0:00

This patient is a 60-year-old female who presents

0:03

with right upper quadrant pain, and for that

0:05

the referring providers asked for an MRI of

0:07

the abdomen with or without contrast, with MRCP.

0:10

So let's go ahead and have a look

0:11

and see what the findings are here.

0:13

Start off with a T2 nonfat saturated image

0:16

in the axial plane and get a lay of the land.

0:18

We're going to focus on the gallbladder over here.

0:21

Just zoom up on it for a second and we can see again

0:24

this gallbladder looks more distended than we would

0:26

expect. If you were to measure in that transverse plane,

0:30

we're getting it just about four centimeters,

0:32

but more than just the absolute measurement,

0:33

it just looks rounder than you would expect.

0:35

As you go downwards, it looks a lot longer

0:38

than, uh, the seven centimeters

0:40

that we usually use for gallbladder length.

0:42

Within it, there are multiple small gallstones

0:44

that are lying dependently over here.

0:47

And, uh, surrounding it, you can see that

0:49

there is all sorts of fluid and wall edema.

0:53

Um, these would be better appreciated

0:54

under a fat saturated image.

0:57

That imaging sequence in this

0:59

instance did not come out too well.

1:00

So we used sort of these epiplanar images which give

1:04

similar information to our fat saturated sequence.

1:07

So I just wanted to show you that and window it a

1:10

little bit just to kind of showcase some of that

1:12

wall edema seen within the gallbladder over here.

1:15

A lot of the edema and surrounding

1:18

inflammatory change in this patient.

1:20

And so again, you have a gallbladder that is

1:23

distended that has surrounding inflammatory change.

1:27

You can see how distended this

1:28

gallbladder is and its length at least.

1:30

And you can see some of the fluid

1:32

inflammatory change around it.

1:33

These are all signs that should make

1:35

one worried for acute cholecystitis.

1:38

Now, one of the other signs that I didn't talk about

1:41

in acute cholecystitis vignette is one that I think is

1:44

actually incredibly useful when I see these cases of

1:47

acute cholecystitis and one that I see not uncommonly.

1:50

So I wanted to share that with you.

1:52

So here we'll look at the T1 fat

1:54

saturated image without contrast.

1:56

And we'll just focus on this image

1:57

here where the gallbladder is.

1:59

And you can see that the liver parenchyma

2:01

on the non-contrast image looks

2:04

relatively normal in its appearance.

2:06

However, when we give contrast in the

2:08

arterial phase in particular, we can see

2:11

that surrounding the gallbladder, the liver

2:13

parenchyma is mildly hyperemic, right?

2:16

So over here, the liver parenchyma is

2:18

slightly brighter than you would expect.

2:20

Certainly, it's brighter than when you compare

2:21

it to other portions of the liver parenchyma.

2:23

Similarly, in other places.

2:26

At the interface of the liver parenchyma and the

2:27

gallbladder, that liver parenchyma is slightly more

2:30

hyperintense in the signal than you would expect.

2:33

Over here as well, slightly hyper

2:35

intense than you would expect.

2:37

And so, this is a hyperemia of the liver

2:39

parenchyma, and it's essentially increased hepatic

2:43

enhancement adjacent to the gallbladder because

2:47

of that inflammatory change of the gallbladder.

2:49

It's just sort of a reactive change within this liver.

2:52

And so, that's just another sign that I often look for.

2:55

In patients whom I’m suspecting to have acute

2:58

cholecystitis, look at the liver parenchyma.

3:00

Is it more hyperemic?

3:01

And if so, that's another supporting

3:03

sign that this gallbladder is inflamed.