Right Upper Quadrant Of Abdomen Research Articles

Accidentally Case of Chilaiditi’s Syndrome in COVID-19 Geriatric Patient

Chilaiditi’s syndrome is a rare disease with an incidence of 0.025-0.28% cases, where it shows colon interposition between diaphragm and right lobe of liver. Usually related to congenital malformation include the absence, weakness, or elongation of suspensory ligaments of transversal colon or falciform ligaments. The 83-year-old woman was admitted with 1-week history of fatigue, lacked the will to eat and drink. Nausea and vomiting were sometimes accompanied with abdominal pain. Patient often had difficulty in defecating even though she had been eating fruits, she often needed laxatives. Patient had a history of osteoarthritis and hypertension.Physical examination appeared moderately-ill, with gasglow coma scale (GCS) 14 and blood pressure 150/90 mmHg. From abdomen epigastric tenderness (+). From thoracic X-ray found visible interposition of colon at right-upper quadrant of abdomen. Geriatric index fall risk assessment = 11 and mini mental state examination (MMSE) = 22. This patient was a geriatric patient with multiple diagnosis and frailty. Patient had a history of osteoarthritis contributes to patient’s instability. Chronic constipation was also quite disturbing cause an interposition of colon. Patient had coincidence with COVID-19 with comorbidity and geriatric syndrome. Thorough care, close monitoring, and optimal management should be applied.

Approach of Individualised Medicine in a Complicated Case of Cholelithiasis, Elongated Uterus with Ovarian Cyst—An Evidence-Based Case Report

AbstractGallstones are the most common biliary pathology. They are formed because of abnormal bile composition. Symptomatic gallstones present as pain in the right upper quadrant or epigastric region, which may radiate to the back. Ultrasonography of the gallbladder is very accurate in the identification of gallstones. Laparoscopic cholecystectomy is a minimal-access approach for the removal of the gallbladder together with its stones. A 28-year-old lady presented with complaints of pain in the right upper quadrant of abdomen, which was relieved by pressure, nausea and occasionally vomiting especially after having a rich meal for 1 month with constant dull pain in lower abdomen during menses for 2 to 3 months. Her ultrasonography of whole abdomen revealed cholelithiasis (stone size 8mm), elongated uterus with left ovarian cyst. Individualised medicine Natrum muriaticum was prescribed in a centesimal scale which showed a positive effect in the case within a short span of time. Causal attribution of changes in her condition to the homoeopathic treatment was assessed by Modified Naranjo Criteria. Future observational studies and randomised control trials are suggested to ascertain the efficacy of homoeopathic medicine in such cases.

A Rare Localization of Tuberculosis: A Case Report and a Review of the Literature

The hepatic tuberculosis is rare. The interest of this Knowledge consists in the diagnostic problems particularly in its primitive and macronodular forms. It touches all ages with a peak of frequency during 17 - 50 years old, and a female prevalence. The clinical picture is polymorphous but it is still dominated by the prolonged fever and the alteration of the general state. Case report: 30-year-old female was admitted to our hospital with painless swelling on the right side of chest and feeling of pressure in the right upper quadrant of abdomen. She has no history of fever, weight loss, and night sweating or poor appetite. On clinical examination, the patient was in good general condition. The inflammatory tumefaction of the right chest wall was marked. The palpation of the abdomen revealed a sensitive hepatomegaly. A CT scan revealed a large cystic liver. The laboratory investigations were normal. This appearance was suggestive of a hydatid cyst of the right liver and a surgical management was decided. But the histological study revealed granulomatous inflammation consisting of tuberculoid type granuloma with caseous necrosis. However, abscess of the liver due to MT was highly suspected and anti-tuberculosis therapy was started, the patient responded well. Conclusion: The analysis of this observation and the data of the literature make it possible to retain the rarity; the polymorph expression and not very suggestive of this location.

