"The history and imaging is discrepant.

10:48

Get a new historian."

10:50

Maybe the patient ate very recently,

10:53

you don't have that history, and the

10:54

gallbladder is just very collapsed.

10:56

Maybe they, again, they're obese and you

10:57

just—there's a lot of overlying bowel gas.

11:00

They haven't been NPO.

11:02

So there are a variety of scenarios where you just

11:04

can't see the gallbladder, and you need to again,

11:06

correlate with prior imaging, get additional history.

11:09

There are scenarios where we have a gallbladder

11:11

completely filled with calc, the so-called

11:13

WES sign (Wall-Echo-Shadow sign), which could

11:16

potentially be mistaken for bowel, and vice versa.

11:19

And these are potentially common

11:21

scenarios that we can all fall into.

11:24

Some background information.

11:26

Gallbladder disorders are very common.

11:29

It's the number one cause of hospital admissions

11:31

for GI tract problems in the U.S., and I realize we

11:33

may have a multinational audience for this lecture,

11:37

but a little bit of data from the States: upwards of

11:40

700,000 cholecystectomies are performed in the U.S.

11:44

Most of these are laparoscopic.

11:46

We'll talk a little bit about that later,

11:48

on in terms of some information I think we

11:50

need to provide to help guide our surgeons.

11:53

And again, a very common disorder in the U.S.

11:56

adult population.

11:58

Unfortunately, some of them are asymptomatic.

12:01

A substantial percentage can be

12:03

symptomatic acutely or subacutely.

12:06

Obviously, sonography is the initial test of choice.

12:09

We may

12:10

encounter gallstones incidentally on other

12:13

modalities, and we may encounter acute chole-

12:15

cystitis on CT because that's not the initial

12:19

consideration in an emergency setting.

12:21

But if that is the concern, clearly

12:23

ultrasound should be done for obvious reasons:

12:26

relatively inexpensive, no ionizing radiation.

12:29

It's portable, can be done at the bedside.

12:32

Whether you have a relatively inexpensive

12:34

handheld machine or an expensive machine, it

12:37

can be done, again, at the bedside,

12:39

or can be done in the ultrasound department,

12:41

wherever that is. It's fairly accurate.

12:43

Again, this depends on a lot of

12:45

factors, as I've already discussed.

12:47

And it can be repeated, and we can in some situations

12:50

suggest or establish alternative diagnoses,

12:53

a bit more accurate with the other modality,

12:56

CT, MR, depending on the particular disorder.

12:59

So let's show some cases. The

13:00

whole—we learn by images, right?

13:02

So in retrospect, and in one of my other

13:05

favorite statements, everybody's

13:07

a genius in retrospect, especially me.

13:09

Especially brilliant when I know the answer.

13:11

Not so easy going ahead forward

13:13

when you don't know the answer.

13:15

But here, in retrospect, on the left was

13:17

a gallbladder showing some small polyps.

13:19

They were not appreciated prospectively.

13:22

And there may be slightly bigger, but a few

13:24

years later, on the right, there they are.

13:26

So gallbladder polyps — this is something

13:28

you see more in the outpatient setting,

13:31

occasionally in the emergency setting.

13:32

Here is an intermediate-sized polyp, six millimeters.

13:35

There's some steatosis, or fat, in the liver.

13:39

And, you know, these generate a ton of

13:41

exams in my experience, and most of them,

13:43

quite honestly, are probably unnecessary.

13:46

And so, you know, the gospel had been for

13:49

years, based on not a lot of actual data, that

13:52

if you have a gallbladder polyp, one or more,

13:56

five millimeters or larger in maximum dimension,

13:58

you should be following them with ultrasound.

14:00

If a centimeter or larger, the gallbladder

14:03

should be likely—should come out.

14:06

And it took until, uh, some years

14:08

later. We are hearing this during

14:09

training, and just people said it.

14:12

Mike Corwin at Beth Israel Deaconess

14:14

in Boston published this paper.

14:16

I happened to be the editor of this paper.

14:19

A series of 346 patients; slightly fewer

14:23

than half had fairly long-term ultrasound follow-up.

14:26

And the grand number of malignancies

14:29

identified in these patients was zero.

14:31

Now, granted, it wasn't a huge paper.

14:34

There were a small number of, quote, neoplasms.

14:36

They weren't actually malignant neoplasms,

14:38

found in the intermediate- to larger-sized polyps.

14:41

And so the conclusion was, you have

14:43

a polyp six millimeters or smaller,

14:45

you may not need to do anything.

14:47

And unfortunately, at least from an

14:49

ethical and quality assurance point

14:52

of view, this is not what's happening.

14:54

At least in my experience, and not only

14:57

my own practice, in lots of other practices.

14:59

Now, if you want a really large database,

15:02

you go to a system like Kaiser or the

15:04

Mayo Clinic or something like that.

15:06

So here's a paper from the Kaiser system, recent

15:09

paper showing in a large number of individuals,

15:12

where they looked at pathology specimens, there

15:15

was no difference in gallbladder cancer rates.

15:18

Again, gallbladder cancer is unusual.

15:19

We'll talk about that at the very end of the

15:21

lecture, whether you had gallbladder polyps on

15:23

pathology specimens and cholecystectomies, or not.

15:27

So that was pretty reassuring,

15:28

supporting evidence to, again, say there's

15:31

probably, you know, you really don't need to be doing

15:34

all these follow-ups, and yet they continue.

15:36

So here's the three-millimeter

15:38

incidental polyp found in my practice.

15:40

August 2022, on the left.

15:43

And so the old radiologist

15:44

said, "Get a six-month follow-up."

15:46

Well, there's no evidence to

15:47

support that kind of practice.

15:49

And here it is on the right, February 2023.

15:52

Shockingly, it's absolutely unchanged. That really

15:56

should not have happened.

15:57

Honestly, I'm at the point where

15:59

I, in my reports with these small polyps,

16:02

say, "No additional imaging is necessary."

16:04

I just come out and say it.

16:05

Here's someone with a fairly long-term follow-up,

16:09

ultrasound 2016 on our left, one of several small

16:13

polyps, and here, interestingly, on CT—and if you

16:17

look really carefully, on a small number of patients,

16:20

you actually can see polyps in the gallbladder.

16:22

Here it is, a little bit easier since we know they were

16:25

there, on a representative image from last year.

16:31

Well, again, I don't quite get

16:32

this, but this was a recent case.

16:35

A bit of an older ultrasound, 2013 on our right,

16:40

showing a small polyp, and almost, you know, a

16:44

decade later, they're getting follow-ups of this.

16:46

Again, there's just no evidence

16:47

to support this practice.

16:50

Our next topic, adenomyomatosis.

16:52

Everybody always confuses this with

16:54

adenomyosis, which is in the uterus.

16:56

This is adenomyomatosis in the gallbladder, and

17:00

this is a very typical appearance in the fundus.

17:03

In this particular patient, there's an associated

17:06

large gallstone, and this was stable on imaging exams

17:10

done a few years apart, as we can see here.

17:14

This is a common condition, upwards of

17:17

pushing 10% of adult ultrasound exams, based

17:21

on a paper from a European journal from a few

17:23

years ago, which is a nice review article.

17:26

This is, again, classically in the fundus.

17:29

It can be in other locations, such as the waist

17:32

of the gallbladder, or diffuse, and has a classic

17:36

ultrasound appearance based on the histopathologic

17:39

correlation with these small bile-filled cystic

17:42

spaces, the so-called Rokitansky-Aschoff sinuses,

17:45

which develop small cholesterol-type crystals.

17:49

Very, very unusual, but you can occasionally have

17:52

a very sick patient with uncontrolled diabetes

17:56

who has emphysematous cholecystitis, and the differential

17:59

would be sort of the dirty shadowing from gas.

18:02

Again, if that's the consideration, you do a CT,

18:05

non-contrast, and it should be fairly obvious.

18:08

That's what it is, and not—

18:10

uh, adenomyomatosis.

