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Image of the Month—Interactive Quiz

Image of Figure 1

Figure.
Gallbladder with a thickened wall and multiple stones.

Farid Meybodi, MBChB; Guy D. Eslick, PhD, FFPH; Michael R. Cox, MBBS, MS, FRACS

An 88-year-old woman presented to the emergency department with a 2-day history of gradual-onset, increasing right upper quadrant pain with aggravation on movement and cough. There was no complaint of nausea, vomiting, or change in her bowel habits. Her medical and surgical history included hypertension, gout, hypercholesterolemia, hysterectomy, diverticulosis, and hip replacement complicated by deep vein thrombosis. Physical examination revealed normal vital signs and respiratory and cardiac functions. On abdominal examination, there was no asymmetry or hernia, bowel sounds were present, and a palpable tender mass was detectable in the right upper quadrant, with significant guarding. The Murphy sign was positive and the rest of the abdominal examination was unremarkable. White blood cell count was 13 600/μL (to convert to x109/L, multiply by 0.001) with a neutrophil count of 11 700/μL, and all liver function test results were normal except for a mildly raised bilirubin level of 1.8 mg/dL (to convert to micromoles per liter, multiply by 17.104). Ultrasonography revealed thickening of the gallbladder wall with multiple calculi (Figure). Diameter of the common bile duct and the intrahepatic biliary system were normal. The patient was considered for laparoscopic cholecystectomy, which was done in less than 24 hours of her admission.

See the full article for an explanation and discussion.