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Special Feature
April 1, 2004

Image of the Month—Quiz Case

Author Affiliations

Grace S.RozyckiMD

Arch Surg. 2004;139(4):449. doi:10.1001/archsurg.139.4.449

A 75-year-old man with a history of type 2 diabetes mellitus, hypertension, and depression sought care at the emergency department with a 5-day history of generalized itching and malaise. At physical examination, the patient was slightly anxious but in no acute distress; his sclera were icteric, and his abdomen was soft, with slight fullness in the right upper quadrant but no discrete masses or tenderness. Laboratory test results demonstrated a white blood cell count of 13 500 cells per microliter (13.5 × 10− 9L) but his electrolyte level was normal. His total serum bilirubin level was 19.5 mg/dL (333.45 µmol/L), and he had an alkaline phosphatase level of 917 IU/L. A computed tomographic (CT) scan of the abdomen was obtained (Figure 1).

A.Complex cystic neoplasm

B.Unusual duplication cysts

C.Periampullary tumor

D.Mirizzi syndrome