18:12

So in this scenario, again, rare to need

18:17

problem-solving, other cross-sectional imaging,

18:20

but there are reports of that in the literature.

18:24

So here's a recent example.

18:26

I don't know why, but the radiologist

18:29

interpreting the exam on the right called

18:31

these, quote, floating cholesterol crystals.

18:35

They are cholesterol crystals.

18:37

They're not really floating.

18:38

They're not in the lumen, they're in the wall,

18:41

and they're producing these ring-down artifacts.

18:44

And this was stable compared with the subsequent

18:48

exam from September of last year, on the left.

18:52

Here's another example.

18:53

In a patient also with gallstones, there's no

18:55

clear association, to my knowledge, with gallstones.

18:58

They just happen to have those in

19:00

these two patients I've shown you here.

19:03

Let's talk about gallbladder wall thickening.

19:05

Again, as I noted, this is the number

19:07

one issue that I see in terms of a

19:10

under-diagnosis prospectively on ultrasound.

19:14

Be very careful.

19:15

Again, I would advise in the acute setting,

19:17

look at the cine images and make sure that

19:20

in fact, you think the gallbladder is normal.

19:24

It can be tough to separate

19:26

it anteriorly from the liver edge.

19:28

And again, it has absolutely

19:30

been a problem in our practice.

19:33

The classic three millimeters still holds—

19:35

more than three millimeters is considered

19:38

abnormal, and the differential is sort of broad: acute

19:42

cholecystitis, chronic cholecystitis, acute-on-

19:45

chronic cholecystitis, acalculous cholecystitis.

19:49

We'll talk about that a little bit later.

19:51

So to diagnose acute cholecystitis,

19:53

classically we're looking for a distended

19:56

gallbladder with calculi. There may be sludge.

20:00

And the sonographic Murphy sign, which is not

20:02

the physical exam Murphy sign. It's the patient

20:04

is asked where they hurt; the sonographer and

20:08

or radiologist puts the probe where it hurts.

20:10

If it corresponds to the gallbladder, that's recorded

20:12

as a, quote, positive sonographic Murphy sign.

20:15

So you can have gallstones, but you don't

20:18

necessarily have acute cholecystitis

20:21

if the other features are not present.

20:23

Other things in the differential: we've already

20:25

talked about adenomyomatosis, but a list including

20:29

ascites, fluid overload states, cirrhosis.

20:33

We had a case very recently of hepatitis

20:36

that simulated acalculous cholecystitis.

20:38

Again, the clinical history

20:40

and labs made the diagnosis.

20:42

And again, uncommonly, malignancy. Correlation

20:46

again with the history and imaging is key.

20:49

So here's a recent case.

20:51

Their gallbladder is a little bit distended.

20:53

The wall is thickened, but there were no calculi.

20:57

There was no sonographic Murphy sign.

20:59

The patient was not on pain meds.

21:01

I'll talk about that a little bit.

21:02

There was a little bit of sludge present,

21:05

but the patient had some fluid overload.

21:07

There was a little bit of ascites,

21:09

and there was some anasarca.

21:10

So the conclusion here was that this was not acute

21:14

cholecystitis, but it was not straightforward.

21:18

You know, you have to look at this case and

21:20

really carefully assess the clinical story and

21:23

the imaging and put it in the right context.

21:28

Here's a 73-year-old man who has a thickened

21:31

gallbladder, and you notice anteriorly, again, it

21:34

can be kind of tough to separate the liver edge

21:36

from the gallbladder wall in the adjacent fat.

21:39

And so in my experience, the measurements

21:41

aren't necessarily that accurate.

21:44

Notice the technologist very nicely has

21:46

noted on the notes that are now permanent

21:49

in the record, that there was no sonographic

21:51

Murphy sign at the time of the exam.

21:54

But sometimes there's no note.

21:56

And unfortunately, I see notes in outpatients

22:00

that there's no pain, and they write all the time,

22:04

"No sonographic Murphy sign."

22:06

Well, why were we even talking about

22:08

that in an asymptomatic outpatient

22:10

where that's not the consideration?

22:12

And paradoxically, in situations where there

22:15

is pain in the emergency setting, sometimes

22:17

they forget to tell us in the notes or in

22:20

the notations on the images whether there

22:23

was or was not a sonographic Murphy sign.

22:26

So I, I have to call and say, "You

22:28

gotta tell me—was there or wasn't there?"

22:30

On the concordant CT, non-contrast.

22:33

Notice the big heart and the congested liver,

22:37

and this all explains the gallbladder edema.

22:41

This was a much more challenging

22:43

case from about three years ago.

22:46

This patient walked in the door with abdominal pain.

22:48

There was a known history of chronic

22:50

Hepatitis B, but the presentation was

22:53

otherwise acute, and unfortunately, this

22:56

ends up being a very complex presentation.

23:00

Hemorrhage in the gallbladder.

23:02

Now looking at that right image, you can't tell

23:04

that that's blood, but certainly you can tell

23:07

there's at least very complex sludge in there.

23:10

It's filled with sludge,

23:12

there's wall thickening, and that

23:14

liver looks pretty terrible, right?

23:16

Even on the grayscale image, it's

23:17

very, very heterogeneous beyond what

23:19

we would expect cirrhosis to be.

23:22

And this unfortunately ends up being serendipitous

23:26

in a way, because we have non-contrast CT—

23:28

hemorrhage in the lumen of the gallbladder because

23:31

this is a hemorrhagic, diffuse hepatocellular

23:34

carcinoma, which on this representative MR

23:38

image with contrast, on the right, is

23:40

invading the central portal venous system.

23:43

So very, very advanced, very unfortunate,

23:46

and very unusual presentation in my

23:49

experience of hepatocellular carcinoma.

23:51

But we know the etiology—it's the Hep B.

23:54

Hepatocellular carcinoma occasionally presents

23:57

with intraperitoneal hemorrhage, but this type of

23:59

presentation is really unusual in my experience.

24:03

So what's the differential for

24:05

this unusual acute scenario?

24:07

Gallbladder hemorrhage in the

24:08

wall, in the lumen, or both.

24:10

And again, you kind of have to go out of your way.

24:12

Either you're doing non-contrast images solely on

24:16

purpose or, you know, as part of a multiphasic exam,

24:19

or you happen to have a dual-energy scanner and

24:23

are obtaining virtual non-contrast images as part

24:26

of your acquisition and reconstruction.

24:29

Or it's just sort of serendipitous,

24:30

'cause you can't give IV contrast.

24:33

Or you have a complex

24:35

cholecystitis, and there is data.

24:37

There's a couple of papers from Korea showing

24:40

that if you go out of your way to do non-contrast imaging in

24:43

the setting of complex cholecystitis, a substantial

24:47

percentage of individuals are gonna have blood in the

24:49

wall and sometimes in the lumen of the gallbladder in

24:52

the setting of necrotizing, gangrenous cholecystitis.

24:56

Other situations where you may have

24:58

gallbladder wall and/or luminal hemorrhage

25:00

include anticoagulation, and again, complex

25:04

cholecystitis, unusual scenarios like trauma.

25:06

Pretty rare to have trauma to the gallbladder,

25:09

because it's such a deep organ, but that is

25:12

described in the blunt and penetrating scenarios.

25:15

And then underlying malignancy, as we've shown

25:18

here. More commonly, you can have

25:22

varying extents of sludge,

25:27

and that can be so-called tumor effect.

25:31

Here's the patient, 83 years old,

25:33

and I've just shown the more recent.

25:36

That was in 2020, of multiple

25:39

ultrasounds that were all unchanged.

25:42

The patient

25:43

was actually asymptomatic.

25:44

This gallbladder was not causing

25:46

pain, so it was left in place.

25:48

And this patient has cirrhosis.

25:50

You'll notice the liver is nodular in its contour.

25:54

And that was why this was being followed.

