0:01

So this next patient is an 80-year-old gentleman who got

0:04

a CT scan, I believe, for abdominal pain, and they found

0:08

something on this study that then prompted an MRI.

0:11

I want to start off with the CT scan just

0:12

to show you what they were worried about.

0:14

So certainly there's a lot of ductal dilatation you

0:16

can see here that certainly they're worried about,

0:18

but there's another lesion here that I want to

0:20

draw your attention to, and that's right over here.

0:23

I'm going to zoom up on it and I'll show

0:24

it to you in different planes as well.

0:27

You can see here, just at the, uh, beginning

0:31

of the gallbladder, there is this sort of

0:33

soft tissue structure that looks like it's

0:34

protruding into the gallbladder wall over there.

0:37

And so that's something that the

0:39

radiologists saw and they were worried about.

0:42

You can see it once again, perhaps

0:46

nicer on the coronal plane over here.

0:49

I'll zoom up on it for a second,

0:52

and I'm going to window it as well, right over there.

0:55

So certainly there's lots of biliary ductal dilatation.

0:58

That's something that needs to be investigated.

0:59

But in addition to that, there's the

1:01

sort of soft tissue structure that's

1:02

associated with the gallbladder.

1:05

And so, the possibility was brought up that

1:07

this could be something that is neoplastic

1:09

in etiology, for which an MRI was requested.

1:14

So here we have the MRI for the patient.

1:16

I'll start off by looking at the axial, uh, and

1:18

coronal T2-weighted images without fat saturation,

1:22

just to get a sense of what this lesion looks like.

1:25

As we're scrolling downwards,

1:26

we'll see lots of biliary ductal dilatation.

1:28

We're going to try to ignore that for the moment

1:30

and just focus on the gallbladder finding.

1:32

You can see it right over here,

1:34

relatively T2 hypointense.

1:37

And when we see it on the coronal image,

1:39

you can see it as a mass-like lesion that's sort

1:42

of protruding from the mucosal surface of the

1:45

gallbladder into the gallbladder lumen itself.

1:50

And we can look at the gallbladder in the T2 fat

1:52

saturated image just to get a sense of what this

1:54

lesion looks like on another T2-weighted sequence.

1:58

It looks very, very hypointense over here.

2:01

on the pre-contrast images.

2:04

It's a little tough to figure out the actual signal

2:06

intensity of this lesion because the gallbladder

2:08

itself is filled with T1 hyperintense content.

2:12

It's a little tough to see what it looks like

2:14

here, but as much as we can see, it looks

2:15

pretty hypointense, at least centrally,

2:17

on the T1-weighted images without contrast.

2:21

And we give contrast and jump right into the

2:23

subtraction images to sort of eliminate all that

2:25

hyperintense content within the gallbladder itself.

2:28

So here we have our T1-weighted fat-saturated

2:31

post-contrast sequence with subtraction.

2:33

I'm looking to see if this little lesion here enhances.

2:37

And as you scroll through it, it looks like

2:40

there is, uh, pretty much a signal void.

2:42

It looks hypointense throughout the gallbladder,

2:44

and certainly in that region, uh, the expected, uh,

2:48

mass itself, you can kind of see a little bit of it

2:51

here, but there's no internal enhancement within it.

2:55

So essentially, we have a mass-like lesion

2:57

that's protruding into the gallbladder

2:59

that's relatively hypointense in all imaging

3:01

sequences that shows no enhancement, and, uh,

3:04

you know, this appearance is quite 73 00:03:06,200 --> 00:03:07,600 characteristic of what we

3:07

call, uh, tumefactive sludge.

3:11

And the word tumefactive is used to

3:13

describe it as a sludge that looks a

3:16

little bit more mass-like or tumor-like.

3:18

But indeed, it's not a tumor because it

3:21

doesn't have any enhancement within it.

3:24

It's important to know what it looks like

3:25

because it could be mistaken for a tumor,

3:27

particularly when you don't have the appropriate

3:29

imaging to really figure out what it is.

3:32

Signal within tumefactive sludge can be variable.

3:35

In this case, it was hypointense.

3:36

But I think the key finding here is that when you give

3:39

contrast, this lesion over here does not enhance.

3:43

When it does not enhance, it's very

3:45

reassuring for tumefactive sludge.

3:48

There's nothing that needs to be done about it.

3:49

It's just sludge that looks a little bit more

3:51

mass-like than normal sludge, which

3:54

typically has that sort of layering effect

3:56

along the dependent portions of the gallbladder.