 So the first they'll do these in order and there's some great excellent questions to look like so it says first one It says do you request contrast studies for gallbladder polyps? Well I am certainly not the expert in in contrast for the gallbladder You know, we generally don't use contrast media in in our practice So I don't really have expertise in that area, but I generally I would say the answer is no I'd have to look at the literature on this most of these are small You know, certainly if it's a true neoplastic quote-unquote process, it's going to have flow to it So it's certainly a great thought, but I don't see how it's going to you know, going to change, you know Change management, honestly Next question is there a grading for adenomyomatosis? Not to my knowledge You know, I would say You know, certainly I would talk about the extent of it again, it's quite variable I don't think it really makes a big difference to my knowledge. You know, it's generally an asymptomatic process You know if the patient has you know chronic pain and it's ascribed to the gallbladder. Is it possible? That they have some sort of dyskinesia that's ascribable to it maybe But in my take on the review of the literature, it's generally asymptomatic So, you know, do you say mild moderate severe? Not really. I usually just describe the extent of it It says please show the image of hemorrhagic cholecystitis again Well, I think you can access the the webinar to leisure. So rather than go through, you know, 40 slides I'll have you do that again, but it basically was the non-contrast image and it and it really wasn't hemorrhagic cholecystitis It was blood extending into the lumen of the gallbladder in the setting of a very complex internally hemorrhagic diffuse epatocytolic carcinoma right that was The explanation ascribed to the hemorrhage in the lumen of the gallbladder The patient had you know very complex vascular involvement and that's presumably why it happened Okay, next question from Ken Siegel it says do you count as What do you count as an actual sonographic Murphy sign? How do you differentiate from right upper quadrant pain which is usual indication for the study? So again, unfortunately I'm generally not the one at the bedside. So if we are highly reliant on our again generally excellent ultra scent technologists for Making the call as to whether they believe there is a sonographic Murphy sign and if your call going back to you know baits remember baits Introduction to the physical exam. That's where I learned about the physical exam Murphy sign of Murphy sign on physical exam Is that you palpate the right upper quadrant? Have the patient take a breath in and if they sort of abruptly stop that Inspiratory efforts like a you know that is ascribed to pain when the gallbladder touches the examiner's finger Right that is not the same as a sonographic Murphy sign the sonograph Murphy sign is It's pointed maximal tenderness right and we might do the same thing with the right lower quadrant or other parts of the body When we're you know trying to figure out what is the thing that is causing discomfort the problem of course is that pain radiates, right? so, you know One of the classic differential presentations From our differential considerations in in acute in aortic dissection is coli Psyduce so, you know we say regardless of your exact protocol for CT angiography and suspected aortic dissection and the vast majority were negative You have to at least go to the mid-abbon because you can have an acute gallbladder and that's been shown over and over again So pain can actually radiate as well. So they're not the same And again, it's it's really reliant on the sonographer, you know being careful and saying yes the pain Corresponds to the probe location corresponding to the gallbladder Okay, next next question says do you consider saying an echogenic interluminal focus with no shattering as in Crusted gallbladder stone. Well, so that can sit there some tricky things one of the One of the the pitfalls I haven't discussed which is another sort of basic thing that's been described for years Which is small Calculi don't necessarily shadow, right? So it depends on on physics it depends on you know the probe and the frequency that you're using and that kind of thing So it can be problematic sometimes when you have small Calculi to determine if they're actually Calculi Or if there is a sludge or if they're polyps, so even that can be problematic I get a very basic thing Do you consider gallbladder polyp morphology stalking management algorithm? Well, again, these are not colonic polyps So generally we don't they're typically not, you know, they usually don't have stalks It's really and I see gallbladder polyps all the time. It drives. They drive me, you know Like I let out a hug, you know, hug, you know when I see one of them They're they're usually not they usually don't have stalks So it's very unusual to see those so typically it's it's it's maximal dimension in whatever plane you see them in Usually they're round or ovoid And great questions. Thank you. So how to report gallbladder a demon and digestive heart disease or ascites? Well, so it really is, you know, looking at everything and that everything If it's just the ultrasound may not may not be clear that you're dealing with Something