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Don’t Miss This Unique Experience Imaging in Japan 2026  isn’t just a conference—it’s an opportunity to grow, connect, and be inspired  in one of the most extraordinary countries in the world. 📅 Conference Dates:  June 1–5, 2026  📍 Location:  Hotel Chinzanso Tokyo + Optional Mini-Conference at Hyatt Regency Kyoto  🔗 View the full program and register now → www.globalradiologycme.com/imaging-in-japan2026 Here are the top 10 reasons you should attend Imaging in Japan 2026: 1. Leading edge, captivating Scientific Program delivered by a World-Class Faculty Led by Scientific Director Neil M. Rofsky, the 2025 program will feature topics in body imaging, cardiothoracic imaging, MSK, neuroradiology, and emergency radiology. Faculty include some of the most respected names in the field: Donald Resnick, Ella Kazerooni, Amish Doshi, and Karen Lee. 2. Tokyo is ranked one of the top cities to visit in the world Travel + Leisure ranked Tokyo #3 in their readers favorite cities in the world in 2026. Forbes ranked Tokyo #3 of Best Cities in the world to visit in 2026. 3. Interactive and engaging Lunch Round Tables Back by popular demand, our daily Round Table sessions offer a chance to discuss current imaging and leadership topics in an informal setting with the faculty. These sessions are often cited by attendees as a highlight of the educational program. 4. The Chinzanso Hotel: A Hidden Gem in the Heart of Tokyo The conference venue, Hotel Chinzanso Tokyo, is a luxurious garden retreat tucked away in central Tokyo. You’ll attend sessions surrounded by centuries-old camellia trees, koi ponds, and stone paths—an inspiring and peaceful place to learn. 5. Kyoto: A Spiritual and Cultural Retreat Don’t miss the optional Wellness and Business Mini-Conference on June 5, 2026 at the Hyatt Regency Kyoto. Explore Japan’s former imperial capital, home to over 1,600 temples, zen gardens, and world-famous sites like the Fushimi Inari Shrine and Arashiyama Bamboo Forest. 6. Cruise and Dinner on Tokyo Bay Network with fellow  registrants and faculty while enjoying a spectacular evening cruise on Tokyo Bay, complete with dinner, drinks, and panoramic views of the city skyline and Rainbow Bridge.  7. Explore Tokyo’s Contrasts From the bustling energy of Shibuya Crossing to the quiet elegance of the Meiji Shrine, Tokyo is a city of contrasts. Shop in Ginza, experience a traditional tea ceremony, take a ride in a rickshaw or marvel at the views from Tokyo Skytree—all just a short ride from the conference hotel. 8. Soak in a Traditional Onsen Experience the healing waters of a Japanese onsen. Whether in Tokyo or Kyoto, you’ll find beautifully designed public baths and hotel spas that offer the perfect post-conference wind-down. 9. Savor Michelin-Starred Cuisine and Street Food Japan has more Michelin-starred restaurants than anywhere else on earth—but the culinary scene goes far beyond fine dining. Don’t leave without trying fresh sushi at Tsukiji Market, sizzling yakitori in a local izakaya, or warm taiyaki from a street vendor. 10. Ride the Shinkansen (Bullet Train) Fast, efficient, and a uniquely Japanese experience, the Shinkansen connects Tokyo and Kyoto in just over two hours.  Experience an exceptional radiology education alongside a memorable cultural journey at this distinctive conference by Global Radiology CME. The Imaging in Japan 2026 event offers professional growth, networking opportunities, and wellness for radiologists worldwide in a culturally vibrant country that seamlessly integrates ancient traditions with contemporary innovations.

61-year-old male with abdominal pain 15 days after capsule endoscopy. • Xray of the Week Figure 1. What are the important findings in this case. Figure 2. Frontal abdomen radiograph demonstrates foreign body consistent with capsule endoscopy device (pill cam) in descending colon. Capsule Retention and Risk Factors: Capsule endoscopy is used for evaluating small-bowel disorders, such as bleeds and Crohn disease.[1] This diagnostic procedure involves swallowing a pill-sized camera that records thousands of images of the alimentary canal including the small intestine, an area difficult to examine via traditional endoscopy. Retention of the camera-containing capsule is the main complication of capsule endoscopy. Traditionally, capsule retention (CR) is defined as the presence of a capsule in the digestive tract for a minimum of 2 weeks. Approximately 2% of all capsule endoscopies result in CR [2] The clinical indication for capsule endoscopy is correlated with different rates of CR. Retention rates for patients post-capsule endoscopy for chronic diarrhea or abdominal pain is approximately 2%.[3] For patients with a greater likelihood of small bowel strictures, retention rates increase to 13%.[4] The highest CR rates of 10-20% are in patients being evaluated for subacute small bowel obstructions.[5,6] Capsule retention can be often be prevented by assessment of functional patency with a Patency Capsule . Use of high-dose non-steroidal anti-inflammatory drugs, previous abdominal radiation therapy, and history of small bowel restrictions generally increase the risk of CR post-capsule endoscopy.[2] Imaging: In asymptomatic patients, plain abdominal x-ray 15-days following capsule ingestion is the preferred confirmation imaging of CR. If capsule endoscopy findings suggest potential CR, then performing an abdominal x-ray 7-days post-capsule ingestion is advisable, since most capsules are excreted within 3-7 days. Capsules that reach the cecum generally are secreted as cases of colonic CR accounting for less than 1% of all retention [7]. Computed tomography (CT) could be used to determine the capsule’s location if it is difficult to do so via x-ray. Treatment: Asymptomatic patients are monitored initially, given that 35-50% of patients with CR naturally excrete the capsule after more than 15 days.[8,9] Surgical or device-assisted enteroscopy retrieval of the capsule is indicated for asymptomatic patients 3-6 months following capsule ingestion. For patients with inflammatory bowel disease, the use of steroids has been shown to assist the excretion of capsules in up to 20-30% of all CR cases.