Experience of Hydatid Cyst Management in a Tertiary Care Center in Kathmandu Nepal

Introduction: Hydatid cyst is a common disease in Asian subcontinent produced by the larval stage of Echinococcus granulosus. The most common site of involvement is the liver. The mode of presentation can vary. The management of hydatid cyst includes medical treatment with albendazole, ultrasound guided aspiration and instillation of scolicidal agents as well as surgical treatment. Surgery can be perfomed by open or laparoscopic approach. The aim of this study is to analyze the cases of hydatid cyst of liver managed in our set up. Methods: This is a retrospective study of 45 patients with hydatid cyst managed in Kathmandu Model Hospital over the last five years. Data were collected from the patients hospital records. Demographic parameters, chief complains, radiological findings, anti-echinococcal immunoglobulin findings, mode of management, complications of surgery were evaluated. Results: Majority of our patients were female (66.7%). Mean age of the patients were 39±17.2 years (16 to 89 years). Most common symptom of presentation was pain in right upper quadrant of abdomen. Most common site of involvement was liver (93.33%) followed by spleen (4.4%). There was one case of ruptured pulmonary hydatid cyst which was referred. Operative management was done in patients (17.77%) out of which five patients (62.5%) underwent laparoscopic partial pericystectomy and omentoplasty. No major complications were encountered in any of the cases managed surgically. Conclusion: Majority of cases occured in liver. Most cases were managed conservatively. Laparoscopic management of hydatid cyst is effective.

A New Hepatotoxic Agent : Goji Berry

ABSTRACT INTRODUCTION: Goji berry has long been used as a healthy aliment for healthy vision, strengthening the immune system, protecting the liver, improving circulation, remedy for diabetes, enhancing sexual performance and general health. But there are not enough study on its constituents, pharmacology and safety. CASE REPORT: This case report describes a 24-year-old female patient was admitted to emergency service due to complaints of nausea, vomiting and abdominal pain. Ictherus at sclera and sensivitiy on the right upper quadrant of abdomen were found on the physical examination. Blood tests revealed high liver function tests. The causes of jaundice and impaired liver function were all excluded and toxic hepatitis due to goji berry consumption was considered in patient. CONCLUSION: Goji berry is a traditional nutrient that is increasingly used for its various effects. To date, there are some articles declared allergic reactions as toxic effect. To our knowledge this case is the first publication that goji berries can be toxic to the liver. Although larger studies are required, it should be kept in mind that liver toxicity may occur during intensive use.

Emergency Medicine Resident versus Radiologist in Detecting the Ultrasonographic Signs of Acute Cholecystitis; a Diagnostic Accuracy Study.

Dependence of ultrasonography on the operator's skill plays a major role in the differences between various studies in reporting its diagnostic accuracy. Therefore, the present study was done with the aim of comparing the ultrasonography findings performed by emergency medicine resident and radiologist in evaluation of acute cholecystitis. The present diagnostic accuracy study has been carried out on patients presenting to the emergency department with complaint of pain in the right upper quadrant of abdomen suspected with acute cholecystitis. All the patients underwent gallbladder ultrasonography by a trained emergency medicine resident and a radiologist and their findings were compared with surgical and pathology findings regarding gallstone and increased gallbladder wall thickness. 51 patients with the mean age of 42.3±15.8 (17-81) years were analyzed (82.4% female). The overall agreement between emergency medicine resident and radiologist in ultrasonographic diagnosis of cholecystitis was 0.421 (95% CI: 0.118-0.724). Based on the pathology and surgical findings, acute cholecystitis was confirmed for all 51 (100%) patients. Meanwhile, based on the ultrasonographic report of radiologist and emergency medicine resident only 45 (88.2%) and 34 (66.7%) patients, respectively, were diagnosed with cholecystitis. Screening performance characteristics of ultrasonography by radiologist for detection of gallbladder stone (p = 0.010) and gallbladder wall thickness (p < 0.0001) were significantly better than emergency medicine resident. The screening performance characteristics of ultrasonography by radiologist in detection of gallstones and increased wall thickness of gallbladder were significantly better.

Blunt chest trauma with diaphragmatic laceration presenting as delayed hemothorax

We report a case of delayed hemothorax resulted from diaphragmatic laceration after blunt chest trauma and its successful treatment. Initial chest X-ray and initial computed tomography (CT) scan revealed no hemothorax in this 19-year-old male with a stable hemodynamic condition although there were multiple contusion wounds with ecchymoses over the right chest wall, shoulder, back and right upper quadrant of abdomen. In the following day, he experienced progressive dyspnea and conscious disturbance. Massive hemothorax was verified through repeated chest X-ray and CT scan. A laceration wound about 3 cm in length with continuous oozing at the dome of the right hemidiaphragm was noted in emergent thoracotomy. The laceration was repaired, and the patient had an uneventful recovery after the surgery. We proposed that traumatic diaphragmatic injury should be considered in any patient who has sustained blunt trauma to the lower chest and upper abdomen regions, watchful observation and high index of suspicion are necessary.

