JAMA Surgery: Pain Topic Collection

Image of the Month—Quiz Case

Marcotte E, Afaneh C, Pomp A, et al. — Mon, 01 Apr 2013 00:00:00 GMT

A 50-year-old woman of Caribbean descent presented to an outside hospital with a history of several months of recurrent postprandial right upper quadrant pain associated with nausea and vomiting. Her white blood cell count and liver function test results were within normal limits. She underwent abdominal ultrasonography and a computed tomography scan of the abdomen, which showed cholelithiasis and a questionable cystic dilatation of the common bile duct. She requested a transfer to the Weill Cornell Medical Center. Serologic test results for Echinococcus were negative. A magnetic resonance cholangiopancreatography was ordered to characterize the anatomy. This showed a roundlesion centered in the hepatic hilum measuring 1.9 × 1.9 × 2.1 cm with thin internal septations (Figure 1). Although it was in proximity to biliary structures, a direct communication was not visualized. There was no evidence of lymphadenopathy. She was scheduled for a laparoscopic cholecystectomy and resection of the lesion (Figure 2).

Image of the Month—Quiz Case

Sigman M, Shaar M, Islam K, et al. — Mon, 01 Apr 2013 00:00:00 GMT

A 62-year-old woman with a medical history of gastroesophageal reflux disease, hypothyroidism, and remote bronchial tuberculosis presented to the emergency department with acute-onset bright red blood per rectum. She denied pain or change in bowel habits until she had large-volume loose bloody stools the day of presentation. She was anemic and hypotensive, requiring intensive care unit admission and multiple transfusions. Multiple diagnostic modalities were used including nuclear medicine bleeding scan, push enteroscopy, and double-balloon endoscopy. Findings were significant only for several nonbleeding gastric antral ulcers on esophagogastroduodenoscopy and rare, nonbleeding ascending colonic diverticula on colonoscopy. Blood was noted in the small intestine on endoscopy without an obvious lesion or source. A follow-up computed tomography enterography showed a 2-cm enhancing mass in the proximal small bowel as displayed in Figure 1.

Image of the Month—Diagnosis

Mon, 01 Apr 2013 00:00:00 GMT