0:00

This one and this one is another beauty of

0:04

a case, if I should say, if I may say so.

0:06

I really like this case.

0:08

So, this is, um, I'm not sure if those age I

0:12

think is sort of irrelevant here, but, uh,

0:14

I think the de-identified age is 30, female,

0:17

30 year old female, so we'll stick with that.

0:19

30 year old female with abdominal pain, and so

0:22

we're just going to go through this case and,

0:24

um, try to see what we think is going on here.

0:27

So, I'll start off with the T2-weighted sequences.

0:30

Non-fat saturated, fat saturated,

0:36

and just sort of scroll through this, and this

0:40

is just images of the abdomen, so I'm going to

0:44

scroll through this once or twice and so you get

0:46

a sense of, you know, where are your eyes going

0:48

to localize what we think of the abnormality is.

0:53

This is a T2 fat-saturated image. Again, we're not

0:55

really looking a lot for anatomy here but we're

0:57

looking for sort of T2 signals of any abnormality.

1:00

And so, is there any place over here where we're

1:04

seeing brighter T2 signal than it should be?

1:07

If so, let's have our eyes focus on that

1:09

and see if we can figure out what it is.

1:13

Let's do a T1 pre-image.

1:20

T1 pre-fat saturated image, perhaps our eyes,

1:26

we're going to go to the same spot where we

1:28

thought there was some abnormality on the T2s.

1:34

And then I am going to sort of do this

1:39

layout here, and we'll scroll through these

1:41

images at one time, dynamic phase images.

1:55

Let's link the scrolling again, and these may be

1:59

a little bit small. But if you think you know

2:02

where the finding is, perhaps we can just focus

2:11

over there.

2:11

Maybe I'll see if I can zoom.

2:14

Actually, this works pretty well here.

2:15

So let me just zoom them up and

2:16

scroll through these up and down.

2:17

We have arterial, portal venous,

2:19

equilibrium phase images, abdominal pain,

2:30

and there's a bunch of other sequences here.

2:32

Let me just finish off with the T1 in and out of

2:34

phase, I guess, for completion's sake, and then

2:37

we'll move on to our question for this case.

2:43

So this is the out of phase, in phase,

2:53

and that's all I have for you.

2:57

So let me bring up the question for this one.

3:00

So this one, I'm not going to present to you,

3:03

you know, what the most likely diagnosis is.

3:05

Rather, you may have come up

3:07

with a diagnosis in your head.

3:08

Maybe not.

3:10

Regardless, I want to get a sense of what you

3:11

want to do next, now that you, the patient has

3:13

abdominal pain, presumably you've seen something,

3:17

and if so, do you want to biopsy what you've seen?

3:20

Do you want to go ahead

3:21

and resect what you've seen?

3:23

Do you want to get another imaging study,

3:24

or do you want to do nothing? Right?

3:26

You know, a lot of times when I approach

3:27

a case and I don't know what's going on,

3:29

that's sort of how I think, you know.

3:31

Is this something that I can ignore?

3:33

Is it something I need to

3:34

get another imaging study on?

3:35

Is it something I need to send to surgery?

3:37

Or is it something I need to send for biopsy?

3:39

And, um, that's what I'm presenting to you.

3:42

So I'm curious to know what you'd want to do.

3:48

All right, PET/CT.

3:49

Um, looks like nobody wants to biopsy it.

3:52

Maybe a few people want to resect what they see.

3:54

Um, a few people don't want to do anything.

3:57

Um, and people, other people want

3:58

to get another imaging study just to help

4:00

them figure out what's going on.

4:01

And I think that's always, uh,

4:03

not an unreasonable option, right?

4:05

Um, and so let's then pull up the next question,

4:08

which will be, "What's the most likely diagnosis?"

4:12

So presumably, the audience has come up with

4:15

a decision point of what they want to do

4:17

based on what they think the diagnosis is.

4:20

Or maybe they don't know what the diagnosis is.

4:22

But, now, presenting to you is one of these

4:27

answers and, uh, of these ones, which one

4:32

do you think is the best diagnosis for this?

4:34

Jejunal diverticulitis.

4:36

Okay.

4:37

Jejunal diverticulitis.

4:39

Nobody picked pancreatitis.

4:40

Okay.

4:41

No. And one small bowel cancer, celiac disease.

4:43

Okay.

4:43

So this is, um, a favorite case of mine.

4:46

I guess they're all my favorite cases.

4:49

But, um, this person comes with abdominal

4:51

pain, had a CT scan that prompted an MRI,

4:53

so I wanted to show you the MRI, and I think

4:54

everyone sort of picked up on the diagnosis,

4:56

or at least on the finding, right?