25:57

Not so much

25:58

the gallbladder. And I don't have a Doppler

26:01

image here, but the Doppler exam showed

26:03

no flow, so there was no underlying mass.

26:05

The wall was not thickened.

26:06

This was just sort of chronic tumor

26:09

effect of sludge, and it looked the

26:11

same every time we imaged the patient.

26:13

But you can imagine that would be problematic the

26:16

first time that you were to scan this patient.

26:19

Here is a more recent case

26:22

that was pretty problematic.

26:24

This was a 20-year-old, this is just from a few weeks

26:27

ago from my practice, who comes in with acute right

26:30

upper quadrant pain, and she's got everything

26:32

going for acute cholecystitis except the gallstones.

26:36

Now, you don't think about a previously healthy

26:39

20-year-old as having acalculous cholecystitis.

26:43

But this is kind of what it is in a way.

26:45

I mean, she's got a little bit of sludge there.

26:47

It's kind of confluent.

26:48

The blue arrow is pointing to that,

26:51

but she's got the Murphy sign.

26:53

She has a distended gallbladder.

26:55

She's got a little bit of mild edema there.

26:58

And, you know, considering how distended

26:59

that gallbladder is, you know, the

27:01

wall is definitely mildly thickened.

27:04

Um, but we just, you know, we have a

27:06

really good look of the gallbladder.

27:07

We don't think we're missing any calculi.

27:09

Again, another pitfall is, you know,

27:11

calculi that kind of are, are hiding in

27:13

the neck, and they're just deep.

27:15

Or the patient has a bigger habitus, or they're

27:17

just overlying bowel gas or something that's

27:19

preventing us from seeing the dependent,

27:23

you know, most aspect of the gallbladder.

27:25

But here we're clearly able to see on,

27:28

you know, all the images, and these are two

27:30

representative images, transverse and, you

27:32

know, sagittal decubitus, the gallbladder.

27:35

We just—there were no calculi at all.

27:37

And yet everything else here

27:38

is adding up to cholecystitis.

27:40

And I was very comfortable sending this patient

27:42

to surgery and likely the operating room. This is

27:45

just behaving like an acute cholecystitis episode.

27:49

Now, there are scenarios where the surgeons will

27:52

take out the gallbladder, um, where we don't have

27:55

gallstones, and where there's just distension,

27:59

or it's a dyskinesia scenario, or there are

28:02

episodes of prior pain, and it doesn't necessarily

28:06

fit your classic definition of acute cholecystitis,

28:09

but everything else sort of adds up to the

28:12

gallbladder being the problem, everything else,

28:14

not, you know, leading to a specific diagnosis.

28:19

Here's another scenario.

28:20

This is a common situation where the CT may

28:23

be done first and the ultrasound done for

28:25

supplemental imaging, and that's where you

28:28

have someone—in this case, you know, you look

28:30

at the CT, and these are true representative

28:32

images with IV contrast—in a 55-year-old.

28:35

And my brain would immediately say

28:37

two things: pancreatitis and alcohol.

28:41

Um, and although the differential would include,

28:44

and in more recent years, hypertriglyceridemia.

28:48

You know, the very low nature of that liver,

28:52

um, number one suspect would be alcohol

28:54

abuse, and it's likely a combination of

28:57

alcohol-related hepatitis and steatosis.

29:01

Now, just as a side note, I'm a little bit

29:04

careful nowadays with what I say in my reports.

29:08

You know, I, I don't use the word "fatty" in my reports.

29:11

You know, patients with access almost

29:14

instantaneously to their imaging reports analyze

29:18

them, and we get—and I'm sure many of you do too—

29:21

where this is now an increasingly common scenario.

29:24

In fact, I think in the US it's now mandated

29:27

that patients have access to pretty much all

29:29

their records, including their imaging reports.

29:31

You know, you know.

29:32

"He or she called me a fatty," right?

29:35

It just is not a great term.

29:37

So I use the more polite term steatosis, and I

29:39

think in general we have to be careful about

29:42

how we phrase things for a variety of reasons.

29:45

In any case, clearly this is, at the minimum,

29:47

a, you know, substantial pancreatitis episode.

29:50

So the ultrasound was done, although

29:52

limited, to look for associated calculi.

29:56

There were no calculi. There was just

29:57

some sludge, a little bit hard to see,

30:00

but that was a representative image.

30:02

Just, you know, limited technically

30:04

because of overlying bowel gas.

30:06

The patient isn't that big.

30:07

It's just that, again, as I stated in the beginning,

30:10

some patients just don't have the greatest sonographic

30:12

characteristics, and it isn't really necessarily

30:15

always a one-to-one correlation with the, you know,

30:18

extent of subcutaneous and intra-abdominal fat.

30:25

So here, this was a really problematic,

30:27

uh, case, and I, I don't think I've

30:28

ever seen anything like this before.

30:30

So, you know, that's the beauty of radiology is

30:33

that, you know, you can be doing this, and this

30:35

is like my 20, I don't know, eighth year, 29th

30:38

year as an attending—losing track at this point.

30:40

But this is something I had never seen.

30:43

This was a very strange-looking

30:45

gallbladder filled with these weird, you

30:48

know, I don't know what exactly this is.

30:50

It looks like sort of—

30:51

clumped sludge and maybe strange gallstones.

30:56

And, you know, similar to what happens when you have

31:00

calculi in the kidneys and you put on Doppler and you

31:03

get these specular reflectors that are not indicative

31:06

of flow, but are, you know, known artifacts.

31:10

You're getting the similar kind of thing here when

31:12

you put on color Doppler. This is not actual flow.

31:15

There's no mass here.

31:17

You know, the wall isn't thickened.

31:20

Um, but this patient had subacute pain,

31:22

and it corresponded to the gallbladder.

31:24

So this gallbladder should be coming out, you

31:27

know, not immediately, but at some point.

31:30

So it was kind of weird.

31:32

I, I did recommend a CT or MR without,

31:35

and with contrast, but not clear that's

31:37

gonna change anything just because it was

31:39

just such, such an unusual presentation.

31:43

And then of course, we see gallstones, you

31:45

know, day in and day out, and very often,

31:47

again, as I've noted, you know, incidental

31:49

and not necessarily related to anything.

31:52

So here's someone who, and this is sort of,

31:55

I guess related because we, we do specifically

31:58

look for this in our workups of bariatric surgical

32:02

patients before they're gonna have surgery.

32:04

Um, we commonly do, you know, right

32:06

upper quadrant ultrasound.

32:07

Here's someone who, uh, has gallstones.

32:09

They had been unchanged.

32:11

If you look very, very carefully in the gallbladder,

32:16

on the CT done a few years earlier, you can

32:19

actually see the suggestion of them. They're there.

32:22

This liver is pretty steatotic.

32:25

In fact, I'd have a hard time saying

32:27

there isn't very subtle cirrhosis here.

32:30

But again, this is an asymptomatic outpatient.

32:33

There's another patient at risk for gallstones.

32:36

This is someone with sickle cell disease,

32:38

um, asymptomatic, but also happens to be,

32:42

uh, pre-op for revision bariatric surgery.

32:47

And there are gallstones there.

32:48

No surprise.

32:49

And you'll notice the spleen is on the bigger side,

32:52

getting about 17 and a half centimeters in length.

32:55

Remember, in sickle cell disease, a bit

32:58

earlier on, you can get a bigger spleen.

33:01

Everybody knows about the, you know, auto-

33:03

splenectomy, and the little calcified

33:05

spleen that we see later in the disease.

33:08

But in fact, somewhat earlier in the

33:10

disease, you can get splenomegaly.

33:12

So remember that.

33:14

And then we have these scenarios, and the

33:17

other pitfall that I see all the time, and it kind

33:21

of drives me crazy, but there's not much I can

33:23

do about it, is the scenario of how do we figure

33:27

out if there is chronic cholecystitis or not.

33:31

And it's analogous to the very difficult

33:35

situation in the minority of patients who

33:37

have subacute to chronic appendicitis.