A Rare Paraneoplastic Manifestation of Hepatocellular Cancer

Introduction: Neutrophilic leukocytosis has been seen in many solid non-hematological tumors producing G-CSF(granulocyte-colony secreting factor). However, few cases have been reported worldwide of hepatocellular cancer (HCC) with neutrophilic leukocytosis. (1)(2) Case: 84 year old male patient presented with failure to thrive and loss of weight. No alcohol abuse. On examination there was tenderness in right upper quadrant of abdomen and splenomegaly. Labs: Hb- 8.6gm/dl, RBC- 2.9 M/mcl,Hct-26.5%, WBC-17.2 K/mcL(Granulocyte- 86.7%, Lymphocyte-8.2%,Monocyte-4%,Eosinophil-1.1% and Basophil 0%). Hepatitis panel was negative. CA 19-9:100.7 U/ml. Pan cultures revealed no growth. JAK2 V617F- Negative. BCR-ABL, t(9,22)- Negative. Bone marrow biopsy: hyper-cellular with cellularity ranging from 60-70% with myeloid hyperplasia and neutrophilia. CT abdomen: Spleen- 16 cm and liver mass- 10cm. Biopsy of the liver mass was done as shown in figure 1.Figure 1Histopathology: Biopsy of liver mass-positive for pan-cytokeratin, weakly positive for HepPar-1 and negative for CK7 and CK20, favoring poorly differentiated adenocarcinoma of liver. Discussion: HCC is 5th leading cancer in men and 8th leading cancer in women worldwide.3 In US annual incidence of hepatocellular cancer is 6 per 100,000 with men at three times higher risk than women 4. The common paraneoplastic syndrome manifestations include hypercalcemia, hypocholesteremia, hypoglycemia and erythrocytosis. On reviewing literature, there were 8 reported cases of HCC with increased G-CSF and interleukin-6 levels that caused neutrophilic leukocytosis. (1) (2) It is known to induce rapid growth of tumors and poorly differentiated carcinoma. Among the cases reported it was noted that these tumors were large in size and the size of the tumor was 10 cm in our patient. Neutrophils produce hydrogen peroxide (H2O2) which causes aggressive tumor growth.1 Increased neutrophil count is a sign of poor prognosis in most of the cancer. The diagnosis of neutrophilic leukocytosis as paraneoplastic manifestation can be supported by elevated G-CSF levels, elevated interleukin-6 levels,decrease in leukocyte count after tumor resection and immunohistochemical analysis of the specimen for G-CSF secreting tumor cells but since our patients opted for palliative therapy none of the mentioned tests was done. All the other causes for neutrophilic leukocytosis was ruled out in our patient and HCC was the only attributable cause.

Importance of Routine Histopathology of Gallbladder after Elective Cholecystectomy for Gallstones

Introduction: Gallstones are the hard deposits in the gallbladder, which is a sac – like organ lying on the inferior surface of liver in the right upper quadrant of abdomen. Cholecystectomy is the first line surgical procedure to manage symptomatic gallstone. Carcinoma gallbladder carries worst prognosis of all cancer mortality and seen in patients with chronic cholecystitis due to cholelithiasis. The purpose of conductingthis study was to highlight the fact, that the histopathology of the gallbladder in Pakistan is only restricted to those specimens, which are associated with macroscopic abnormalities.Objective: The frequency of gallbladder carcinoma in routine histopathology after elective Cholecystectomy for gallstones who did not show any macroscopic findings preoperatively.Material and Methods: This cross sectional study of 250 patients of both gender aged between 18 – 60 years was conducted in surgical OPD/North Surgical Unit of Mayo Hospital, Lahore in one year duration from 01-01-2014 to 31-12-2014. The non-probability purposive sampling technique was used in this study. Informed consent was taken from all the patients. Their demographics like name, age, gender and address were noted. Open / laparoscopic cholecystectomy was performed depending upon patient’s choice. All gallbladder specimens, those with no obvious gross abnormalities were sent for histopathology (Gross findings, histopathological diagnosis). All data was recorded on a pre-designed proforma and analyzed using SPSS version 20. Mean and standard deviation were used to express the continuous variables like age, stone size and duration of disease. All qualitative variables like gender, number of stones and gallbladder carcinoma were presented in the form of frequency and percentages. Stratification was done for duration of disease, number of stone, size of stone and gender to address effect modifiers. Post stratification chi-square test was applied keeping P-value ≤ 0.05 as significant.Results: In this study the mean age of the patients was 39.52 ± 12.38 years. Among 250 patients, 75 (30%) were males and 175 (70%) females. The mean duration of disease was 5.61 ± 2.75 months. Gallbladder carcinoma on routine histopathology after elective Cholecystectomy was observed in 18 (7.2%) patients whereas 232 (92.8%) patients did not have gallbladder carcinoma. All of the 18 patients who had carcinoma were females which showed a highly significant difference (p &lt; 0.05). Among 153 cases with &lt; 7 mm stone size, carcinoma was observed in 11 patients and in 97 cases with ≥ 7 mm stone size, carcinoma was observed in 7 cases. Among 124 cases with &lt; 5 months of duration of disease, carcinoma was observed in 9 patients and in 126 cases with ≥ 5 months of duration of dis-ease, carcinoma was observed in 9 cases. Among 93 cases with &lt; 2 stones, carcinoma was observed in 7 patients and in 157 cases with ≥ 2 stones, carcinoma was observed in 11 cases. Statistically insignificant difference was found between the duration of disease, number and size of stones and carcinoma of the patients (P &gt; 0.05).Conclusion: Although the frequency of gallbladder carcinoma on histopathology is low, but not negligible, therefore histopathology of gallbladder specimen is necessary to rule out carcinoma.