above and beyond the gallbladder. It's it's it's getting the history It's looking at the chest radiograph if you have it if looking at recent MRCTs, etc You know, I the cases that I showed I have the we had the luxury of correlative imaging Often, you know cats is rule of imaging there. There's no prior imaging when you need it, right? That that always is the case when you have we're often is the case when you have something that's problematic And you go God, I really wish I had a X and you don't have it So it it may just you know require You know picking up the phone. I had a bless this heart and laying no longer with us One of the radiologists I trained with in Syracuse at the VA He used to say kind of a gruff guy, but he had a particle and you say a hardest thing for radiologists to do is to get out Of his or her chair, you know Well analogous to that one of the hardest things is actually pick up the phone and talk to somebody and I know We're like incredibly busy and sometimes it could be you know a little bit later in the day when we have it Chance to catch our breath. That'd be that minute But getting some information is important. How do you define distention? Well, I'm not aware So that paper over the 2.2 centimeter actually is one of the few papers actually quantified distention It's sort of a gestalt thing, right? I would say in an adult when I see a gallbladder in long axis that's pushing like seven That's six and a half seven or more centimeter That's when I start to talking about distention, but it it's sort of like a gestalt You know, you look and you go that gallbladders distended Next question. Do you let the patient? Sorry, okay Let me go up here It says do you let the patient prepare a three-day fat-free diet and state in the report following a Contracted gallbladder cases. Well again, we're talking about you know the emergency setting So, I mean we generally have nothing to do with preparation of patients So, um, you know, this is in the emergency setting and we have like no control over anything So, uh, would I do any I don't make any recommendations for follow-up in that particular scenario specifically Um, when should we advise the clinician to go for biopsy directly without asking for cross-sectional imaging? Um, not exactly sure what that refers to so I'm going to skip that Okay, next question. It says how To diagnose tumor factor sludge and blood of tumor very very difficult. So, you know common things are common, right? So Uh gallbladder cancer, thankfully is is really quite unusual Um, you know, it has a very typical presentation when it's more advanced that it's you know elderly women older women It it's locally invasive. It's associated with the gallstones Um, you know, when you see a a mass center in the gallbladder that seems to be invading You know differential is a it's you know, hyalur, you know, cholangiocarcinoma gallbladder cancer Um, again, it's a spectrum it runs from you just can't see it. It's a microscopic diagnosis to There's you know, focal regional wall thickening that you know is nonspecific. So Um, you you try your best to put on flow in a color empowered oplur It can be very difficult and similar to scenarios like I've seen In equality assurance and legal cases where the bladder not the gallbladder, but the bladder In the pelvis is diffusely thick and then you know, you just can't tell I mean one of my other I'm I get a chance to say all my favorite lines here One of my favorite lines is I don't have a needle on a microscope But I wish I did you know, I was going to be One of the things I was going to do before I picked radiology was pathology, right? So I wish I had a needle on a microscope, but I don't So, you know, I can't tell looking at a cp What's diffuse cystitis from what's a diffuse neoplasm? And we've seen examples where There was one or the other or both and you know, they're you just can't tell And so if the gallbladder is diffusely thickened I don't think you can tell, you know Chronic, you know subacute coli cystitis from neoplasm, you know when there's a focal mass and when there's bulky nodes It's obvious. It's easy When it's diffuse very difficult when there's focal areas and you really try to put flow on and You don't see it. We've seen cases where there actually is flow, you know There's there's microscopic vascularity and ultrasound just wasn't able to show it. So Okay, next question to cholesterol OCs. Well, so, you know going back So I get to also cite some other medical school books So remember robins and cotran again, I'm really dating myself here So and that's been you know gone through many iterations over time So there are a variety of other cholesterol OCs the so-called strawberry gallbladder and stuff It's a spectrum again. It's mostly a you know histopathologic diagnosis So that's in the differential. It was on that slide I didn't have a chance to go into all the nuances in a 50 minute lecture But there are a variety of other cholesterol OCs Be above me on the you know adenomyomatosis where you would see diffuse thickening But you wouldn't see the you know cholesterol cliffs You wouldn't have the classic findings on sonography. You would just have non specific thickening So a bit less common in my experience certainly but in the differential diagnosis Should every chronic holy cystitis