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Right Upper Quadrant Pain and Fever

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BACKGROUND

An 85-year-old man presents to the emergency room with right upper abdominal pain and weakness for the past 2 days. He denies having shortness of breath, fevers, or chest pain. He has a medical history significant for hypertension, congestive heart failure, and adult-onset diabetes. He states that he is taking all of his medications as prescribed.

On physical examination, the patient has a blood pressure of 157/51 mm Hg, heart rate of 112 beats per minute, temperature of 36.4°C (97.5°F), and respiratory rate of 20 breaths per minute. The patient is visibly jaundiced on general inspection. Findings on cardiac and respiratory examination are normal, but he has tenderness to palpation in the right upper quadrant, with guarding. No abdominal rigidity or rebound is noted.

Laboratory investigations reveal the following levels: WBC count 15.3 X 10⁹/L, total bilirubin 18.2 mg/dL, direct bilirubin 14.2 mg/dL, alkaline phosphatase 132 U/L, aspartate aminotransferase 152 U/L, alanine aminotransferase 63 U/L, amylase 185 U/L, and lipase 81 U/L. Ultrasonography of the right upper quadrant reveals abnormalities (see Image 1), and a follow-up abdominal CT scan confirms the findings (see Image 2).

What is the diagnosis?

Hint
This condition is most commonly seen in elderly men with type 2 diabetes.

Authors:	Renita Butler, MD, Resident, Department of Radiology, University of Texas Southwestern Medical Center, Dallas Pramod Gupta, MD, Staff Physician, Department of Radiology, Dallas VA Medical Center, Tex

eMedicine Editor:	Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine, Section of Emergency Medicine, Department of Surgery, Attending Physician, Medical Director, Department of Emergency Services, Yale-New Haven Hospital, Conn

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