Squamous Cell Carcinoma of Gallbladder – An Uncommon Presentation

A 51-year-old male patient presented with pain in the upper right quadrant of abdomen since two months, associated with weight loss and fever. Contrast enhanced computed tomography abdomen revealed gallbladder with wall thickening which was asymmetric and heterogeneous at junction of body. An initial diagnosis of cholecystitis with element of cholangitis and abnormal wall thickening with multiple tiny calculi was considered. Open radical cholecystectomy was done. Microscopic and immunohistochemical findings established the diagnosis of moderately differentiated squamous cell carcinoma of the gallbladder. Adjuvant chemotherapy regimen consisting of paclitaxel 175 mg/m 2 and carboplatin AUC 6 was given three weekly for six cycles in the present case. Six months after treatment completion, patient is on regular follow up and disease free on clinical and radiological examination.

Clinical Image: Carcinoid Syndrome

A 21-yr-old female, presented with history of painful lump in right upper quadrant of abdomen with diarrhea and facial flushing (Figure 1) of 15 days duration. There was no associated vomiting, jaundice, melena, headache or any respiratory complaints. On examination, she had hepatomegaly extending 7cm below right costal margin. All routine hematological and biochemical values were normal except for elevated S. Lipase levels.

Informative content of clinical symptoms of acute appendicitis in different terms of pregnancy.

With the purpose to evaluate diagnostic efficacy of some clinical symptoms of acute appendicitis 75 women in different terms of pregnancy were examined. Informative content of such symptoms as Kocher- Volkovich, Rovsing, Bartomje - Michelson, Sitkovsky, Gabay, Brendo, Michelson, Ivanov was studied. Pain syndrome was fixed in all examined women. Pain localization was various and depended on the pregnancy term. During the I trimester of pregnancy the most often pain was manifestated in epigastrium and right lower quadrant, rarely in other abdomen regions. In the II trimester in majority of cases pain occurred in right lower quadrant. During III trimester pain prevailed in right upper quadrant of abdomen. Analyzing informative component of researching symptoms there was noted significant decrease (р&lt;0,05; р&lt;0,01; р&lt;0,001) of their diagnostic value with growth of pregnancy term. Therefore Kocher – Volkovich and Rovsing symptoms were the most informative in the I trimester of pregnancy. Diagnostic efficacy of Brendo(67,3%), Michelson(55,7%), Ivanov(59,6%) symptoms was higher than that of Kocher – Volkovich (36,5%), Rovsing (28,8%), Sitkovsky (51,9%), Bartomje – Michelson (55,7%) symptoms, their value was diminishing together with increase of pregnancy terms.

Jejunojejunal Intussusception

A 36-year-old man presented with nausea, vomiting, constipation, and progressively abdominal distention. His medical and surgical histories were insignificant. On arrival, physical examination revealed a distended abdomen with tympanic percussion and tenderness at the right upper quadrant of abdomen. Abdominal radiograph demonstrated dilated bowel loops. Ultrasonography (US) showed several dilated bowel loops and a target lesion, which indicated intussusception (Figure 1, arrow). Computed tomography (CT) of abdomen (Figure 2) disclosed a jejunojejunal intussusception (arrow) with small bowel obstruction. Exploratory laparotomy with segmental resection of the jejunum was performed and a 3 × 3 cm polypoid mass was found within the resected jejunum. Further pathologic examinations of the lesion confirmed the diagnosis of Burkitt's lymphoma. The postoperative course was smooth, and he was discharged later.

