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Challenging Body Case 6

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0:00

This one and this one is another beauty of

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

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I really like this case.

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

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think is sort of irrelevant here, but, uh,

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

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

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30 year old female with abdominal pain, and so

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

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

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

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Non-fat saturated, fat saturated,

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and just sort of scroll through this, and this

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

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scroll through this once or twice and so you get

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

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to localize what we think of the abnormality is.

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

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really looking a lot for anatomy here but we're

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looking for sort of T2 signals of any abnormality.

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

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seeing brighter T2 signal than it should be?

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

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and see if we can figure out what it is.

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Let's do a T1 pre-image.

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T1 pre-fat saturated image, perhaps our eyes,

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

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thought there was some abnormality on the T2s.

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And then I am going to sort of do this

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layout here, and we'll scroll through these

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images at one time, dynamic phase images.

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

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a little bit small. But if you think you know

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where the finding is, perhaps we can just focus

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over there.

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Maybe I'll see if I can zoom.

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Actually, this works pretty well here.

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So let me just zoom them up and

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scroll through these up and down.

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We have arterial, portal venous,

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equilibrium phase images, abdominal pain,

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and there's a bunch of other sequences here.

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

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

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

2:43

So this is the out of phase, in phase,

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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,

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you know, what the most likely diagnosis is.

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Rather, you may have come up

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with a diagnosis in your head.

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Maybe not.

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Regardless, I want to get a sense of what you

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

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abdominal pain, presumably you've seen something,

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

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Do you want to go ahead

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and resect what you've seen?

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Do you want to get another imaging study,

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or do you want to do nothing? Right?

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You know, a lot of times when I approach

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

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

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Is this something that I can ignore?

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Is it something I need to

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get another imaging study on?

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Is it something I need to send to surgery?

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Or is it something I need to send for biopsy?

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

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

3:48

All right, PET/CT.

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Um, looks like nobody wants to biopsy it.

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Maybe a few people want to resect what they see.

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

3:57

Um, and people, other people want

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to get another imaging study just to help

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them figure out what's going on.

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And I think that's always, uh,

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not an unreasonable option, right?

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

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

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So presumably, the audience has come up with

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a decision point of what they want to do

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based on what they think the diagnosis is.

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

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But, now, presenting to you is one of these

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answers and, uh, of these ones, which one

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do you think is the best diagnosis for this?

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Jejunal diverticulitis.

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Okay.

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Jejunal diverticulitis.

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Nobody picked pancreatitis.

4:40

Okay.

4:41

No. And one small bowel cancer, celiac disease.

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Okay.

4:43

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

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I guess they're all my favorite cases.

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But, um, this person comes with abdominal

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pain, had a CT scan that prompted an MRI,

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

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everyone sort of picked up on the diagnosis,

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or at least on the finding, right?

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The finding is sort of on the left side

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of the abdomen, left upper quadrant.

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

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

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inflammation associated what ever this finding.

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It's just lots of fluid.

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It's relatively focal.

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And so you're not surprised that this

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patient has abdominal pain, uh, because

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there is an inflammatory process that's

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going on in this person's abdomen.

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I'm going to show you this sequence.

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

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talk about T2-weighted sequences being

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so valuable and they certainly are, but I

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have to say, you know, in this instance,

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I think the T1 becomes very important.

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

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and evaluate the finding that we're seeing.

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What do you notice about it on the T1 weighted

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sequences in terms of its actual signal?

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Right? For a lesion like this,

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or whatever's going on here, it actually

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is quite bright, uh, within it.

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

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things on T1 fat-saturated sequences include

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the usual things, like, could be hemorrhage,

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

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this is a melanoma met or something like that.

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But one of the other organs that's particularly

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

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

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bright on the T1 fat-saturated images is pancreas.

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When it's a healthy pancreas,

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look how bright it is.

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It's the brightest organ that you're

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going to see when it's nice and healthy.

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And so now that you start to look at this,

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you can say, okay, this is relatively bright.

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And so, okay, I'm going to put

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that in the back of my head.

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Let's look at the post-contrast sequence.

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Um, let's window this a little bit.

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6:29

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

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the pancreas enhances really nicely,

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but now that I've sort of implanted the seed

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in your head that, could this be pancreas?

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Gee whiz, this looks a lot like

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pancreatic tissue, doesn't it?

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It is lobular, it has those clefts

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that you see in the pancreatic tissue,

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and it's hugging the small bowel.

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And so, this indeed turned out to be

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a case of ectopic pancreatic rest

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with pancreatitis.

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And so this was, uh, one of those cases

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

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showed this to me a couple of years ago.

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And, you know, there's cases that

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you come across that sort of change

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the way you look at, uh, at scans.

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

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so eager now to always find ectopic pancreatic

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tissue that I closely look at the stomach,

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the duodenum, um, and even the proximal bowel,

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

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

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the presence of, uh, ectopic pancreatic tissue.

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

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

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stomach, duodenum, and proximal small bowel.

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

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and it's often submucosal in location.

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Classic appearance in upper GI, which I must

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

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uh, sort of a round to oval submucosal mass with

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

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you know, does it look like pancreatic tissue?

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I've seen since this case at least two

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other cases that we've been able to call

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prospectively just based on the fact that,

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you know, we know what we're looking for

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with that sort of globular pancreatic tissue.

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Um, and it becomes quite apparent

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on the T1-weighted sequences where

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the pancreas is the brightest organ.

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And so as, uh, it's ectopic pancreatic

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tissue can undergo anything the pancreas can

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undergo, which means it can become inflamed,

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can have adenocarcinomas

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or other tumors develop within them.

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I haven't seen cases like that myself.

8:24

This was a fabulous case of pancreatitis,

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um, arising from an ectopic pancreatic,

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uh, rest in the small bowel.

Report

Description

Faculty

Mahan Mathur, MD

Associate Professor, Division of Body Imaging; Vice Chair of Education, Dept of Radiology and Biomedical Imaging

Yale School of Medicine

Tags

Pancreas

Non-infectious Inflammatory

MRI

Gastrointestinal (GI)

Body

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