33:40

But this is a much, much more common situation in

33:43

the gallbladder. Now, in my system, NYU, we have

33:47

the luxury of, and I think it's really fantastic.

33:50

We get, on every patient who we do an imaging

33:54

exam interpretation, if they go to surgery

33:59

or have a biopsy.

34:01

We get the reports from the pathologists, and I think,

34:04

again, this is fantastic. But when it comes to the

34:07

gallbladder, it drives me crazy because there are so

34:11

many patients that are being labeled when they get

34:15

their gallbladders out as having chronic cholecystitis

34:20

or acute on chronic cholecystitis, and you just simply

34:23

cannot make that diagnosis on the basis of sonography.

34:29

In my experience, you just can't.

34:32

So it really comes down to history,

34:35

and correlation with prior imaging.

34:38

Now here's a scenario where it's more straightforward.

34:41

This is a 73-year-old who had multiple ultrasound

34:45

exams, and they're having chronic pain, and

34:48

the pain corresponds to the gallbladder,

34:50

so there's no mystery or dilemma here.

34:52

We know this is chronic cholecystitis.

34:54

The gallbladder wall really doesn't look bad at all.

34:57

There are multiple gallstones.

34:59

This ultrasound looks the same every time we image it.

35:03

I've just put two representative scans here, one

35:06

from 2021 on the left and one from 2018 on the right.

35:10

Looks the same every time we image

35:12

this patient over and over again.

35:13

Why this gallbladder is not removed?

35:15

Presumably the patient's at, you

35:17

know, high surgical risk, because this

35:19

gallbladder otherwise should have come out.

35:21

Okay, here's another scenario.

35:23

Again, the same probable reason

35:25

why it hasn't been removed.

35:27

This is an 87-year-old, and every exam looks the same.

35:30

We have exams dating back.

35:32

From 2021 to 2016, going from our left to

35:36

our right, and even earlier exams, which

35:38

I didn't include, they all look the same.

35:41

There's gallstones, there's wall

35:43

thickening, and there is fluid.

35:45

And again, this should have come out if

35:48

this patient was a surgical candidate.

35:50

This is clearly.

35:51

Chronic, very chronic cholecystitis, but

35:54

when the patient walks in the door and we

35:57

don't have prior imaging and we don't have

35:58

a good history, it's very difficult to tell.

36:01

And I, I, I see patients all the time where, eh,

36:04

there's gallstones, the wall's thickened, and

36:07

it's unclear if there's really pain that can be

36:09

ascribed for the gallbladder and they opt to take it

36:12

out and the report comes back, chronic cholecystitis.

36:15

And I'm like, you know what?

36:16

There's no way I can make that diagnosis reliably.

36:20

Sorry.

36:20

It's just, it's like sort of beyond a pitfall.

36:24

It's not anything we can do about.

36:26

And so just be aware of this.

36:28

This is a very common thing, and if you

36:30

don't happen to have this type of rad-path

36:33

correlation mechanism, and many of you probably

36:35

don't, you're not gonna be aware of it.

36:38

I sort of wonder, you know, it's sort

36:40

of like, do the pathologists go out

36:42

of their way to kind of label that?

36:44

You know, I don't think they do.

36:46

I think it's a real phenomenon.

36:47

You know, sort of wonder with the appendix, you

36:49

know, did they give it a little bit of inflammation?

36:52

Sort of, you know, a little cover the tookus of

36:54

the surgeon who otherwise might have, might be

36:57

accused of doing an unnecessary appendectomy.

36:59

You know, if there are gallstones or

37:00

there are gallstones, you know, they

37:02

don't have to, the pathologists don't

37:03

have to go out of their way to cover.

37:06

You know, the surgeon, it, it, it needs

37:08

to come out, it needs to come out.

37:09

You know, I think it's a, a real phenomenon.

37:11

It's just something that I don't think we

37:13

have the capacity to diagnose based on a

37:16

single ultrasound exam in most scenarios.

37:19

Okay.

37:19

Next topic.

37:20

Again, another basic thing.

37:21

We mentioned this in the beginning,

37:22

the contracted gallbladder.

37:23

Here it is on the left.

37:25

Very difficult to tell, much going on, similar

37:27

to any sort of luminal bowel structure.

37:30

Here it is on the corresponding CT.

37:31

Not too impressive.

37:33

Here's a more recent patient in this instance.

37:35

There's heart disease.

37:36

The gallbladder on CT.

37:38

You might say, eh, it's a little

37:39

bit of wall thickening, yes or no.

37:40

Very tough given.

37:42

Its collapsed state.

37:43

Here it is on the sonogram.

37:45

No surprise.

37:46

The patient ate just prior to the sonogram.

37:49

Looks pretty negative.

37:50

No Murphy sign.

37:52

And here's another scenario.

37:53

We see where the gallbladder is emphysematous.

37:56

We've already gone over the differential for this.

37:58

In this case, it's heart disease.

38:00

And so the concern was raised by the radiologist

38:03

interpreting this as cholecystitis.

38:05

Well, take a look at the right heart.

38:08

I mean, the heart isn't that big, but the

38:10

right heart is big compared with the left.

38:12

And there's left ventricular hypertrophy.

38:14

And look at the liver.

38:15

It's congested, and that inferior vena

38:17

cava is big and the hepatic veins are

38:19

big, and there's an effusion on the right.

38:22

So there's lots of stuff telling you

38:23

there's significant heart disease, which

38:25

certainly explains the gallbladder edema.

38:28

And then here's the corresponding

38:30

subsequently done sonogram showing the

38:32

gallbladder edema without gallstones.

38:35

Again, this is a common type of scenario.

38:38

So ultrasound of acute cholecystitis,

38:41

in addition to the things we've already

38:42

discussed, especially if there is a.

38:46

Calculus or calculi that truly do

38:47

seem to be impacted in the neck.

38:49

We're looking for fluid, inflammation

38:51

adjacent to the gallbladder.

38:52

Again, this can be more obvious on CT or

38:55

MR. Already talked about the Murphy sign.

38:58

We'll show examples of how that can be a problem.

39:01

Distension, we've shown that. Hyperemia,

39:04

hypervascularity, we'll show an example

39:06

of that. Edema of the adjacent liver.

39:07

Again, that can be a bit more apparent on MR or CT.

39:11

And then here's something I wasn't

39:12

that aware of, lack of compressibility.

39:15

It's sort of similar to what

39:17

we look for with the appendix.

39:19

I was moderating a session at the RSNA some years

39:22

ago, and a European radiologist got up and said,

39:25

you know, nobody talks about this in America.

39:27

The, you know, compressibility of the gallbladder.

39:30

And it, it sort of makes

39:31

sense when you think about it.

39:33

So I threw that in there as

39:34

another sign of acute cholecystitis.

39:37

So here's a, a very recent case that's

39:39

just a few weeks old from my practice.

39:41

31-year-old, acute right upper quadrant pain.

39:44

And there's basically everything you

39:46

need here to make the diagnosis. Note

39:48

the image center right saying Murphy sign positive.

39:52

Again, very helpful.

39:53

There's gallstones with shadowing, there's

39:55

fluid, the gallbladder is distended, and

39:57

the image to our right shows increased flow.

40:00

We've got everything we need.

40:02

Um.

40:03

But I think the other teaching point

40:05

here is if you look at the wall, it's

40:07

beyond just thickened, six millimeter.

40:10

It's starting to look heterogeneous.

40:12

And that's concerning to me for necrosis.

40:15

And I alluded earlier to the fact that we need

40:18

to give as much information to our referring

40:21

clinicians and then subsequently, our potential

40:23

operating surgical colleagues as possible.

40:26

I don't think it's just good

40:27

enough to say yes, it's positive.

40:28

Next case, next patient.

40:31

The implication here is that this might need

40:33

open as opposed to laparoscopic cholecystectomy.

40:36

And there's some work using CT, as well as a nice

40:40

paper from France, from the journal Radiology some

40:43

years ago, showing that this had predictability

40:45

in terms of the need for open versus laparoscopic.