[2] Importance of Prompt Management: Patients with missed CR could develop bowel obstruction and perforation.[2] Disintegration of the capsule could expose the camera’s lithium battery to the digestive tract, increasing the risk of mucosal damage. Identifying and managing CR is important to prevent avoidable gastrointestinal complications. ​​​​ References: 1. Lee HS, Lim YJ, Kim KO, et al. Outcomes and Management Strategies for Capsule Retention: A Korean Capsule Endoscopy Nationwide Database Registry Study. Dig Dis Sci. 2019;64(11):3240-3246. doi: 10.1007/s10620-019-05659-7 2. Rondonotti E. Capsule retention: prevention, diagnosis and management. Ann Transl Med. 2017;5(9):198. doi: 10.21037/atm.2017.03.15 3. Rezapour M, Amadi C, Gerson LB. Retention associated with video capsule endoscopy: systematic review and meta-analysis. Gastrointest Endosc. 2017;85(6):1157-1168.e2. doi: 10.1016/j.gie.2016.12.024 4. Cheifetz AS, Lewis BS. Capsule endoscopy retention: is it a complication? J Clin Gastroenterol. 2006;40(8):688-691. doi: 10.1097/00004836-200609000-00005 5. Cheifetz AS, Sachar DB, Lewis BS. Small Bowel Obstruction — Indication or Contraindication for Capsule Endoscopy. Gastrointest Endosc. 2004;59(5):P102. doi: 10.1016/S0016-5107(04)00509-7 6. Yang XY, Chen CX, Zhang BL, et al. Diagnostic effect of capsule endoscopy in 31 cases of subacute small bowel obstruction. World J Gastroenterol. 2009;15(19):2401-2405. doi: 10.3748/wjg.15.2401 7. Sachdev MS, Leighton JA, Fleischer DE, et al. A prospective study of the utility of abdominal radiographs after capsule endoscopy for the diagnosis of capsule retention. Gastrointest Endosc. 2007;66(5):894-900. doi: 10.1016/j.gie.2007.06.066 8. Fernández-Urién I, Carretero C, González B, et al. Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population. Rev Esp Enferm Dig. 2015;107(12):745-752. doi: 10.17235/reed.2015.3820/2015 9. Rondonotti E, Soncini M, Girelli C, et al. Small bowel capsule endoscopy in clinical practice: a multicenter 7-year survey. Eur J Gastroenterol Hepatol. 2010;22(11):1380-1386. doi: 10.1097/MEG.0b013e3283352ced Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program , with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team . Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students. Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare. To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/ All posts by Eric Errampalli Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

63 year old male. Headache for 1 month and unsteady gait. What is the diagnosis? • Xray of the Week Figure 1. Brain CT. Name the significant findings. Figure 2. A, B, C: Non-contrast axial CT displaying subtle bilateral isodense subdural hematomas. There is medial displacement of gray matter with left (orange arrows) worse than right (red arrows). Shift of midline structures to the right is also a clue to the diagnosis. D: Non-contrast coronal CT indicating isodense subdural hematoma (orange arrows). Note again the midline shift to the right. Figure 3. Post op CT brain on same patient. Note the lower attenuation fluid after treatment. Partial evacuation of hematoma with hypodense regions indicating residual fluid and blood products (red and orange arrows). Discussion: Subacute subdural hematomas (SDH) are usually due to clinically undetected acute SDH. Two leading causes are tearing of the bridging vessels due to abrupt acceleration-deceleration of the head or accumulation around a parenchymal laceration (1). This trauma leads to blood accumulation between the arachnoid and dura layers of the brain (2). Risk factors include cerebral atrophy (elderly patients or chronic alcoholics), anticoagulation use, or recent thrombolysis (3). The patient may or may not have a history of head trauma. Common presenting features include headache, decreased memory, confusion, and motor dysfunction (4). SDH can cross suture lines since they occur deep to the dura mater; this differs from epidural hematomas which usually do not cross suture lines since blood cannot extend beyond the point where the dura attaches to the cranial sutures (5). Subacute subdural hematomas are categorized as isodense biconcavities on CT. When blood clots degrade, the density decreases and becomes more similar to the brain parenchyma. Furthermore, subacute (and chronic) SDHs may show septations within an iso/hypodense hematoma due to reactive granulation tissue formation (6). Subacute hemorrhages can be challenging to recognize because of the isodense characteristics. Therefore, one must also look for signs of mass effect such as asymmetry of the lateral ventricles, shifting of midline structures, sulcal effacement, and sulci that do not extend into the skull (Figs. 1-2) (7). Management of subacute SDH is determined by whether a patient is symptomatic or exhibiting signs of mass effect; those who are asymptomatic may be candidates for conservative treatment (8). Mainstay surgery modalities include twist-drill craniostomy, burr-hole craniostomy, and craniotomy (8). Figure 2 shows this patient following bilateral craniotomy. ​​​​ References: Williams KA Jr, Kouloumberis P, Engelhard HH. Subacute subdural hematoma in a 45-year-old woman with no significant past medical history after a roller coaster ride. Am J Emerg Med . 2009;27(4):. doi: 10.1016/j.ajem.2008.08.005 Pierre L, Kondamudi NP. Subdural Hematoma. [Updated 2019 Dec 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532970/ Lupescu IC, Stefanescu VC, Lupescu IG, Dulamea AO. Subacute Subdural Hematoma Presenting as Non-Fluent Aphasia. Maedica (Bucur) . 2019;14(1):63-66. doi: 10.26574/maedica.2019.14.1.63 Yadav YR, Parihar V, Namdev H, Bajaj J. Chronic subdural hematoma. Asian J Neurosurg . 2016;11(4):330-342. doi: 10.4103/1793-5482.145102 Heit JJ, Iv M, Wintermark M. Imaging of Intracranial Hemorrhage. J Stroke . 