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Special Feature |

Image of the Month—Quiz Case FREE

David J. Rea, MD; Jon A. van Heerden, MD
[+] Author Affiliations

Author Affiliation:Division of Gastroenterologic and General Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn.

Section Editor: Grace S. Rozycki, MD

Arch Surg. 2004;139(12):1383. doi:10.1001/archsurg.139.12.1383.
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Published online

A 44-year-old woman complained of progressive nausea, vomiting, and increasing right upper quadrant pain. Approximately 1 month earlier, she had presented to the emergency department with a generalized tonic-clonic seizure. A computed tomographic scan at that time showed a left temporal hematoma and 2 hyperattenuated lesions located in the left thalamus and left caudate lobe; subsequent magnetic resonance imaging showed multiple hemorrhagic lesions throughout the brain that were worrisome for metastatic disease. Extensive evaluation was performed, and an abdominal computed tomographic scan showed a 2 × 5-cm lesion in the left lobe of the liver with some small scattered lesions of unknown significance. The hepatic lesion underwent biopsy with ultrasound guidance and was found to be a metastatic malignant melanoma; incidentally noted was the possibility of sludge or polyps on ultrasound examination of the gallbladder. The patient began treatment with whole brain radiation and high-dose interferon alfa-2a.

At the time of surgical consultation, the patient had been experiencing 2 days of nausea, vomiting, and right upper quadrant pain that radiated to the right scapula. She was also severely anorectic because of her symptoms. On physical examination, she was cachectic and had a palpable, distended, tender gallbladder and a tender liver. A computed tomographic scan was obtained (Figure 1). The patient underwent open cholecystectomy the following day. The gross pathological specimen is shown in Figure 2.

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Figure 1.
Graphic Jump Location

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Figure 2.
Graphic Jump Location


A.Pigment gallstones

B.Malignant melanoma of the gallbladder

C.Gallbladder polyps

D.Cholesterolosis of the gallbladder


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Figure 1.
Graphic Jump Location
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Figure 2.
Graphic Jump Location




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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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