40:48

So keep that in mind.

40:49

Here's a 20-year-old, again, a very recent patient,

40:53

multiple gallstones with posterior shadowing.

40:55

The gallbladder's distended.

40:57

The wall isn't that impressive, but it's sort

40:59

of borderline, maybe a little bit heterogeneous.

41:02

But here's the really other important point.

41:04

The patient got pain meds in the ED

41:07

and so there was no clear Murphy sign.

41:09

So we've got everything else going for

41:11

acute cholecystitis, but there's no Murphy sign.

41:14

So when you call this in to the ED,

41:15

you say, okay, there's no Murphy sign,

41:17

but it looks like the cholecystitis.

41:19

Did they get pain meds?

41:20

Yes, they did.

41:21

And the pain meds could be, you know, Tylenol.

41:24

So be very, very careful about this.

41:26

Um, it is absolutely possible to be misled into

41:30

thinking it's something else or subacute or something.

41:33

And again, that has major implications for management.

41:36

I'm showing these next images out of sequence.

41:39

But notice again, there's sludge.

41:41

There's distension.

41:42

The wall is really quite heterogeneous,

41:44

and there's a Murphy sign again,

41:46

nicely demonstrated, um, written by our technologist.

41:49

But look how incredibly ugly this looks on CT.

41:52

In fact, there's an abscess.

41:53

The thing is broken down and it's necrotic.

41:56

It's frankly gangrenous.

41:57

You would say, is this patient a diabetic?

41:59

We don't have gas, but this looks terrible.

42:01

Did we need an ultrasound?

42:03

No, we clearly didn't.

42:04

But it makes a nice teaching case.

42:06

So again, be, you know, alert to the fact

42:10

that you're not just saying yes or no,

42:12

we're trying to give additional information.

42:14

CT is actually an excellent test, maybe the

42:16

first test, and it's very, very rare in my

42:19

experience that you have a totally negative.

42:23

You know, scan even in retrospect, and it ends

42:25

up being cholecystitis on imaging done, you know,

42:28

very shortly after, it almost never happens.

42:30

Um, in fact, in some literature it's

42:32

actually more sensitive than ultrasound.

42:35

Interestingly, that may be a bit counterintuitive,

42:37

but if you think about it, think about inflammation

42:40

in the fat, a bit more obvious on CT, no matter

42:42

where it is in the abdomen and pelvis, than on

42:44

sonography. The gallstones are the problem, right?

42:47

They can be really subtle.

42:48

You need to carefully window and level.

42:50

Again, if you have dual energy capability,

42:52

look, you know, use that. And the complications,

42:55

gas, gangrene, hemorrhage, perforation,

42:58

associated findings of pancreatitis,

43:01

biliary problems, et cetera, more obvious.

43:03

Uh, on CT in many instances.

43:05

Olga Brook at BI Deaconess Medical Center,

43:07

also nice paper from about 12 years ago or so.

43:11

It's a small series, but it's very instructive.

43:13

They looked at multiple modalities.

43:15

There were three overall, uh, three

43:17

over calls and 11 under calls.

43:19

Eight on ultrasound, six on CT.

43:23

On ultrasound, there were three

43:24

patients where there was edema.

43:27

But there weren't, wasn't distension in the, there

43:29

were final diagnosis as you see here, and this

43:31

was, um, you know, not actually cholecystitis.

43:34

Those were the over calls.

43:35

The under calls, presumably, if I recall

43:38

correctly, were patients where they

43:40

missed the edema, as I noted on CT.

43:45

Um, there was gallbladder edema that wasn't

43:47

seen, so they were evident in retrospect. It's

43:50

not that the findings weren't there, it's

43:52

just that nobody picked it up prospectively.

43:55

Um, there's a nice paper from two years ago

43:57

from Abdominal Radiology, fairly large series.

44:00

This was from a California group, and it turns out

44:03

again, sort of going along with that European who

44:06

said, Hey, we should be compressing the gallbladder.

44:09

Um, a width of less than 2.2 centimeter in sonography

44:12

was very sensitive for excluding acute cholecystitis,

44:15

regardless of all the other ultrasound findings.

44:19

I've windowed and leveled this, uh, to sort of bring

44:21

out the calculus so it's a little bit dark, but again,

44:24

we didn't really need, you know, both exams, but

44:26

clearly acute cholecystitis present on both modalities.

44:31

Here's an 89-year-old, and this and the next few

44:35

cases will make the point that you have, you

44:38

know, everything going for a cholecystitis but no

44:40

Murphy sign because the patient is on pain meds.

44:44

So be very, very careful.

44:47

Um, talk to somebody.

44:49

Don't just blow this off.

44:50

Ah, you know, and the gallbladder's

44:51

wall's not that impressive.

44:53

It's borderline.

44:54

Um, but the patient, you know, may have had a

44:57

Murphy sign in the ER and they gave them pain meds.

44:59

This had pus at cholecystostomy tube placement.

45:03

There's another patient.

45:04

Everything going for cholecystitis,

45:06

sludge, mild wall thickening.

45:09

Non-dependent, uh, um, um, uh, you know,

45:11

non-mobile dependent gallstone, et cetera.

45:14

You see the shadowing?

45:15

No Murphy sign. Why? They had pain meds on board.

45:18

They initially had a physical exam

45:20

Murphy sign in the ED.

45:23

Here's a patient again, we've already talked about

45:25

the complementary role of ultrasound and CT and then

45:28

in the ER or shortly after the ER setting, MRI in

45:32

the setting of gallstone pancreatitis, not acute

45:34

cholecystitis, but we have multiple gallstones leading

45:38

in this scenario to gallstone pancreatitis, nicely

45:42

demonstrated on the representative image on the right.

45:47

This is problematic.

45:48

This was an initial CT on the left.

45:51

It's collapsed, but it's emphysematous.

45:54

And there were small gallstones on the

45:57

sonography done shortly after. Wall thickening.

45:59

Again, no Murphy sign as the patient's

46:01

on pain meds. Positive at surgery.

46:05

Again, going back to the issue of chronic cholecystitis,

46:08

again, I, I've sort of thrown up my

46:11

hands and given up. The wall here was not thickened.

46:14

This patient had chronic cholecystitis on pathology,

46:17

comes in for the first time with abdominal pain.

46:20

There's no way.

46:21

Didn't know this is chronic.

46:22

The wall doesn't look bad.

46:24

We just see gallstones there.

46:26

There's no Murphy sign, but they're on pain meds.

46:28

The pathology said, you know.

46:31

Chronic cholecystitis.

46:32

Again, this is just very challenging.

46:35

I don't think it's that important because

46:38

if the gallbladder's got stones and the

46:40

patient has pain, it's gonna come out.

46:42

But it's a matter of when it's gonna come out.

46:44

You know, is it gonna come out at 3:00 AM

46:46

or it can just be done semi-electively.

46:48

That's the, I think the major

46:50

point for clinical management.

46:52

And then acalculous cholecystitis,

46:54

another really problematic disease.

46:56

We learn about this, you know, in our

46:58

hospitalized, you know, post cardiac patients,

47:00

can be similarly problematic, uh, because, you

47:04

know, we don't have the gallstones, we have

47:06

everything else, and these folks often end up

47:07

with a cholecystostomy tube because of high risk.

47:12

Um, here's another example of

47:14

sort of tumor effect sludge.

47:16

There's no flow.

47:17

Again, be careful about how you set your, you know,

47:20

parameters when looking at this type of a thing.

47:23

Is it a mass?

47:24

Is it not a mass?

47:25

You might need to do another imaging exam, you know,

47:28

CT or MR to make sure that it truly isn't a mass.

47:32

But this ended up being in the setting of

47:34

chronic cholecystitis on, um, pathology.

47:39

We'll finish up with two cases.

47:41

This is, and I guess no lecture nowadays in

47:44

the abdomen would be complete without some COVID case.

