Interactive Transcript
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So this next patient is an 80-year-old female.
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Ultrasound to evaluate for right upper quadrant pain.
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And they saw a finding on this
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which then prompted an MRI.
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So I'm going to go right to the
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finding which prompted this MRI.
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So most of this ultrasound looks pretty good.
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Now let's focus on the gallbladder.
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Gallbladder looks pretty
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unremarkable for the most part.
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Neck looks very good as well.
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I don't see any stones within it.
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And as you start to get to
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the fundus of the gallbladder,
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notice that there is a discrete
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mass that's associated with the fundus.
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A little bit heterogeneous in its appearance.
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There are some areas that are relatively hypoechoic,
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and there are other areas that are relatively
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hyperechoic, for example, in the center of it.
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You can see that mass over here, and when they put
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color flow within it, certainly there are portions
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within it that look like they have vascularity.
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And so this was an indeterminate
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finding and MRI was requested to further
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evaluate this, which is very reasonable.
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So we'll move on to the MRI.
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This was done as a liver mass protocol.
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And as we start scrolling through these images,
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we'll notice in the gallbladder it looks pretty good.
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And right about the fundus of the gallbladder,
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we see this mass over here, and that corresponds
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to the finding that we saw on the ultrasound.
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If we look at our T2-weighted image, non-fat saturated,
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we can see the finding again of the gallbladder fundus.
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And it's important to sort of describe this finding.
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I think in describing it, one can come to the diagnosis
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fairly easily, just based on these images themselves.
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So it's a focal finding.
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It's seen in the gallbladder fundus and it's
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really consists of a cluster of T2 hyper
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intense cyst-like outpouchings that are, as I
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said, associated with the gallbladder fundus.
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And this appearance is quite
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characteristic of a finding known as
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adenomyomatosis.
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So adenomyomatosis is a benign
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finding and often it's incidental.
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It doesn't really cause any symptoms per se and
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what it is is that you get for some reason
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gallbladder wall thickening due to proliferation
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of the mucosa and also hypertrophy of the
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muscularis layer within the gallbladder.
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As a result of that you have invagination of the
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mucosa into that muscular layer, which is very
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thickened now, and you get these little sinuses.
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They call them Rokitansky-Ashoff sinuses.
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And these sinuses can contain bile, sludge, calculi,
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also cholesterol crystals which have a characteristic
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appearance on ultrasound with a comet tail artifact.
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And on MRI, they really manifest as this mass-like
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lesion composed of T2 hyperintense structures that
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are sort of arranged as if they're like in a cluster.
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And sometimes, this is known as the pearl
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necklace sign as well, that you can see.
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It looks much more like a pearl necklace perhaps
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on these images than it does on the coronal
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images, but nevertheless that is the imaging
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appearance of adenomyomatosis.
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Portions of this can enhance. Certainly, the
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periphery of it and some of the walls of the
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sinus outpouchings themselves can enhance, but
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the internal content should not enhance, because
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it simply contains bile or sludge or stones or
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cholesterol crystals, all of which should not enhance.
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Now, why is this an important finding to know about?
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Well, it's really important because, uh, you can
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see it again over here, but it's very important
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to know about because it can be mistaken for a
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gallbladder neoplasm, something that needs to be
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resected, something that needs to be intervened on.
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So this is a very common thing. So if you
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know what it looks like, you can call it
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confidently and hopefully reassure both your
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referring provider and your patient that it's
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something they really don't need to worry about.
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