Malignant Peritoneal Mesothelioma: Clinicopathological Characteristics of Two Cases

Introduction. Peritoneal mesothelioma is a rare tumor, presenting difficulties in diagnosis and treatment. Peritoneum is the second most common area of the mesothelioma after pleura, and even synchronous pleural and peritoneal mesotheliomas are observed in 30–45% of all cases. The diagnosis may be difficult due to lack of specific symptoms and clinical findings. In addition, a delay in the diagnosis is not rare especially in the absence of previous asbestos exposure. Here we report two cases of malignant peritoneal mesotheliomas. The diagnostic and therapeutic approaches for these rare neoplasms are discussed. Case Presentation. The cases were two men (one aged 54 years old and the other 40 years old). Prolonged abdominal pain and swelling were the primary presentation symptoms and findings. The mesotheliomas were developed in the right upper quadrant of abdomen in both of the cases. Both cases were treated with surgical resection. Final diagnosis were possible with histological and immunohistochemical documentation of tumor characteristics, which were consistent with dictating a mesothelial origin. No history of asbestos exposure was reported. Conclusion. Peritoneal mesotheliomas are rare clinical entities. However, patients with prolonged abdominal pain and abdominal masses should be considered to have atypical pathologies such as peritoneal mesotheliomas.

LIFE THREATENING BLEEDING FROM A GASTROINTESTINAL STROMAL TUMOUR: A CASE REPORT

LIFE THREATENING BLEEDING FROM A GASTROINTESTINAL STROMAL TUMOUR: A CASE REPORT (Abstract): Gastrointestinal stromal tumours (GIST) are rare tumours of the gastrointestinal tract. They can cause massive gastrointestinal haemorrhage as illustrated in our case. Our patient was admitted to the emergency in shock due to massive haematochezia. The patient was revived with multiple transfusions and crystalloids. 99m-Tc labeled Red Blood Cells (RBC) scan showed bleeding from right upper quadrant of abdomen. Laparotomy revealed a tumour in jejunum which was resected and proved to be GIST by immunohistochemistry. The patient improved dramatically after surgery and his haemoglobin level stabilized at 10g/dL. Repeat RBC scan revealed that there was no bleeding. The postoperative recovery was uneventful. CONCLUSION: GISTs are rare but clinical important tumours. As in our case they can cause life threatening bleeding. Intensive care to stabilize the patient and modern diagnostic methods like RBC scan has proved invaluable. Segmental enterectomy has been the definitive treatment the tumour and the gastrointestinal haemorrhage.

Chilaiditi’s Syndrome with Interposed Sigmoid Colon Mimicking Traumatic Pneumoperitoneum

1Department of Internal Medicine; 2Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Correspondence: Dr Chang-Hsien Liu, No. 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan. Telephone 886-2-87927244, fax 886-2-87927245, e-mail cute610627@yahoo.com.tw Received for publication May 3, 2013. Accepted May 6, 2013 Case presentation A 61-year-old man experienced a contusion on the right hypochondrium in a traffic accident. He was immediately taken to the emergency department and presented with severe pain over the contusion site. His surgical history was unremarkable. On arrival, physical examination revealed decreased breathing sounds in the right lower lung area on auscultation. Distention, hypertympanic percussion and local tenderness over the right upper quadrant of abdomen were also observed. A posteroanterior chest radiograph revealed elevation of the right hemidiaphragm with concerning features for subphrenic free air as well as fracture of right fifth to eighth ribs (Figure 1A). A computed tomography scan of the abdomen with coronal reconstruction revealed hepatodiaphragmatic interposition of the dilated sigmoid colon (Figure 1B). No evidence of pneumoperitoneum was identified. Conservative treatment with oxygenation, chest care and pain control was performed. After the medical therapy, the patient was discharged uneventfully.