2017;19(1):11-27. doi: 10.5853/jos.2016.00563 Grainger and Allison. Adam Kenji Yamamoto and Ashok Adams: Grainger & Allison's Diagnostic Radiology, 54, 1387-1410 Emergency Radiology. Glenn D. Barest, Asim Z. Mian, Rohini N. Nadgir and Osamu Sakai: Emergency Radiology: The Requisites, Chapter 1, 1-60 Cai Q, Guo Q, Zhang F, et al. Evacuation of chronic and subacute subdural hematoma via transcranial neuroendoscopic approach. Neuropsychiatr Dis Treat . 2019;15:385-390. Published 2019 Jan 30. doi: 10.2147/NDT.S193548 Deven Champaneri is a medical student at Edward Via College Osteopathic Medicine (VCOM) – Carolinas and plans to pursue residency in diagnostic radiology. While he was rotating through various specialties, he realized his passion for DR and valued its role in all aspects of medicine. He graduated from the University of South Carolina in 2017 with a degree in Business Marketing. During his undergraduate studies, he was involved with multiple volunteer organizations, such as Camp Kemo a summer camp for children with cancer and Palmetto Richland Children’s Hospital . Currently, he mentors at-risk high-school students and tutors students for Step 1/COMLEX 1. In his spare time he enjoys, golfing, backpacking, cooking, and spending time with family. UPDATE 2025: Dr. Champaneri is now a radiology resident at Medical University of South Carolina Follow Deven Champaneri on Twitter @ devenchampaneri All posts by Deven C hampaneri Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Global Radiology CME is pleased to congratulate the Award Winners for Best E-Posters and The Donald Resnick MSK Quiz at Imaging in Prague 2019. Awards were presented at The Gala Dinner at the Prague Municipal House on June 10, 2019. Neuroradiology E-Poster: Victor Teng - Flexion MRI in Hirayama Disease Dr. Teng is a radiologist at National University Health System Singapore. He was presented with the Award by Dr. Blake Johnson, Co-Scientific Director and Neuroradiology Faculty for Imaging in Prague 2019. Body Imaging E-Poster: Grace Rubin - Breast Tuberculosis - A review of 62 cases Dr. Rubin is Clinical Head of Radiology, at Helen Joseph Hospital in Johannesburg, a University of Witwatersrand affiliated academic hospital. She was presented with the Award by Dr. Neil Rofsky, Body Imaging Faculty at Imaging in Prague 2019. MSK Imaging E-Poster: Junsiyuan Li - Fibrolipomatous Hamartoma of the Median Nerve Dr. Li is a senior radiology resident at Singapore General Hospital, SingHealth. He was presented with the Award by Dr. Phillip Tirman, Co -Scientific Director and MSK Imaging Faculty at Imaging in Prague 2019. Donald Resnick MSK Quiz Award: Andrew Kingzett Taylor Dr. Kingzett Taylor serves as an MSK radiologist at Pacific Radiology, located in Wellington and Manawatu, New Zealand. He completed a visiting fellowship at the MSK Section of UCSF and the San Francisco MRI Centre. Dr. Donald Resnick, an ACR Gold Medalist and esteemed MSK Imaging faculty member of Global Radiology CME, is seen presenting him with the Award. More award winners here .

This prestigious award is presented by Professor Resnick to the winner of his annual MSK imaging quiz at the Global Radiology CME conference. Participants are challenged with complex MSK imaging cases at the start of the day, with answers revealed during the final time slot of the MSK session. Dr. Resnick's reputation for presenting captivating and often surprising cases adds an element of intrigue to the session, making it a highlight of the conference for many attendees. The trophy symbolizes not only excellence in MSK imaging but also the dedication and commitment of the winner to the field. Join us at our next conference to test your skills and compete for this coveted award. 2025  - Shown above is Dr. Donald Resnick, the world's leading authority in musculoskeletal imaging, presenting the prestigious Global Radiology CME  Resnick MSK Quiz Award  to Dr. Andrew Whan of Barwon Medical Imaging in the Melbourne region of Australia during Imaging in Greece 2025 . Dr. Whan completed his radiology training at Austin Hospital, earning the Gold Medal as the top candidate in the Royal Australian and New Zealand College of Radiologists (RANZCR) Fellowship Exam. In 2001, he undertook advanced fellowship training in MRI and breast imaging at Austin Hospital, followed by additional fellowship training in musculoskeletal MRI in Perth. Dr. Whan currently serves as an Examiner for RANZCR  and holds the position of Associate Professor and Tutor at Deakin Medical School , Deakin University. 2024 - Pictured above is the authority in MSK imaging, Dr. Donald Resnick presenting the coveted Global Radiology CME annual Resnick MSK Quiz Award to Andrew Kingzett Taylor of Pacific Radiology in New Zealand at Imaging in Copenhagen 2024 . This marks his second win, following his previous award in 2019. Dr. Kingzett Taylor was a visiting fellow to the musculoskeletal section at the University of California, San Francisco in 1998 and 1999. 2023 - Pictured above is the MSK radiology luminary and prolific writer, Dr. Donald Resnick presenting the much sought after Global Radiology CME annual Resnick MSK Quiz Award to Stuart Rubin of Windsong Radiology in Buffalo, New York at Imaging in Israel 2023 . Dr. Rubin did a MSK fellowship at Columbia-Presbyterian Medical Center in New York, NY. He comes from a family of three generations of doctors. In addition to his father and grandfather, his siblings are all physicians. 2022  - Dr. Donald Resnick, the legendary MSK radiologist, is seen presenting the prestigious Global Radiology CME annual Resnick MSK Quiz Award to Nancy Prendergast of University Radiology Group in New Jersey, USA at Imaging in Dublin 2022 . Following medical school at Brown University and radiology residency at New York University Medical Center, Dr. Prendergast completed a Musculoskeletal Radiology fellowship at New York University Medical Center in 1993. 2019 - Dr. Donald Resnick, the 2018 ACR Gold Medalist, is shown in the image awarding the inaugural Global Radiology CME Resnick MSK Quiz Award to Andrew Kingzett Taylor of Pacific Radiology in New Zealand at Imaging in Prague 2019 . Seen above, Dr. Resnick expressed his admiration for Dr. Kingzett Taylor's exceptional performance in interpreting the complex cases.

