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‘ MRI HOT RIM SIGN’ ITS RELEVANCE IN MODERN ERA ?

‘ MRI HOT RIM SIGN’ ITS RELEVANCE IN MODERN ERA ?. Dr BBB Shafi , Dr F Guglielmo, Dr D Mitchell Thomas Jefferson University Hospital, Philadelphia, USA. HOT RIM SIGN. First Reported In 1984

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‘ MRI HOT RIM SIGN’ ITS RELEVANCE IN MODERN ERA ?

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  1. ‘MRI HOT RIM SIGN’ITS RELEVANCE IN MODERN ERA ? Dr BBB Shafi, Dr F Guglielmo, Dr D Mitchell Thomas Jefferson University Hospital, Philadelphia, USA

  2. HOT RIM SIGN • First Reported In 1984 • Peripherally Enhancing Rim Due To Radiotracer Uptake of Surrounding Inflammatory Parenchyma With A Photopenic Gallbladder Fossa Demonstrated On A HIDA Scan. • Associated With An Increased Incidence Of Gangrenous And/Or Perforated Gallbladder. Cawhtorn et Al, ClinNucl Med, 1984. Ziessman et al, SeminNucl Med 2003. Joseph  et al, ClinNucl Med 2005. Swayne  et al, J Nucl Med 1990.

  3. HOT RIM SIGN: HIDA scan showing increased activity in the gallbladder fossa on dynamic images (red arrow head) and non-visualization of the gallbladder (green arrow head image A). Changes persist on delayed images (image B)

  4. OUR HOT RIM CASE • 65 Year Old Female • Known Gallstones • Presents With Biliary Colic And Raised Inflammatory Markers • Pre And Post Contrast MRI With MRCP was performed

  5. MRI HOT RIM SIGNAxial MRI images showing a distended gallbladder with wall thickening and edema (arrow on 1st image) with focal fat sparing around the gallbladder fossa related to perfusional alteration (arrow on 2nd image) with associated restricted diffusion (arrows on image 3 and 4) Image 1 (T2W Sequence) Image 2 (T1W Out of phase) Image 3 (DWI) Image 4 (ADC)

  6. Dynamic post contrast sequences show progressively enhancing thick walled gallbladder with increased hepatic parenchymal enhancement (shown with arrows in figure 1, 2 and 3) Image 1 (arterial phase) Image 2 (venous phase) Image 3 (equilibrium phase)

  7. BUT THERE IS SOMETHING ELSEOn Dynamic post contrast sequences, there is an enhancing tract which extends from the gallbladder to the neighboring thick walled hepatic flexure (shown by the arrows on images 1, 2 and 3) Image 1 Image 2 Image 3

  8. On diffusion weighted sequences the tract between the gall bladder and hepatic flexure shows restricted diffusion (shown by arrows on images 1 and 2 which is DWI and ADC respectively) Image 1 (DWI) Image 2 (ADC)

  9. On dual echo gradient images air can be seen with in the gall bladder which is more prominent on in phase images due to susceptibility (indicated by arrows on images 1 and 2). Sparing from steatosis is again seen along the gall bladder fossa Image 1 (Dual echo gradient in phase) Image 2 (Dual echo gradient out of phase)

  10. Subsequent contrast enhanced CT scan shows hot rim sign (arrows on image 1), a tract between the gallbladder and hepatic flexure (arrow on image 2 and gallstones and air in the gallbladder (arrows on image 3) Image 1 (axial portal venous phase) Image 2 (axial portal venous) Image 3 (coronal portal venous)

  11. FINAL DIAGNOSIS Cholecystocolonic Fistula Secondary to Acute Calculous Cholecystitis

  12. SUBSEQUENT SURGICAL TREATMENT • Right hemicolectomy and partial cholecystectomy. • Gallbladder was adherent to the gallbladder fossa and could not be completely excised.

  13. KEY LEARNING POINTS • Look out for Hot Rim Sign, this is not limited to Nuclear Medicine. • Diagnosis of Cholecystocolonic fistula is achieved preoperatively in only 7.9% of patients. (1) • Use of different MRI sequences can help in diagnosis. (1). Costi R et al. Cholecystocolonic fistula: facts and myths. A review of the 231 published cases. Journal of hepato-Biliary-Pancreatic-Surgery. January 2009, Volume 16, 1, pp 8–18.

  14. Cholecystocolonic fistula-Interesting facts • Rare disease, 0.2 % biliary disorders-elderly ladies in their sixties. • Classical Triad: Diarrhea, RUQ pain, and cholangitis (Jaundice/Fever). • Not only difficult preop diagnosis - challenging scenario for surgeons during operation.

  15. Cholecystocolonic Fistula • Cholecystitis-erosion of a Gallstone In 90% Of Cases.  • Inflammation-Adhesions-Pressure Necrosis-Fistula Formation. • Constitutes 15% of cholecystoenteric fistulas and as causing 4.8% of gallstone ileus cases. • Surprisingly, in approximately one case out of five (42/231), patients presented with occlusion by biliary ileus, vast majority in sigmoid. Costi R et al. Cholecystocolonic fistula: facts and myths. A review of the 231 published cases. Journal of hepato-Biliary-Pancreatic-Surgery. January 2009, Volume 16, 1, pp 8–18.

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