4:58

The finding is sort of on the left side

4:59

of the abdomen, left upper quadrant.

5:01

Um, clearly I, I think on the T2 fat sat

5:03

images, you can see that there's a lot of

5:05

inflammation associated what ever this finding.

5:07

It's just lots of fluid.

5:08

It's relatively focal.

5:09

And so you're not surprised that this

5:11

patient has abdominal pain, uh, because

5:13

there is an inflammatory process that's

5:14

going on in this person's abdomen.

5:17

I'm going to show you this sequence.

5:18

You know, a lot of times you, I like to

5:20

talk about T2-weighted sequences being

5:22

so valuable and they certainly are, but I

5:24

have to say, you know, in this instance,

5:25

I think the T1 becomes very important.

5:27

So, let's look at the T1-weighted sequence

5:29

and evaluate the finding that we're seeing.

5:33

What do you notice about it on the T1 weighted

5:34

sequences in terms of its actual signal?

5:37

Right? For a lesion like this,

5:40

or whatever's going on here, it actually

5:41

is quite bright, uh, within it.

5:44

And so, yes, you may think, okay, bright

5:46

things on T1 fat-saturated sequences include

5:49

the usual things, like, could be hemorrhage,

5:50

I suppose, um, could be, uh, melanoma, maybe

5:55

this is a melanoma met or something like that.

5:57

But one of the other organs that's particularly

5:59

bright on, um, yeah, I think, uh, one of the,

6:03

uh, audiences, uh, picked up on this, that it's

6:06

bright on the T1 fat-saturated images is pancreas.

6:09

When it's a healthy pancreas,

6:10

look how bright it is.

6:12

It's the brightest organ that you're

6:13

going to see when it's nice and healthy.

6:15

And so now that you start to look at this,

6:17

you can say, okay, this is relatively bright.

6:20

And so, okay, I'm going to put

6:22

that in the back of my head.

6:24

Let's look at the post-contrast sequence.

6:25

Um, let's window this a little bit.

6:27

6:29

And you can see that, uh, you know, obviously

6:30

the pancreas enhances really nicely,

6:33

but now that I've sort of implanted the seed

6:35

in your head that, could this be pancreas?

6:37

Gee whiz, this looks a lot like

6:39

pancreatic tissue, doesn't it?

6:41

It is lobular, it has those clefts

6:43

that you see in the pancreatic tissue,

6:45

and it's hugging the small bowel.

6:48

And so, this indeed turned out to be

6:50

a case of ectopic pancreatic rest

6:54

with pancreatitis.

6:55

And so this was, uh, one of those cases

6:58

where, you know, um, I think a colleague of mine

7:00

showed this to me a couple of years ago.

7:01

And, you know, there's cases that

7:03

you come across that sort of change

7:05

the way you look at, uh, at scans.

7:07

And this was one of them because, um, and I'm

7:10

so eager now to always find ectopic pancreatic

7:12

tissue that I closely look at the stomach,

7:14

the duodenum, um, and even the proximal bowel,

7:17

just a little bit, sort of up to this location,

7:19

to always look for, um, to always look for, uh,

7:25

the presence of, uh, ectopic pancreatic tissue.

7:29

And so, uh, By 90 percent of the time,

7:31

it's going to be in the upper GI tract,

7:33

stomach, duodenum, and proximal small bowel.

7:34

Most common location is the gastric antrum, 177 00:07:36,554 --> 00:07:39,824 uh, typically, uh,

7:39

and it's often submucosal in location.

7:41

Classic appearance in upper GI, which I must

7:44

admit I haven't seen, but I've read about, is,

7:47

uh, sort of a round to oval submucosal mass with

7:50

a central embolication and, uh, you know, the key is,

7:54

you know, does it look like pancreatic tissue?

7:56

I've seen since this case at least two

7:59

other cases that we've been able to call

8:00

prospectively just based on the fact that,

8:03

you know, we know what we're looking for

8:05

with that sort of globular pancreatic tissue.

8:08

Um, and it becomes quite apparent

8:09

on the T1-weighted sequences where

8:11

the pancreas is the brightest organ.

8:12

And so as, uh, it's ectopic pancreatic

8:14

tissue can undergo anything the pancreas can

8:16

undergo, which means it can become inflamed,

8:19

can have adenocarcinomas

8:20

or other tumors develop within them.

8:21

I haven't seen cases like that myself.

8:24

This was a fabulous case of pancreatitis,

8:26

um, arising from an ectopic pancreatic,

8:28

uh, rest in the small bowel.