26 M jumped to catch a baseball and landed on his left foot while rotating to the right . Diagnosis? • Xray of the Week Figure 1. The patient jumped to catch a baseball and landed on his left foot while rotating to the right . Diagnosis? Figure 2. Lateral Subtalar Joint Dislocation . (A) AP radiograph demonstrates the talus (yellow arrow) with anatomical alignment to the distal tibia. The calcaneus (blue arrow) and navicular are rotated laterally. (B) Lateral radiograph demonstrates the talus (yellow arrow) with anatomical alignment to the distal tibia. The calcaneus (blue arrow) is rotated laterally. Subtalar Joint Dislocation Subtalar joint dislocation is a rare but significant orthopedic injury characterized by the disruption of the talocalcaneal and talonavicular articulations while preserving the tibiotalar and calcaneocuboid joints. It accounts for approximately 1% of all dislocations and typically results from high-energy trauma, such as motor vehicle accidents, falls from height, or sports injuries. Medial dislocations, also known as acquired clubfoot , constitute about 80% of cases, whereas lateral dislocations ( acquired flatfoot ) account for the remaining 20%. Posterior and anterior dislocations are exceedingly rare. Etiology and Pathophysiology The injury mechanism involves forced inversion or eversion of the foot with an axial load. Medial dislocations result from inversion forces, leading to disruption of the lateral ligamentous structures and impingement of the talar head against the extensor tendons. As in this case, lateral dislocations result from eversion forces, causing injury to the deltoid ligament and potentially the posterior tibial tendon. Associated fractures, particularly of the lateral process of the talus or the anterior calcaneal process, are present in up to 50% of cases and may complicate reduction. Imaging Findings Radiographic evaluation is the first-line imaging modality, with anteroposterior, lateral, and oblique foot radiographs demonstrating misalignment of the talocalcaneal and talonavicular joints (Figs. 1,2). Medial dislocations present with the talar head displaced laterally and the calcaneus medially, while lateral dislocations exhibit the opposite pattern. Fractures of the lateral talar process, anterior calcaneal process, or posterior malleolus should be carefully assessed. CT imaging is invaluable in evaluating associated fractures, assessing articular congruity post-reduction, and planning surgical intervention if necessary. Multiplanar reconstructions can aid in identifying subtle talar dome impaction or osteochondral injuries. MRI is reserved for evaluating ligamentous and tendinous injuries, particularly in chronic or irreducible cases. Treatment and Prognosis Closed reduction under sedation or anesthesia is the primary treatment modality. Reduction is typically achieved by applying traction and reversing the mechanism of injury, followed by immobilization in a short-leg cast or boot for 4–6 weeks. Open reduction may be required in cases of interposed soft tissue or osteochondral fragments preventing closed reduction. Post-reduction imaging, including CT, should be obtained to confirm alignment and exclude occult fractures. The prognosis is generally favorable if early, stable reduction is achieved. However, complications such as post-traumatic arthritis, subtalar instability, and avascular necrosis of the talus may occur, particularly in cases of delayed treatment or associated fractures. Long-term outcomes depend on the severity of cartilage damage and the presence of concomitant injuries. References Bohay DR, Manoli A 2nd. Subtalar joint dislocations. Foot Ankle Int . 1995;16(12):803-808. doi: 10.1177/107110079501601212 Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int . 2001;22(5):392-398. doi: 10.1177/107110070102200506 Prada-Cañizares A, Auñón-Martín I, Vilá Y Rico J, Pretell-Mazzini J. Subtalar Dislocation: Management and Prognosis for an Uncommon Orthopaedic Condition. Int Orthop. 2016;40(5):999-1007. doi:10.1007/s00264-015-2910-8 - Pubmed Rammelt S & Goronzy J. Subtalar Dislocations. Foot Ankle Clin. 2015;20(2):253-64. doi:10.1016/j.fcl.2015.02.008 - Pubmed Ruhlmann F, Poujardieu C, Vernois J, Gayet L. Isolated Acute Traumatic Subtalar Dislocations: Review of 13 Cases at a Mean Follow-Up of 6 Years and Literature Review. J Foot Ankle Surg. 2017;56(1):201-7. doi:10.1053/j.jfas.2016.01.044 - Pubmed Cheruvu M, Narayana Murthy S, Siddiqui R. Subtalar Dislocations: Mechanisms, Clinical Presentation and Methods of Reduction. World J Orthop. 2023;14(6):379-86. doi:10.5312/wjo.v14.i6.379 - Pubmed Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.   He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

What is the device in the chest? What are potential complications? • Xray of the Week Figure 1. What is the device in the chest? Figure 2. Frontal and lateral chest radiograph demonstrates foreign body consistent with Bravo pH Capsule in the esophagus. Figure 3. Enlarged and lateral chest radiograph demonstrates foreign body consistent with Bravo pH Capsule in the esophagus. Bravo pH Monitoring System: Radiologic Considerations and Clinical Implications The Bravo pH monitoring system is a catheter-free, ambulatory device designed to evaluate esophageal acid exposure over 48–96 hours. It is widely used in the diagnosis of gastroesophageal reflux disease (GERD), particularly in patients with persistent symptoms despite medical therapy or in those being considered for anti-reflux surgery. The system consists of a small pH capsule that is temporarily affixed to the esophageal mucosa via endoscopy and transmits pH data to an external receiver. The capsule typically detaches within 5 days and passes