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Special Feature
December 1, 2004

Image of the Month—Quiz Case

Author Affiliations

Copyright 2004 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2004

Arch Surg. 2004;139(12):1383. doi:10.1001/archsurg.139.12.1383

A 44-year-old woman complained of progressive nausea, vomiting, and increasing right upper quadrant pain. Approximately 1 month earlier, she had presented to the emergency department with a generalized tonic-clonic seizure. A computed tomographic scan at that time showed a left temporal hematoma and 2 hyperattenuated lesions located in the left thalamus and left caudate lobe; subsequent magnetic resonance imaging showed multiple hemorrhagic lesions throughout the brain that were worrisome for metastatic disease. Extensive evaluation was performed, and an abdominal computed tomographic scan showed a 2 × 5-cm lesion in the left lobe of the liver with some small scattered lesions of unknown significance. The hepatic lesion underwent biopsy with ultrasound guidance and was found to be a metastatic malignant melanoma; incidentally noted was the possibility of sludge or polyps on ultrasound examination of the gallbladder. The patient began treatment with whole brain radiation and high-dose interferon alfa-2a.

At the time of surgical consultation, the patient had been experiencing 2 days of nausea, vomiting, and right upper quadrant pain that radiated to the right scapula. She was also severely anorectic because of her symptoms. On physical examination, she was cachectic and had a palpable, distended, tender gallbladder and a tender liver. A computed tomographic scan was obtained (Figure 1). The patient underwent open cholecystectomy the following day. The gross pathological specimen is shown in Figure 2.

What Is the Diagnosis?

A.Pigment gallstones

B.Malignant melanoma of the gallbladder

C.Gallbladder polyps

D.Cholesterolosis of the gallbladder