47:47

So this is a COVID case from early in our experience.

47:51

Um, and there's some subtle peripheral pneumonitis

47:54

here, but there's also some periportal edema.

47:58

And there was some gallbladder

48:00

thickening, and ends up being sludge.

48:03

And I was a bit surprised when this actually

48:06

ended up being a cholecystitis at surgery.

48:09

And this is the outlier.

48:11

So in the early COVID experience,

48:14

you know, a substantial

48:15

percentage of patients had GI tract

48:17

symptoms, generally non-specific LFTs,

48:20

very frequently abnormal ultrasound of the

48:22

right upper quadrant, frequently abnormal.

48:24

We were doing these abbreviated

48:26

protocols up to 50% or more.

48:29

Have something going on with

48:30

respect to the gallbladder.

48:32

Some combination of sludge, calculi, distension,

48:35

but only a very small percentage of patients.

48:37

And I've looked at the literature as recently

48:39

as a few weeks ago, uh, actually have, you know,

48:43

acute cholecystitis, mostly in case reports.

48:47

Um, other things to be aware in our early

48:49

experience there, you know, we, we had major

48:51

issues with unusual vessels clotting off, but,

48:55

you know, increased echogenicity of the liver,

48:57

heterogeneity of the liver, and periportal edema.

49:00

Our final case is this 71-year-old with gallstone

49:04

pancreatitis, but also kind of unusual.

49:10

It's almost fungating looking.

49:12

If you look at it carefully.

49:13

Soft tissue thickening along the gallbladder.

49:15

The gallbladder is sort of serpiginous

49:17

shaped, and this ended up being cancer.

49:19

It was not anticipated.

49:21

Prospectively was not called prospectively.

49:24

In retrospect, it's cancer.

49:26

And you can see on the corresponding

49:28

CT there is, uh, inflammation.

49:30

There's the gallstone pancreatitis,

49:32

but this ends up being cancer.

49:34

So unfortunately this is, you

49:35

know, the needle in the haystack.

49:37

It's pretty rare.

49:38

Benign gallbladder disorders are very common.

49:41

A focal polypoid mass, um, especially

49:43

if it's locally invasive, is most

49:45

specific, but has the worst prognosis.

49:48

But if you have focal diffuse thickening,

49:50

even without a discrete mass in an older patient,

49:53

especially a woman with gallstones, the concept of

49:55

chronic irritation, um, you know, consider malignancy.

49:59

It is tricky.

50:01

It may be something like with the chronic

50:04

cholecystitis, again, much more common, that you

50:07

may encounter as an oopsie on the pathology report.

50:11

And remember, there's associations with this.

50:14

Um, so, you know, be careful.

50:17

Just look carefully.

50:18

Again, it may be something microscopic that

50:21

may not be something that realistically

50:23

you could even make the diagnosis of.

50:26

Uh, going forward, I want to thank Dr.

50:28

Marguerite at Revson, my colleague and

50:30

friend at Yale who initially asked me to

50:31

put this talk together about two years ago.

50:34

So, in conclusion, ultrasound of the gallbladder,

50:37

usually this is fairly straightforward, both in the

50:39

outpatient and in the ED, um, emergency setting, but.

50:44

A non-trivial minority of patients.

50:46

This is problematic even for those

50:48

of us who are pretty experienced, for

50:50

the sonographers and radiologists.

50:53

Um, comparing with prior imaging if you have them.

50:56

Close correlation with a history and physical exam,

50:59

and complementary short-term follow-up imaging, if any,

51:03

can all help to improve accuracy in patient care.

51:05

And again, I realize in the acute setting it may

51:08

not be easy to talk to people, but really, for

51:10

the problematic ones, we really should do that.

51:12

I'm gonna skip these questions

51:14

in the interest of time.

51:15

Here's some representative

51:17

images you can, uh, reference.

51:18

You can look at these at your leisure.

51:21

And again, I really appreciate the

51:22

opportunity to, uh, present to you

51:25

today for those who are, uh, on the, uh.

51:30

The webinar, uh, live and those who are

51:32

going to be looking at this down the road.

51:35

Um, so with that, I'm, I, I, I

51:38

was able to open the Q and A box.

51:40

We have about, uh, eight, nine minutes.

51:43

So, uh, I am going to attempt to answer the questions.

51:47

I. So the first, and I'll do these in order, and

51:51

there's some great, excellent questions to look like.

51:53

So it says, first one, it says, do you request

51:55

contrast studies for gallbladder polyps?

51:57

Well, um, I am certainly not the expert

52:01

in, in contrast for the gallbladder.

52:04

Um, you know, we generally don't use

52:06

contrast media in, in our practice.

52:09

Um, so I don't really have expertise in that area,

52:12

but I, I, I generally, I would say the answer is no.

52:15

Uh, I'd have to look at the literature on this.

52:17

Most of these are small.

52:19

Um, you know, certainly if it's a true neoplastic

52:21

quote unquote process, it's gonna have flow to it.

52:24

So it's certainly a great thought, but I

52:26

don't see how it's going to, you know, gonna

52:28

change, you know, change management, honestly.

52:32

Um, next question.

52:33

Is there a grading for adenomyomatosis?

52:37

Not to my knowledge.

52:39

Um, you know, I, I would say, um.

52:43

Certainly I, I would talk about the extent of it.

52:46

Again, it's quite variable.

52:48

Um, I don't think it really makes

52:50

a big difference to my knowledge.

52:52

You know, it's generally an asymptomatic process.

52:56

Um, you know, if the patient has, you

52:59

know, chronic pain and it's ascribed to the

53:01

gallbladder, is it possible that they have some

53:05

sort of dyskinesia that's ascribable to it?

53:08

Maybe.

53:09

But in my take on the review of the

53:11

literature, it's generally asymptomatic.

53:14

So, you know, do you say mild, moderate, severe?

53:17

Not really.

53:18

I, I usually just describe the extent of it.

53:22

Um, it says, please show the image

53:24

of hemorrhagic cholecystitis again.

53:27

Well, I think you can access

53:28

the webinar at your leisure.

53:30

So rather than go through, you know, 40

53:32

slides, I'll have you do that again, but it,

53:35

it basically was the non-contrast image, and it,

53:37

and it really wasn't hemorrhagic cholecystitis.

53:40

It was blood extending into the lumen

53:43

of the gallbladder in the setting of

53:45

a very complex internally hemorrhagic,

53:48

diffuse hepatocellular carcinoma.

53:51

Right?

53:51

That was the explanation, ascribed to the

53:54

hemorrhage in the lumen of the gallbladder.

53:57

The patient had, you know, very complex vascular

53:59

involvement, and that's presumably why it happened.

54:02

Okay, next question from, uh, uh, Ken Siegel.

54:06

Um, it says, do you count as, uh, what do you

54:10

count as an actual sonographic Murphy sign?

54:14

How do you differentiate from right

54:15

upper, upper quadrant pain, which

54:16

is usual indication for the study?

54:18

So again, unfortunately I'm generally not the one at

54:22

the bedside, so we are highly reliant on our, again,

54:26

generally excellent ultrasound technologists for.

54:30

Making the call as to whether they believe

54:33

there is a sonographic Murphy sign.

54:35

And if you recall going back to, you know, Bates,

54:38

remember Bates’ Guide to Physical Examination.

54:41

That's where I learned about

54:42

the physical exam Murphy sign.

54:44

The Murphy sign on physical exam is that

54:46

you palpate the right upper quadrant, have the

54:48

patient take a breath in, and if they sort of

54:51

abruptly stop that inspiratory effort, it's like

54:54

a, you know, that is ascribed to pain when the

54:58

gallbladder touches the examiner's finger, right?

55:02

That is not the same as a sonographic Murphy sign.

55:05

The sonographic Murphy sign is it's

55:07

point of maximal tenderness, right?

