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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.



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.