though the GI tract into the stool. Radiographically, the device is typically positioned about 5–6 cm above the gastroesophageal junction. Unlike traditional catheter-based monitoring, Bravo improves patient tolerance and compliance, leading to more accurate symptom correlation and better diagnostic yield. Complications of Bravo pH Monitoring Although Bravo pH monitoring is minimally invasive, several potential complications have been reported, including: Chest pain and discomfort, occurring in 15–20% of patients, occasionally severe enough to require early capsule removal. Dysphagia or globus sensation, particularly if the capsule is placed too proximally. Mucosal ulceration and bleeding, especially in patients with pre-existing esophagitis or delayed esophageal clearance. Capsule misplacement or detachment failure, leading to inaccurate pH readings and potential patient discomfort. Aspiration or prolonged capsule retention, although rare, requiring endoscopic retrieval if retained beyond 30 days. Radiologic Considerations: Bravo pH Capsule on Imaging Although not an imaging-based diagnostic tool, radiology plays a key role in evaluating capsule placement and identifying complications. Confirming Capsule Placement The Bravo capsule appears as a small, radiopaque metallic-density structure in the distal esophagus, typically 5–6 cm above the gastroesophageal junction, on fluoroscopy, chest X-ray, or CT (Figs 1-3). Fluoroscopy can confirm proper adherence in cases of chest discomfort or suspected misplacement. Assessing for Complications CT imaging may reveal adjacent mucosal thickening, edema, or ulceration in patients with persistent symptoms. In suspected prolonged retention, an abdominal X-ray can confirm whether the capsule has passed through the GI tract or remains in place beyond the expected detachment period. In rare cases of suspected esophageal perforation, contrast esophagography may demonstrate extraluminal leakage . Avoiding Misinterpretation The Bravo capsule can be misinterpreted as a foreign body or endoscopic clip, particularly in oncologic imaging. Awareness of its expected location and morphology prevents unnecessary biopsy or surgical consultation. Conclusion The Bravo pH monitoring system remains integral to GERD diagnosis, offering prolonged, catheter-free acid monitoring. However, it presents unique radiologic challenges, as it can be mistaken for a foreign body, endoscopic clip, or pathologic mass. Understanding the expected imaging characteristics, potential complications, and appropriate differential considerations allows radiologists to optimize patient management and avoid unnecessary procedures . References Gyawali CP, Kahrilas PJ, Savarino E, et al. Modern diagnosis of GERD: the Lyon Consensus. Gut . 2018;67(7):1351-1362. DOI: 10.1136/gutjnl-2017-314722 Savarino E, Bredenoord AJ, Fox M, et al. Expert consensus document: Advances in the physiological assessment and diagnosis of GERD [published correction appears in Nat Rev Gastroenterol Hepatol. 2018 May;15(5):323. DOI: 10.1038/nrgastro.2018.32 .]. Nat Rev Gastroenterol Hepatol . 2017;14(11):665-676. DOI: 10.1038/nrgastro.2017.130 Gawron AJ, Pandolfino JE. Ambulatory reflux monitoring in GERD--which test should be performed and should therapy be stopped?. Curr Gastroenterol Rep . 2013;15(4):316. doi: 10.1007/s11894-013-0316-6 Sigakis CJG, Mathai SK, Suby-Long TD, et al. Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest. Radiographics . 2018;38(4):1027-1045. DOI: 10.1148/rg.2018170096 Bredenoord AJ, Pandolfino JE, Smout AJ. Gastro-oesophageal reflux disease. Lancet . 2013;381(9881):1933-1942. DOI: 10.1016/S0140-6736(12)62171-0 Weusten BL, Roelofs JM, Akkermans LM, Van Berge-Henegouwen GP, Smout AJ. The symptom-association probability: an improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology . 1994;107(6):1741-1745. DOI: 10.1016/0016-5085(94)90815-x Spechler SJ. Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion . 1992;51 Suppl 1:24-29. DOI: 10.1159/000200911 Naik RD, Meyers MH, Vaezi MF. Treatment of Refractory Gastroesophageal Reflux Disease. Gastroenterol Hepatol (N Y) . 2020;16(4):196-205. PMCID: PMC8132683 Yadlapati R, Pandolfino JE. Personalized Approach in the Work-up and Management of Gastroesophageal Reflux Disease. Gastrointest Endosc Clin N Am . 2020;30(2):227-238. DOI: 10.1016/j.giec.2019.12.002 Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol . 2006;101(8):1900-1943. DOI: 10.1111/j.1572-0241.2006.00630.x Richter JE, Pandolfino JE, Vela MF, et al. Utilization of wireless pH monitoring technologies: a summary of the proceedings from the esophageal diagnostic working group. Dis Esophagus . 2013;26(8):755-765. DOI: 10.1111/j.1442-2050.2012.01384.x Zerbib F, Roman S, Bruley Des Varannes S, et al. Normal values of pharyngeal and esophageal 24-hour pH impedance in individuals on and off therapy and interobserver reproducibility. Clin Gastroenterol Hepatol . 2013;11(4):366-372. DOI: 10.1016/j.cgh.2012.10.041 Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol . 2022;117(1):27-56. DOI: 10.14309/ajg.0000000000001538 Boeckxstaens GE, Rohof WO. Pathophysiology of gastroesophageal reflux disease. Gastroenterol Clin North Am . 2014;43(1):15-25. DOI: 10.1016/j.gtc.2013.11.001 Tutuian R, Castell DO. Reflux monitoring: role of combined multichannel intraluminal impedance and pH. Gastrointest Endosc Clin N Am . 2005;15(2):361-371. DOI: 10.1016/j.giec.2004.10.002 Spechler SJ. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. The Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group. N Engl J Med . 