55:08

And we might do the same thing with the right

55:10

lower quadrant or other parts of the body

55:13

when we're, uh, you know, trying to figure out

55:14

what is the thing that is causing discomfort.

55:17

The problem of course is that pain radiates, right?

55:19

So, you know, uh, one of the classic

55:24

differential presentations, uh.

55:27

Or differential considerations in, in acute,

55:30

uh, in aortic dissection is cholecystitis.

55:33

So, you know, we say regardless of your exact

55:37

protocol for CT angiography in suspected aortic

55:41

dissection, and the vast majority of 'em are

55:42

negative, you have to at least go to the mid-abdomen

55:45

because you can have an acute gallbladder.

55:47

And that's been shown over and over again.

55:48

So, uh, pain can absolutely radiate

55:51

as well, so they're not the same.

55:53

Um, and again, it's, it's really reliant on

55:56

the sonographer, you know, being careful and

55:58

saying, yes, the pain corresponds to the probe

56:02

location, corresponding to the gallbladder.

56:05

Okay.

56:05

Next, next question says, do you consider

56:07

saying an echogenic intraluminal focus with

56:10

no shadowing as encrusted gallbladder stone?

56:13

Well, so that can do some tricky things.

56:16

One of the.

56:17

Uh, one of the, the, the pitfalls I haven't

56:19

discussed, which is another sort of basic

56:21

thing that's been described for years, which is

56:23

small calculi don't necessarily shadow, right?

56:27

So it depends on, on physics, it depends

56:29

on, you know, the probe and the frequency

56:31

that you're using and that kind of thing.

56:33

So it can be problematic sometimes

56:36

when you have small calculi.

56:37

To determine if they're actually calculi or

56:40

if they're areas of sludge or if they're polyps.

56:42

So even that can be problematic.

56:44

Um, again, a very basic thing.

56:47

Do you consider gallbladder polyp,

56:49

morphology, stalk, and management algorithm?

56:51

Well, again, these are not colonic polyps,

56:54

so generally we don't, um, they're typically

56:57

not, you know, they usually don't have stalks.

57:01

It's really, and I see

57:02

gallbladder polyps all the time.

57:03

It drives, they drive me, you know, got,

57:05

like, I, I let out a ugh, you know, ugh, you

57:08

know, when I see one of them, they're, they're

57:10

usually not, they usually don't have stalks.

57:12

So it’s very unusual to see those.

57:15

So typically it's, it's, it's max dimension

57:17

in whatever plane you see them in.

57:19

Usually they're round or ovoid.

57:22

And great questions.

57:23

Thank you.

57:23

So how to report gallbladder edema in

57:25

congestive heart disease or ascites?

57:27

Well, so it, it really is, you know,

57:30

looking at everything and that everything,

57:32

if it's just the ultrasound may not, may

57:35

not be clear that you're dealing with

57:37

something above and beyond the gallbladder.

57:39

It's, it's, it's getting the history, it's

57:41

looking at the chest radiograph if you have it.

57:43

It's looking at recent MR, CTs, et cetera.

57:46

You know, I, the cases that I showed, I have

57:48

the, we had the luxury of correlative imaging.

57:51

Often, you know, Katz’s rule of imaging: there

57:54

there's no prior imaging when you need it, right?

57:56

That, that always is the case when you have,

57:58

or often is the case when you have something

58:00

that's problematic and you go, God, I

58:02

really wish I had a X and you don't have it.

58:04

So it, it, it may just, you know, require,

58:07

um, you know, picking up the phone.

58:09

Uh, I had a, bless his heart, Ed Lane, no longer with us.

58:13

One of the radiologists I trained with

58:14

in, in Syracuse at the VA, he used to say,

58:17

kind of a gruff guy, but he had a party.

58:19

Golden.

58:19

He’d say the hardest thing for a radiologist

58:21

to do is to get outta his or her chair.

58:24

You know, well, analogous to that, one

58:26

of the hardest things to do is actually

58:27

pick up the phone and talk to somebody.

58:28

And I know we're like incredibly busy, and sometimes

58:31

it could be, you know, a little bit later in the

58:33

day when we have a, a, a chance to catch our breath.

58:36

That'd be that minute.

58:37

Uh, but getting some information's important.

58:39

How do you define distension?

58:41

Well, I'm not aware.

58:42

So that paper over the 2.2 centimeter actually is

58:45

one of the few papers that actually quantified distension.

58:48

Um, it's sort of a gestalt thing, right?

58:50

I, I would say in an adult, when I see a

58:53

gallbladder in long axis that's pushing like

58:55

seven, six and a half, seven or more centimeters,

58:59

that's when I start talking about distension.

59:02

But it, it, it's sort of like a gestalt, you know,

59:03

you look and you go, that gallbladder's distended.

59:06

Um, next question.

59:08

Do you let the patient, uh, sorry.

59:10

Okay.

59:11

Uh.

59:11

Let me go up here.

59:12

It says, do you let the patient prepare a

59:15

three-day fat-free diet and state in the report

59:17

file in a contracted gallbladder cases?

59:20

Well, again, we're talking about,

59:21

you know, the emergency setting.

59:23

So I mean, we generally have nothing

59:25

to do with preparation of patients.

59:28

So, um, you know, this is in the emergency

59:31

setting and we have like no control over anything.

59:34

So, uh, would I do any, I, I don't make

59:37

any recommendations for follow-up in

59:39

that particular scenario specifically.

59:42

Um, when should we advise the clinician

59:44

to go for biopsy directly without

59:45

asking for cross-section imaging?

59:48

Um, not exactly sure what that

59:50

refers to, so I'm gonna skip that.

59:53

Okay.

59:53

Next question.

59:53

It says how to diagnose

59:57

tumor-factor gallbladder tumor?

59:58

Very, very difficult.

60:00

So, you know, common things are common, right?

60:02

So, uh, gallbladder cancer, thankfully

60:05

is, is really quite unusual.

60:08

Um, you know, it has a very typical presentation.

60:10

When it's more advanced, it, it, it's,

60:12

you know, elderly women, older women.

60:14

It, it, it's locally invasive, it's

60:16

associated with gallstones.

60:18

Um, you know, when you see a, a mass centered

60:21

on the gallbladder that seems to be invading.

60:23

You know, differential is, you know, hilar,

60:25

you know, cholangiocarcinoma, gallbladder cancer.

60:28

Um, again, it's a spectrum.

60:30

It runs from, you just can't see it.

60:31

It's a microscopic diagnosis to, um,

60:34

there's, you know, focal regional wall

60:36

thickening that, you know, is nonspecific.

60:39

So, um, you, you try your best to put

60:42

on flow, you know, color and power

60:43

Doppler. It can be very difficult.

60:45

And similar to scenarios like I've seen in

60:48

your quality assurance in legal cases where

60:50

the bladder, not the gallbladder, but the

60:52

bladder in the pelvis is diffusely thick,

60:55

and then you, you know, you just can't tell.

60:56

I mean, one of my other, I'm, I get a chance to say one

60:59

of my favorite lines here, one of my favorite lines is I

61:01

don't have a needle and a microscope, but I wish I did.

61:03

You know, I was gonna be one of

61:05

the things I was gonna do before I

61:06

picked radiology was pathology, right?

61:08

So I wish I had a needle and a microscope, but I don't.

61:11

So, you know, I can't tell looking at a CT what's

61:15

diffuse cystitis from what's a diffuse neoplasm.

61:18

And we've seen examples where.

61:20

There was one or the other or both.

61:22

And you know, there you just can't tell.

61:24

And so if the, the gallbladder's diffusely thickened.

61:27

I don't think you can tell, you know, chronic, you

61:30

know, subacute cholecystitis from neoplasm, you know,

61:33

when there's a focal mass and when there's bulky

61:34

nodes, it's obvious, it's easy when it's diffuse.

61:37

Very difficult when there's focal areas and you really

61:40

try to put flow on and it, it, it, you don't see it.

61:44

We've seen cases where there actually is flow, uh,

61:47

you know, there's, there's microscopic vascularity

61:50

and ultrasound just wasn't able to show it, so.

