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.
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.
A. Necrotizing fasciitis
B. Cholecystocutaneous fistula
C. Everted xiphisternum
D. Abdominal wall endometrioma
Gordon PE, Miller DL, Rattner DW, Conrad C. Image of the Month—Quiz Case. Arch Surg. 2011;146(4):487. doi:10.1001/archsurg.2011.66-a