A previously healthy man in his 50s was referred with right upper abdominal pain he had experienced for 20 days, with high-grade fever and chills since the first week. There was no history of trauma or alcohol intake. Clinical examination revealed no icterus or significant lymphadenopathy. There was guarding and tenderness in the right upper quadrant; the liver was firm, smooth, and palpable 3 cm below the right costal margin.
Laboratory investigations were remarkable for white blood cell counts of 13 200/μL (to convert to × 109 per liter, multiply by 0.001) and alkaline phosphatase of 259 U/L (to convert to microkatals per liter, multiply by 0.0167). Ultrasonography of the abdomen revealed a large hypoechoic area in the right lobe of the liver along with gallstones. A contrast-enhanced computed tomography (CECT) scan was performed (Figure 1).
Bharathy KGS, Borle D, Kumar N. Acute Calculous Cholecystitis With Intrahepatic Gallbladder Perforation. JAMA Surg. Published online February 01, 2017. doi:10.1001/jamasurg.2016.5544