61:52

Okay.

61:53

Next question.

61:53

The cholesterolosis.

61:54

Well, so, you know, going back, so I get to

61:57

also cite some other medical school books.

61:59

So remember Robbins and Cotran.

62:01

Again, I'm really dating myself here,

62:03

so, um, and that's been, you know,

62:05

gone through many iterations over time.

62:07

So there are a variety of other, the

62:09

so-called strawberry gallbladder and stuff.

62:11

It's a spectrum.

62:13

Again, it's mostly a, you know, histopathologic

62:15

diagnosis, so that's in the differential.

62:18

It, it was on that slide.

62:19

I didn't have a chance to go into all the

62:20

nuances in a 50-minute lecture, but there are

62:23

a variety of other cholesteroloses above,

62:25

beyond the, you know, adenomyomatosis, where

62:27

you would see diffuse thickening, but you

62:29

wouldn't see the, you know, cholesterol clefts.

62:31

You wouldn't have the classic findings on

62:33

sonography, you would just have non-specific thickening.

62:36

So a bit less common in my experience, certainly.

62:38

But in the differential diagnosis, should

62:41

every chronic cholecystitis be taken out?

62:43

Well, if you're, if you're a general

62:46

surgeon, um, and, and the patient is

62:48

in high risk, the answer would be yes.

62:50

Um.

62:51

Uh, and not to implicate our surgeons, but

62:54

unfortunately I did M and M at 7:00 AM on Monday,

62:57

and they did that in a patient who they thought, you

62:59

know, had a lot of risk factors, but they thought

63:01

was, was, you know, cleared for surgery and optimized

63:04

and had a cholecystostomy tube for like a year.

63:07

And they, it unfortunately led to a death.

63:09

I mean, it, it, it just, so you know, N equals one

63:12

doesn't prove anything, but, um, you know, I, I think

63:16

it, it really depends if they're surgical candidates.

63:19

Um, if it was me and I was having, you

63:21

know, repetitive pain and I'm a surgical

63:24

candidate, would I want to have it out?

63:25

Yes.

63:26

Um, but you know, again, it's, it's

63:29

a patient-by-patient consideration.

63:31

But you know, again, these are most of the time

63:34

in my experience, chronic cholecystitis, the

63:37

diagnosis is not established based on imaging.

63:40

It's established at histopathology.

63:42

Next question.

63:43

Do you see, oh, this is coming from

63:45

somewhere internationally, which is great.

63:47

Uh, do you see gallbladder wall

63:49

thickening in the setting of Dengue fever?

63:51

Well, thankfully, I, I don't see a lot of

63:52

Dengue fever in, in Mineola, Long Island.

63:55

Um, believe it or not, we do actually

63:57

see occasional tropical diseases.

63:59

Um, we have, we've seen, I had, I had

64:01

malaria here, you know, 30, 40 years ago as

64:03

a medical student, not me, but we saw it.

64:06

Um, we do see TB, we've seen

64:07

a whole bunch of TB cases.

64:09

We see some unusual things, but I, I've

64:11

never personally seen Dengue fever.

64:13

I'm not, not an expert on, on tropical diseases

64:15

specifically. That I'll have to look up.

64:17

I'll make a note of that.

64:18

Um, you know, there are, you know,

64:20

certainly, uh, a host of things.

64:22

You can see, you know, there, there were descriptions

64:25

in, in, in COVID, interestingly, unfortunately, of

64:28

hydrops of the gallbladder in, in kids with these,

64:31

you know, severe, you know, sort of SARS-type

64:33

response, uh, or MERS, whatever they were calling it.

64:37

Severe inflammatory response

64:38

with, with kids, with COVID.

64:40

Unfortunately, you know, there's a host of, of,

64:42

of things that can happen with a gallbladder

64:44

and a variety of, of unusual disorders, and, and,

64:47

and, and, um, you know, COVID is one of them.

64:50

I, I'm not aware that it happens in

64:52

Dengue fever. I'd have to look that up.

64:54

Um, should we term calcifying

64:56

sludge ball as a soft calculus?

64:58

I, I would avoid that term.

64:59

I, well, what's a, what's a calcifying sludge ball?

65:02

I mean, it's a calculus, so I would

65:04

just call it a calculus. Again, how to

65:06

differentiate adenomyomatosis from cancer.

65:08

Uh, there is no association to my knowledge.

65:11

Again, adenomyomatosis is common.

65:12

Cancer is rare.

65:14

I've never seen them occur in, in conjunction with

65:16

each other, and one does not lead to the other.

65:19

Um, and, and so, you know, typically you'll

65:22

see the, the, the usual findings at sonography.

65:24

They're, they're highly specific.

65:26

So I, I really don't think there should be a problem.

65:29

But there are reports, again, in the literature

65:31

of the occasional, you know, equivocal or

65:33

problematic case where you go to CT, MR and

65:36

what is noted is that there should not be

65:39

enhancement on CT or MR with the former, and

65:42

there will be enhancement with the latter.

65:43

So that's an excellent question.

65:45

Again, I didn't have time to get into all of the

65:47

nuances, and I think this is the final question.

65:50

I managed to get to every one of these, which is great.

65:52

How many comet-tail artifacts needed is adenomyomatosis

65:54

and there's just subtle wall thickening?

65:55

Well, again, it, it, there's a spectrum of this.

65:59

I would, again, you should be able to access the

66:01

paper that I cited from, um, the European literature.

66:05

That's, uh, a colleague of mine

66:06

who edits the journal out of Italy.

66:08

It's an excellent review article.

66:10

I would, I would ask you to look at that.

66:12

Um, I haven't memorized the article, it's been about

66:14

two years since I looked at it, but I believe there's

66:17

a fairly comprehensive review of that, and there's

66:20

some other review articles and, you know, there's

66:22

a review in any of the major ultrasound textbooks.

66:24

You can look at this in terms of the spectrum of it.

66:27

Um, so again, if there's problematic, you know,

66:31

diagnosis, you can repeat the ultrasound maybe in,

66:35

you know, three to six months, you can do MR, MRCP.

66:38

I think the biggest problem is

66:39

when there's focal thickening.

66:41

I didn't mention this, but when there's focal

66:43

thickening of the fundus, um, I should, should say

66:46

my, my, my mother-in-law who's, uh, uh, Dominican,

66:50

uh, you know, taught me about, you know, la Fonda.

66:52

So fundus comes from the Latin, meaning a bag, and

66:56

fundus is, is, you know, the typical classic location.

67:00

And a bit easier, again, much easier on sonography.

67:02

But when you see a focal mass on CT

67:04

or MR in the gallbladder, the concern is

67:07

that, am I missing a, you know, a tumor?

67:08

Is it, so the differential, is it just a waist?

67:11

Is it adenomyomatosis?

67:13

Not a waist, like a waste of time, but a

67:15

waist, like a waist around a, you know, a belt.

67:17

Um, is it a mass, mass, or is it, you know, adenomyomatosis?

67:21

And almost always it's, it's not a malignancy,

67:24

but that's the scenario where you're gonna

67:26

potentially do additional imaging or follow-up.

67:29

So I think we got through everything.

67:31

And, um, I finished about seven minutes over the hour,

67:34

but hopefully this answered all of those questions.

67:36

And with that, I'm gonna turn

67:37

things over to, uh, to staff.

67:39

And again, I really greatly

67:41

appreciate the opportunity.

67:42

We had great participation.

67:43

I think we had over 180 participants

67:46

live at the, the peak of this.

67:48

And again, it's an honor to be able to do this.

67:50

Thank you very, very much.

67:51

Dr. Kaz, thank you so much for that really

67:54

great lecture and case review and for answering

67:56

everyone's questions and for everyone else

67:58

participating in this NOON conference.

68:00

Thank you so much.

68:01

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68:08

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68:10

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68:12

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68:14

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68:17

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68:19

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68:25

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