0:01

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

0:03

History provided is abnormal liver function tests.

0:07

And so they got an MRI of the abdomen with

0:10

or without intravenous contrast with MRCP

0:13

to evaluate the etiology of these findings.

0:17

So again, lots of stuff going on in this patient.

0:20

However, we're going to focus on the gallbladder.

0:23

And as we focus on the gallbladder, we can see that

0:26

this gallbladder looks very distended, much more

0:30

distended than we've seen in some of the prior cases.

0:32

And so that automatically gets us

0:34

worried that there's some sort of

0:36

potential inflammatory process going on.

0:38

So let me just scroll through it one time and then

0:42

go through some of the other findings we see here.

0:45

Small gallstone, another small gallstone that we just

0:48

passed through. T2 hypointense and sort of a rounded shape.

0:52

I want to start going slowly through this area

0:54

here and we can see that there's a bunch of cysts.

0:59

But also, if we were to follow the wall of

1:00

this gallbladder, it looks pretty consistent

1:03

over here, present, maybe thins out a little

1:06

bit here, present here again, but from

1:09

here to here, it looks like there's a gap.

1:11

Not only is there a gap, but it looks like there

1:14

is this hyperintense T2 content, essentially the

1:17

bile that's spilling out through this gap over here.

1:20

And so that's going to become worrisome for us.

1:22

And I'll tell you a little bit

1:23

about what that could mean.

1:24

Besides the gallbladder distension,

1:26

there's a lot of inflammation here.

1:27

Again, it would be better appreciated on some of the

1:29

T2-weighted saturated images, but there's a lot of edema

1:32

and fluid that's surrounding this gallbladder.

1:34

So this gallbladder really is inflamed, but on top of

1:37

that, it looks like a portion of the wall is missing.

1:39

And not only is a portion of the wall

1:41

missing, but there's actual internal

1:42

content within the gallbladder, i.e., the bile

1:45

42 00:01:45,470 --> 00:01:46,250

1:46

that's spilling out through this area.

1:49

Let's see some of the findings on the coronal image.

1:52

The gallbladder distension, I think, is

1:55

again nicely appreciated, at least in the

1:58

longitudinal dimension on the coronal images.

2:01

You can see some of the gallstones over here.

2:03

That focal area of gallbladder

2:06

discontinuity is present over here.

2:09

It's a little bit harder to appreciate on the coronals.

2:11

I'll move on to the post-contrast images.

2:14

A little bit of motion here; however, we can still

2:18

evaluate that area of gallbladder wall discontinuity,

2:22

sort of along the inferior aspect of the gallbladder

2:25

where there's just an area that's missing.

2:27

The gallbladder wall is not enhancing

2:29

in this area, and bile is spilling out.

2:32

So this is another complication that we

2:34

can see with acute cholecystitis, and

2:37

it's known as perforated cholecystitis.

2:39

And so, you know, you can have acute

2:41

cholecystitis over time; the wall can become

2:45

necrotic and you get gangrenous cholecystitis.

2:48

And really as a continuum of that, when a wall

2:50

becomes necrotic, you have content that then spills

2:53

out of that wall into the adjacent soft tissue.

2:56

That's when we call it perforated cholecystitis.

3:00

Oftentimes, these are so discrete abscesses.

3:02

We'll see what that looks like

3:03

in some of the other cases.

3:05

And when you do see this, often, you know, you'll

3:08

have to do a cholecystostomy. If there's an abscess,

3:10

you're going to have to drain that abscess.

3:12

You're not going to go ahead and take this

3:14

gallbladder out immediately; you're going to

3:16

sort of allow it to cool off a little bit.

3:18

And proceed with cholecystectomy

3:20

when it's clinically feasible.

3:22

So again, this is just another complication

3:24

that we can see with acute cholecystitis when

3:27

you start to have gangrene of the wall and

3:29

now we call it gangrenous cholecystitis.

3:32

And as a result of that, you

3:34

have gallbladder contents that are now spilling

3:37

out to that area of necrotic gallbladder wall.

3:40

We start to call it perforated cholecystitis.