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Special Feature
April 2011April 18, 2011

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Department of Surgery, Massachusetts General Hospital (Drs Gordon, Rattner, and Conrad), and Tufts University School of Medicine (Ms Miller), Boston.




Copyright 2011 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2011

Arch Surg. 2011;146(4):487. doi:10.1001/archsurg.2011.66-a

An 83-year-old woman with a noncontributory surgical history presented with nearly 1 month of mild, intermittent right upper quadrant pain. She soon noticed a slowly growing mass in this area. She denied fever, chills, nausea, or a history of trauma. Physical examination revealed a fluctuant, palpable mass in the right upper quadrant with overlying erythema and mild tenderness to palpation (Figure, A). Laboratory values were significant for a white blood cell count of 13.4 million /μL (to convert to × 109/L, multiply by .001). Noncontrast abdominal computed tomography demonstrated a large hiatal hernia, small bilateral pleural effusions, and a right anterior abdominal wall subcutaneous lesion that was approximately 5 × 9 cm. In addition, there were multiple large gallstones within an edematous gallbladder with pericholecystic fat stranding (Figure, B). Surgical management was indicated.

Image not available

Physical examination and computed tomography findings. A, Right upper quadrant erythema, mild tenderness to palpation, and distention overlying a protruding, fluctuant mass in the right upper quadrant. B, Computed tomography image reveals a 5 × 9-cm right anterior abdominal wall lesion.

What Is the Diagnosis?

A.  Necrotizing fasciitis

B.  Cholecystocutaneous fistula

C.  Everted xiphisternum

D.  Abdominal wall endometrioma