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Special Feature
November 15, 2010

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Department of Surgery, San Antonio Military Medical Center, Lackland Air Force Base, Texas (Drs Propper, Lundy, Tyner, and Rasmussen); and Norman M. Rich Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland (Dr Rasmussen).



Arch Surg. 2010;145(11):1125. doi:10.1001/archsurg.2010.244-a

A 26-year-old man presented with abdominal pain that had increased in severity over 48 hours prior to evaluation. After further questioning, the patient admitted to daily intravenous heroin use and hospitalization at another facility a month previously following an assault. At the time of this previous injury 1 month prior, the patient stated that he had sustained blunt abdominal injuries and had undergone a procedure to stop bleeding.

At our institution, the patient had a Glasgow Coma Scale score of 15 and a systolic blood pressure of 70 mm Hg, which improved after crystalloid infusion. Abdominal examination revealed percussion tenderness consistent with peritonitis. Laboratory results revealed an elevated white blood cell count. Abdominal computed tomography revealed a 24 × 18-cm abnormality in segments VI and VII with evidence of metallic coils in a branch of the right hepatic artery (Figure 1and Figure 2). It was presumed that these coils were remnants from the management of the blunt hepatic injury sustained a month prior. In the presence of sepsis with hypotension and physical examination findings confirming peritonitis, an urgent exploratory midline laparotomy was performed following administration of antibiotics and a brief crystalloid resuscitation.

Figure 1. 
Scouting computed tomographic scan.

Scouting computed tomographic scan.

Figure 2. 
Axial slice on computed tomography. R indicates right; L, left.

Axial slice on computed tomography. R indicates right; L, left.

What Is the Diagnosis?

A. Giant hepatic cyst

B. Giant hepatic abscess

C. Sigmoid volvulus

D. Giant hepatic cystadenoma