1992;326(12):786-792. DOI: 10.1056/NEJM199203193261202 Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the Device • Xray of the Week Routine CXR for cough demonstrates metallic device. Name the cardiac implant. Figure 1. The circled device is a CardioMEMS HF System used to measure and monitor pulmonary artery (PA) pressure and heart rate. The patient also has a biventricular pacemaker. (Image courtesy of Mark Beller, MD.) Figure 2. Video Explaining percutaneous placement technique for the CardioMEMS. Figure 3. The CardioMEMS HF System. A. Implantable monitoring device. B. RemoteCare external electronics unit. The CardioMEMS™ HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. Using a percutaneous approach (Fig. 2), the sensor (Fig. 3A) is implanted in the pulmonary artery. Once the device is implanted, daily pressure readings are obtained with the external electronics unit (Fig. 3B) and wirelessly transmitted to the patient's physician for continuous monitoring. Fig 4. Magnified views of the CXR and CT Scan of a second patient with the CardioMEMS HF System in the right lower lobe pulmonary artery. References: 1. Abbott CardioMEMS Website 2. Chaudhry SI, Mattera JA, CurtisJP, et al., (2010). Telemonitoring in patients with heart failure. NEJM, 363(24), 2301-2309.  http://dx.doi.org/10.1056/NEJMoa1010029 3. Kohler F, Winker S, Schieber M, et al. (2010, November). Telemedical interventional monitoring in heart failure (TIM-HF), a randomized, controlled, intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with chronic heart failure. Presented at the meeting of the American Heart Association, Chicago, IL. http://dx.doi.org/10.1161/CIR.0b013e318200c0b5 4. van Veldhuisen DJ, Braunschweig F, Conraads V, et al, for the DOT-HF Investigators. (2011). Intrathoracic impedance monitoring, audible patient alerts, and outcome in patients with heart failure. Circulation, 124(16), 1719-1726.  http://dx.doi.org/10.1161/circulationaha.111.043042 5. Adamson PB, Abraham WT, Bourge RC, et al. (2014). Wireless pulmonary artery pressure monitoring guides management to reduce decompensation in heart failure with preserved ejection fraction.Circulation: Heart Failure, 7(6), 935- 944. http://dx.doi.org/10.1161/circheartfailure.113.001229 6. Abraham WT, Stevenson L, Bourge RC, et al. (2016). Sustained efficacy of pulmonary artery pressure to guide to adjustment of chronic heart failure therapy: Complete follow-up results from the CHAMPION randomized trial. The Lancet, 387(10017), 453-461.  http://dx.doi.org/10.1016/S0140-6736(15)007233-0 7. Adamson PB, Abraham WT, Bourge RC, et al. (2010). CardioMEMS heart sensor allows monitoring of pressures to improve outcomes in NYHA class III heart failure patients (CHAMPION) Trial: Impact of hemodynamic guided care on patients with preserved ejection fraction. Journal of Cardiac Failure, 16(11), 913.  http://dx.doi.org/10.1016/j.cardfail.2010.09.012 8. Weiner S, Abraham WT, Adamson PB, et al. (2011). Effect of CRT on heart failure related hospitalizations in patients with reduced EF utilizing remote pulmonary artery pressures in the CHAMPION Trial. Heart Rhythm, 8(5S), S437. http://dx.doi.org/10.1016/j.hrthm.2011.03.033 9. Conyers JM, Rajiah P, Ahn R, Abbara S, et al. Imaging features of leadless cardiovascular devices. Diagn Interv Radiol. 2018 Jul; 24(4): 203–208. d oi: 10.5152/dir.2018.17462 10. How to Implant the CardioMEMS Heart Failure SensorA step-by-step review of the sensor implantation procedure, including pre- and postprocedural assessment.By David M. Shavelle, MD, FACC, FSCAI. https://citoday.com/2018/02/how-to-implant-the-cardiomems-heart-failure-sensor/ Related posts: Bicuspid Aortic Valve and Aortic Stenosis Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Micra Intracardiac Pacemaker Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Right upper quadrant pain unstable patient. What procedure is indicated? • Xray of the Week Figure 1. What action should be taken for this patient with right upper quadrant pain who is also hemodynamically unstable? Figure 2. A. MRI of abdomen. The patient is pregnant (orange arrows), therefore ionizing radiation with CT scan or fluoroscopy can not be used for imaging guidance. Gallbladder with wall thickening (green arrow) and adjacent fluid (yellow arrow) indicate acute cholecystitis. A nuclear medicine hepatobiliary scan was also performed (not shown) and demonstrated no radiopharmaceutical present in the gallbladder due to cystic duct obstruction. B. Ultrasound of gallbladder used for guidance of percutaneous needle (red arrow) placement for cholecystostomy. C. Ultrasound of gallbladder demonstrating drainage catheter in the lumen (blue arrow). Discussion: Cholecystitis is the second most common surgical emergency seen in pregnancy after appendicitis. [1] Surgical intervention is typically safe for both the mother and fetus , due to improved morbidity when utilizing the laparoscopic approach rather than open cholecystectomy. [2]. In cases of high risk pregnancy or when treating an unstable peripartum patient, percutaneous cholecystostomy is an important important image-guided, minimally invasive alternative to surgical cholecystectomy [ 3-6 ]. This technique has proven effective for cases of acute cholecystitis occurring during the third trimester, allowing for management until delivery when surgery becomes safer. [7] . Percutaneous cholecystostomy is usually followed by laparoscopic cholecystectomy in the postpartum period once the patient has been stabilized [ 3,7 ]. In pregnancy, ultrasound is used for imaging guidance due to lack of ionizing radiation encountered with CT scan or fluoroscopy [5]. The transhepatic or transperitoneal insertion of an access needle is followed by gallbladder catheterization with either the Seldinger technique or a trocar system [8-11]. Figures 1 and 2 are imaging studies on a pregnant patient with acute cholecystitis and was too unstable to undergo surgery. The patient underwent a percutaneous cholecystostomy using the Seldinger technique and US guidance. After the patient delivered and was stable, the patient had a laparoscopic cholecystectomy and fully recovered. Major complications of percutaneous cholecystostomy include hemorrhage, pneumothorax, biliary leak, and peritonitis, with the transhepatic approach having increased risk of pleural or hepatic damage [8,9,11]. ​​​​ References: Angelini DJ. Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy. J Midwifery Womens Health . 2003;48(2):111-118. doi: 10.1016/s1526-9523(02)00417-8 . Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North Am . 2014;94(2):455-470. doi: 10.1016/j.suc.2014.01.005 Hojberg Y, Patel K, Shebrain S. Utilizing Percutaneous Cholecystostomy Tube as a Temporary Minimally Invasive Approach for Acute Cholecystitis during Third Trimester of a High-Risk Pregnancy. Case Rep Gastroenterol . 2022;16(1):49-54. Published 2022 Feb 14. doi: 10.1159/000522060 Baron   TH , Grimm   IS , Swanstrom   LL . Interventional approaches to gallbladder disease . N Engl J Med . 2015 ; 373 ( 4 ): 357 – 65 . doi: 10.1056/NEJMra1411372 Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond. Radiographics . 2023;43(8):e230029. doi: 10.1148/rg.230029 Rana P, Gupta P, Chaluvashetty SB, et al. Interventional radiological management of hepatobiliary disorders in pregnancy. Clin Exp Hepatol . 2020;6(3):176-184. doi: 10.5114/ceh.2020.99508 Caliskan K. The use of percutaneous cholecystostomy in the treatment of acute cholecystitis during pregnancy. Clin Exp Obstet Gynecol . 2017;44(1):11-13. https://pubmed.ncbi.nlm.nih.gov/29714857/ Ginat D and Saad W. Cholecystostomy and Transcholecystic Biliary Access. Tech Vasc Interv Radiol. 2008;11(1):2-13. doi: 10.1053/j.tvir.2008.05.002 Little MW. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68(7): 654-660. doi: 10.1016/j.crad.2013.01.017 Venara A, Carretier V, Lebigot J, E Lermite. Technique and indications of percutaneous cholecystostomy in the management of acute cholecystitis in 2014. J Visc Surg. 2014;151(6):435-439. doi: 10.1016/j.jviscsurg.2014.06.003 Beland MD, Patel L, Ahn SH, Grand DJ. Image-Guided Cholecystostomy Tube Placement: Short- and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement. AJR Am J Roentgenol. 2019;212: 201-204. doi: 10.2214/AJR.18.19669 Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Radiology PowerPoint Tip • Xray of the Week • Week #49 Have you ever wondered how to get a scrollable image stack of CT or MR images on a single PowerPoint slide. There is a way to do it! Australian Emergency Medicine Specialist Dr. Andy Buck shares how to get a scrollable image stack on a single PowerPoint slide on a Mac. The basic steps on Mac: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use Osirix to convert from DICOM to JPEG. Make sure the images are de-identified either with PACS or Osirix. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Select all and click Animate> Appear. 5. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 6. Below under "Timing", click Start> On Click. 7. Save. 8. In presentation mode, use mouse or wheel to scroll through the images. Here is a video of the Windows version by senior editor at Radiopaedia.org , Dr. Matt Skalski : How to add scrollable stack of CT or MRI Images on Microsoft PowerPoint 365 (2020) from Chris Nguyen: Basic steps for Windows: 1. Export the image stack from PACS as JPEG images. If your PACS can not export as JPEG, use DICOM Converter to convert from DICOM to JPEG. Make sure the images are de-identified in PACS prior to download. 2. Resize all images to 630 x 630 pixels. 3. Copy and paste the entire set of JPEG images to a single blank slide. 4. Click animations on the toolbar, click on Custom Animation 5. Click the little triangle on Add Effect>Entrance> Appear. 6. On the right side, where the list of "Play Selected" is, select all (with Ctrl-A) 7. Above at "Start" select "On Click". 8. Save. 9. In presentation mode, use mouse or wheel to scroll through the images. How to export a perfect size and format for Carestream PACS users: 1. First make an empty new folder in your documents folder called "CT stack" or something else related to the case. You will use this to save the images. 2. In PACS, use layout 4 on 1 in stack mode. Make sure this box is selected. 3. Click "hide DICOM Annotations" to de-identify the images. 4. Click Export > Save > Save as File 5. In the dialogue box -File Name: Browse back to your empty folder called "CT stack" select and make a name for the images -Save as type: JPEG -Selection: Current Selection -Size: As displayed on screen 5. Click Save 6. Navigate back to your images and import to PowerPoint as described above in the basic steps for Windows or Mac starting at step #3. This is a PowerPoint PPT file I did as a demo: Click here to download Kevin M. Rice, MD serves as the Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Radiologist with Renaissance Imaging Medical Associates . Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

