0:01

So this next patient is an 80-year-old female.

0:04

Ultrasound to evaluate for right upper quadrant pain.

0:07

And they saw a finding on this

0:08

which then prompted an MRI.

0:09

So I'm going to go right to the

0:10

finding which prompted this MRI.

0:15

So most of this ultrasound looks pretty good.

0:17

Now let's focus on the gallbladder.

0:18

Gallbladder looks pretty

0:20

unremarkable for the most part.

0:22

Neck looks very good as well.

0:23

I don't see any stones within it.

0:26

And as you start to get to

0:27

the fundus of the gallbladder,

0:32

notice that there is a discrete

0:35

mass that's associated with the fundus.

0:37

A little bit heterogeneous in its appearance.

0:39

There are some areas that are relatively hypoechoic,

0:42

and there are other areas that are relatively

0:44

hyperechoic, for example, in the center of it.

0:47

You can see that mass over here, and when they put

0:50

color flow within it, certainly there are portions

0:52

within it that look like they have vascularity.

0:57

And so this was an indeterminate

0:58

finding and MRI was requested to further

1:01

evaluate this, which is very reasonable.

1:04

So we'll move on to the MRI.

1:06

This was done as a liver mass protocol.

1:09

And as we start scrolling through these images,

1:12

we'll notice in the gallbladder it looks pretty good.

1:15

And right about the fundus of the gallbladder,

1:17

we see this mass over here, and that corresponds

1:20

to the finding that we saw on the ultrasound.

1:24

If we look at our T2-weighted image, non-fat saturated,

1:29

we can see the finding again of the gallbladder fundus.

1:32

And it's important to sort of describe this finding.

1:35

I think in describing it, one can come to the diagnosis

1:38

fairly easily, just based on these images themselves.

1:41

So it's a focal finding.

1:42

It's seen in the gallbladder fundus and it's

1:45

really consists of a cluster of T2 hyper

1:49

intense cyst-like outpouchings that are, as I

1:53

said, associated with the gallbladder fundus.

1:55

And this appearance is quite

1:58

characteristic of a finding known as

2:02

adenomyomatosis.

2:04

So adenomyomatosis is a benign

2:07

finding and often it's incidental.

2:10

It doesn't really cause any symptoms per se and

2:14

what it is is that you get for some reason

2:16

gallbladder wall thickening due to proliferation

2:20

of the mucosa and also hypertrophy of the

2:23

muscularis layer within the gallbladder.

2:25

As a result of that you have invagination of the

2:28

mucosa into that muscular layer, which is very

2:30

thickened now, and you get these little sinuses.

2:33

They call them Rokitansky-Ashoff sinuses.

2:36

And these sinuses can contain bile, sludge, calculi,

2:41

also cholesterol crystals which have a characteristic

2:43

appearance on ultrasound with a comet tail artifact.

2:47

And on MRI, they really manifest as this mass-like

2:51

lesion composed of T2 hyperintense structures that

2:55

are sort of arranged as if they're like in a cluster.

2:57

And sometimes, this is known as the pearl

3:00

necklace sign as well, that you can see.

3:02

It looks much more like a pearl necklace perhaps

3:04

on these images than it does on the coronal

3:07

images, but nevertheless that is the imaging

3:10

appearance of adenomyomatosis.

3:18

Portions of this can enhance. Certainly, the

3:21

periphery of it and some of the walls of the

3:23

sinus outpouchings themselves can enhance, but

3:25

the internal content should not enhance, because

3:28

it simply contains bile or sludge or stones or

3:32

cholesterol crystals, all of which should not enhance.

3:35

Now, why is this an important finding to know about?

3:38

Well, it's really important because, uh, you can

3:41

see it again over here, but it's very important

3:42

to know about because it can be mistaken for a

3:45

gallbladder neoplasm, something that needs to be

3:48

resected, something that needs to be intervened on.

3:50

So this is a very common thing. So if you

3:53

know what it looks like, you can call it

3:54

confidently and hopefully reassure both your

3:58

referring provider and your patient that it's

4:00

something they really don't need to worry about.