be taken out? Well, If you're if you're a general surgeon and and the patient is in high risk the answer would be yes And not to implicate our surgeons, but unfortunately I did M&M at 7 a.m. On Monday And they did that in a patient who they thought you know had a lot of risk factors But they thought was was you know cleared for surgery and optimized And had a coley cystosomy tube for like a year and they it unfortunately led to a death I mean it it just so you know any close one doesn't prove anything but You know, I think it it really depends if they're surgical candidates If it was me and I was having you know repetitive pain and I'm a surgical candidate what I want to have it out. Yes But you know again, it's a patient by patient consideration But you know again these are most of the time in my experience chronic holy cystitis The diagnosis is not established based on imaging. It's established at histopathology Next question. Do you see? Oh, this is coming from somewhere internationally, which is great Uh, do you see gallbladder wall thickening in the setting of dengue fever? Well, thankfully I I don't see a lot of dengue fever and in many all along island. Um, believe it or not We do actually see occasional tropical diseases Um, we have we've seen I had malaria here, you know, 30 40 years ago as a medical student Not me, but we saw it. Um, we do see tb. We've seen a bunch of tb cases. We see some unusual things But I've never personally seen dengue fever. I'm not not an expert on on tropical diseases specifically That'll have to look up. I'll make a note of that. Um, you know, there are, you know, certainly A host of things you can see, you know, there there was descriptions in in in covet interestingly unfortunately of High drops of the gallbladder in in kids with these, you know, severe, you know, sort of SARS type response Or mers, whatever they were calling it severe inflammatory response with with kids with covet unfortunately You know, there's a host of of of things that can happen with the gallbladder in a variety of of unusual disorders And and um, you know, covet is one of them. I I'm not aware that it happens in dengue fever to have to look that up Should we term calcifying sludge ball as a soft calculus? I I would avoid that term I don't well, what's a what's a calcifying sludge ball? I mean, it's a calculus So I would just call it a calculus Again, how to differentiate adenomyomatosis from cancer. There is no association to my knowledge again adenomyomatosis is common cancer is rare I've never seen them occur in in conjunction with each other and one does not lead to the other Um, and and so, you know, typically you'll see the the the usual findings that's sonography. They're they're highly specific So I really don't think there should be a problem But there are reports again in the literature of the occasional, you know Equivocal or problematic case where you go to c2r mr And what is noted is that there should not be Enhancement on c2r mr with a former and there will be enhancement with a latter So that's an excellent question again End of time to get into all of the nuances and I think this is the final question I managed to get to every one of these which is great. How many common to artifacts needed is animal and there's just subtle wall thickening Well, again, there's a spectrum of this. I would again, you should be able to access the Paper that I cited from um, the european literature. That's a colleague of mine who edits the journal out of italy It's an excellent review article. I would I would ask you to look at that I haven't memorized the article. It's been about two years since I looked at it But I believe there's a fairly comprehensive review of that any And there's some other review articles and you know, there's a review in any of the major ultrasound textbooks You can look at this in terms of the spectrum of it So again, if there's problematic You know diagnosis you can repeat the ultrasound maybe in, you know, three to six months you can do mr mrcp I think the biggest problem is when there's focal thickening. I didn't mention this but when there's focal thickening of the fundus um, I should should say my my my mother-in-law who's uh, the Dominican Uh, you know taught me about like, you know la funda So fundus comes from the latin meaning a bag and fundus is is, you know, the typical classic location And a bit easier again much easier on sonography But when you see a focal mass on ct or mr in the gallbladder The concern is that am I missing a you know a tumor? Is it the differential? Is it just a waste? Is it adenomyomatosis? Not a waste like a waste of time, but a waste like a waste around the you know a belt Um, is it a mass mass or is it, you know adenomyomatosis and almost always it's it's not a malignancy But that's the scenario where you're going to potentially do additional imaging or follow So I think we got through everything and um, I finished about seven minutes over the hour But hopefully this answered all of those questions and with that I'm going to turn things over to Uh, to staff and again, I really greatly appreciate the opportunity and we had great participation I think we had a over 180 participation A participation live at the the peak of this and again, it's an honor to be able to do this Thank you very very much