RUQ pain, septic, unstable BP • Xray of the Week Figure 1. What is the important finding on these images. Figure 2. A. HIDA scan showing liver, common bile duct, small bowel B. Magnified view HIDA scan showing common bile duct (green arrow) and duodenum (blue arrow). Note that tracer is not present in the gallbladder due to cystic duct obstruction. C. Abdominal CT showing enlarged gallbladder with gas in the gallbladder wall (yellow arrow) and cholelithiasis (red arrow). Discussion: Emphysematous cholecystitis is a rare, life-threatening form of acute cholecystitis that occurs when gas-producing bacteria invade the gallbladder wall and cause necrosis (1). Air accumulates in the wall as seen in figure 2C, which can be attributed to gallbladder ischemia, tissue infarction, drugs, abdominal trauma, or incompetence of the sphincter of Oddi (1). Emphysematous cholecystitis typically occurs in diabetic men and puts patients at increased risk of gallbladder perforation (2). Emphysematous cholecystitis has echogenic foci with reverberation artifact on ultrasound, but ultrasound is less sensitive and specific than CT scan (3). The appearance of air in the lumen on ultrasound is also known as the “ring-down artifact” or “dirty shadowing” (4). Emphysematous cholecystitis can be distinguished from acute cholecystitis on CT due to the presence of gas in the gallbladder wall or lumen (1,5). On CT, emphysematous cholecystitis may also demonstrate pericholecystic inflammatory changes, intrahepatic abscess, gallbladder wall thickening, cholelithiasis, and intraperitoneal free air (1,3). On MRI, emphysematous cholecystitis shows intraluminal gas and intramural necrosis as well as gallstones in the neck of the gallbladder (1). Emphysematous cholecystitis may also present with the “champagne sign” or effervescent gallbladder sign on MRI, which refers to the foci of gas in the wall (1). Treatment of emphysematous cholecystitis includes broad-spectrum antibiotics and emergency cholecystectomy, although patients not suitable for surgery may undergo temporary percutaneous cholecystostomy (2,3). Click here to see what was done for this patient: Treatment of Emphysematous Cholecystitis ​​​​ References: Safwan M, and Penny SM. Emphysematous Cholecystitis: A Deadly Twist to a Common Disease. Journal of Diagnostic Medical Sonography, vol. 32, no. 3, May 2016, pp. 131–37. doi: 10.1177/8756479316631535 Yen WL, Hsu CF, Tsai MJ. Emphysematous cholecystitis. Tzu Chi Medical Journal. 2016;28(1):37-38. doi: 10.1016/j.tcmj.2015.12.001 Sunnapwar A, Raut AA, Nagar AM, Katre R. Emphysematous cholecystitis: Imaging findings in nine patients. Indian J Radiol Imaging. 2011;21(2):142-146. doi: 10.4103/0971-3026.82300 Aherne A, Ozaki R, Tobey N, Secko M. Diagnosis of emphysematous cholecystitis with bedside ultrasound in a septic elderly female with no source of infection. J Emerg Trauma Shock. 2017;10(2):85-86. doi: 10.4103/JETS.JETS_75_16 Chen, Ming-Yu, et al. Emphysematous Cholecystitis in a Young Male without Predisposing Factors: A Case Report. Medicine, vol. 95, no. 44, Nov. 2016, p. e5367. doi: 10.1097/MD.0000000000005367 Amara Ahmed is a medical student at the Florida State University College of Medicine . She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature , a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 UPDATE: Dr. Ahmed will be a radiology resident at University of Florida in July 2024. All posts by Amara Ahmed Kevin M. Rice, MD  is the president of Global Radiology CME and is a radiologist with Cape Radiology Group . He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital  in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide  innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.  He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator  by AuntMinnie.com . He has continued to teach by mentoring medical students interested in radiology . Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Septic Shock and Abdominal pain • Xray of the Week 2018 A 57 yo M presented to the Emergency Department with septic shock and vague abdominal pain. What is the diagnosis and what is the treatment of choice? Figure 1. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound. Figure 2. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound. Red arrow: Thick-walled gallbladder with surrounding mesenteric fat stranding indicative of acute cholecystitis seen on CT scan. Green arrow: Edema in thickened gallbladder wall seen on ultrasound. Figure 3. CT images following placement of cholecystostomy tube (Green arrow). Discussion: Acute cholecystitis is the main complication of gallstones and is a common cause of acute right upper quadrant pain. While the vast majority are associated with gallstones, 5-10% of cases are due to acalculous cholecystitis. As in this case, if there are no gallstones, the diagnosis of acute acalculous cholecystitis can be suggested if there is gallbladder wall thickening and surrounding edema (Fig. 1-2). Adjacent fluid, abscess, and positive ultrasonographic Murphy sign may also be present. Severe trauma, critical illness, burn, diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest are all associated with acute acalculous cholecystitis. The most common indication for percutaneous cholecystostomy is with cases of known cholecystitis -either calculous or acalculous- in patients who are too high risk for surgery. However, the procedure should be considered in critically ill patients with unexplained sepsis. Complications of the procedure include bile leak, bleeding, and bowel injury. The most common cause of bile leak and recurrent sepsis is catheter dislodgement, which is why it is advised to coil the tube inside the gallbladder if possible. References: 1. Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol. Clin. North Am. 2010;39 (2): 343-57, x. 2. Mirvis SE, Vainright JR, Nelson AW et-al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR Am J Roentgenol. 1986;147 (6): 1171-5. 3. Joseph T, Unver K, Hwang GL et-al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol. 2012;23 (1): 83-8.e1 . 4. Huang CC, Lo HC, Tzeng YM et-al. Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department. Emerg Med J. 2007;24 (12): 836-40 Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates . Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD