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An otherwise healthy 68-year-old white man presented with a 4-day history of hyperthermia, a 6/10 dull pain (analogic pain scale) at the right superior abdominal quadrant, and nausea. Physical examination revealed a temperature of 40.1°C and mild right subcostal tenderness without rebound. Laboratory testing showed a perturbation of hepatic enzymes, an alteration of renal function, and an elevated white blood cell count. Ultrasound revealed the presence of gallbladder stones and of a round hypoechogenic image in the fourth hepatic segment 5 cm in diameter; a computed tomographic (CT) scan of the abdomen confirmed the presence of a hypodense image in the liver and revealed the presence of gas in the gallbladder (Figure 1).
. Computed tomographic scan (2-dimensional) of the abdomen shows a 5-cm abscess of fourth hepatic segment associated with pneumobilia.
A. Hepatocellular carcinoma infiltrating the intrahepatic biliary tree
B. Cholecystocolonic fistula associated with hepatic abscess
C. Echinococcus hydatid associated with acute cholecystitis by anaerobic bacteria
D. Posttraumatic hepatic hematoma and pneumobilia
Costi R, Bataille N, Cazaban A, Montariol T. Image of the Month—Quiz Case. Arch Surg. 2009;144(5):481-482. doi:10.1001/archsurg.2009.64-a