RT Journal
A1 Bhattacharya B, Katta US, Facciuto M
T1 IMage of the month—quiz case
JF Archives of Surgery
JO Archives of Surgery
YR 2011
FD May 1
VO 146
IS 5
SP 627
OP 627
DO 10.1001/archsurg.2011.99-a
UL http://dx.doi.org/10.1001/archsurg.2011.99-a
AB 
A 35-year-old Hispanic man presented to the emergency department with a 5-week history of abdominal pain. The pain radiated from the right upper quadrant to his back. The patient denied any nausea, vomiting, fevers, chills, or changes in bowel habits. His medical history was significant for non–insulin-dependent diabetes for which he takes metformin and pioglitazone. The patient's social history was significant for smoking 5 to 6 cigarettes per day, and he denied alcohol use. Physical examination revealed right upper quadrant tenderness, and findings of ocular examination were negative for sclera icterus. Results of laboratory testing were significant for a total bilirubin level of 1.8 mg/dL and an indirect bilirubin level of 1.0 mg/dL (to convert to micromoles per liter, multiply by 17.104). The remainder of liver function test results were within the reference range. A complete blood cell count demonstrated a white cell count of 5.2 without a left shift. Preoperative gallbladder ultrasound demonstrated a complex heterogeneous mass in the gallbladder fossa measuring 5.4 × 5.1 × 4.6 cm, with no common bile duct dilatation. Magnetic resonance imaging obtained preoperatively is shown (Figure 1) along with a pathology specimen obtained during the operation (Figure 2).