Gallbladder perforation with formation of hepatic subcapsular biloma, treated with endoscopic nasobiliary drainage

A 66-year-old man presented with right upper quadrant pain and progressive dyspnea for 2 days. He had history of chronic obstructive pulmonary disease and chronic kidney disease. On admission, he was febrile and had sinus tachycardia. Laboratory findings showed an elevated white blood cell count of 18.01 × 109/L with 92.1 % neutrophils. Liver function tests revealed normal alanine aminotransferase (14 U/L [3 – 37 U/L]), normal total bilirubin (0.6 mg/dL [0 – 1.0 mg/dL]), and elevated alkaline phosphatase (157 U/L [39 – 120 U/L]). Ultrasonography showed a big encapsulated cystic lesion in right upper quadrant of abdomen, with amorphous echogenic material within the lesion. The gallbladder was small in size and a 0.9-cm gallstone was noted ([Fig. 1]).

An Unusual Case of Foreign Body in the Anterior Abdominal Wall

Accidental or intentional ingestion of sharp metallic foreign bodies is a common clinical occurrence. Predisposing factors include excessive alcohol intake, mental impairment and psychiatric illnesses. Usually, the detection of a migratory foreign body is incidental when patients present with unrelated symptoms. A 50-year-old woman attended the surgical outpatient clinic with a foreign body in the anterior abdominal wall. A foreign body was easily palpable on the right upper quadrant of abdomen. Patient was admitted electively and taken to theatre for removal of foreign body under general anaesthesia. Patient made an uneventful recovery and was discharged with no further follow-up.KeywordsForeign body; Abdomen; Ingestion; Perforation

PORCELAIN GALLBLADDER

To the Editor: An 80-year-old man came to a family medicine outpatient clinic for his annual health examination. His past history was notable for chronic cholecystitis, chronic hepatitis B carrier status, iron deficiency anemia, and chronic renal insufficiency. His chest radiography revealed a round opacity with rim and internal amorphous hyperdensities in the right upper quadrant of the abdomen (Figure 1). Laboratory values were within reference ranges except for an elevated serum creatinine level (1.6 mg/dL) and a low hemoglobin level (11.1 g/dL). Abdominal radiography 1 week later confirmed a similar finding in addition to degenerative joint disease of the spine. Computerized tomography identified a thick layer of nonuniform calcifications coating the inner wall of the Phrygian cap of the gallbladder as a large porcelain gallbladder (Figure 2). Chest radiography revealed a round opacity (arrow) with rim and internal amorphous hyperdensities in the right upper quadrant of abdomen. Abdominal computerized tomography showed a thick layer of nonuniform calcifications coating the inner wall of the Phrygian cap of the gallbladder as a large porcelain gallbladder. Porcelain gallbladder is an uncommon finding of chronic cholecystitis characterized by extensive calcification of the gallbladder wall.1 The term “porcelain gallbladder” is used to describe the bluish discoloration and brittle consistency of the gallbladder wall.2,3 The prevalence of porcelain gallbladder in cholecystectomy specimens has ranged from 0.06% to 0.8%.2,3 In 95% of porcelain gallbladder specimens, cholelithiasis is the accompany finding.2 Porcelain gallbladders are five times as common in women as in men, usually in the sixth decade.3 Diagnosis is frequently made by the detection of a palpable mass in the right upper quadrant of the abdomen or incidentally in an abdominal roentgenogram.3,4 The significance of porcelain gallbladder has been thought to be strongly associated with gallbladder cancer, which has a grave prognosis. The incidence of gallbladder cancer in porcelain gallbladder was reported to be 12% to 61% in an early 1960s series,3,5–10 but two 2001 studies showed a lower incidence of gallbladder cancer in porcelain gallbladder (0% and 5%).6,7 These results have raised the question as to whether prophylactic cholecystectomy is necessarily indicated for those who are asymptomatic or have multiple comorbidities.6,7,11 Laparoscopic cholecystectomy is even suggested in the complete intramural calcification type of porcelain gallbladder, which carries a lower risk of gallbladder cancer than the incomplete mucosal calcification type.4,8,11 At present, prophylactic cholecystectomy is the treatment of choice for porcelain gallbladder.11,12 The natural history of porcelain gallbladder is unclear, as is the causal relationship between porcelain gallbladder and gallbladder cancer. The last report suggested that the smaller number of porcelain gallbladders and different ethnicities in the two 2001 reviews might have confounded the incidence of gallbladder cancer in porcelain gallbladders significantly.10 The patient was informed of the risk malignant degeneration of the porcelain gallbladder, but he refused surgery. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: Study concept and design: Fang-Yeh Chu. Acquisition of subjects and data: Fu-Hsiung Su. Analysis and interpretation of data: Wing-Keung Cheung. Preparation of manuscript: Hsiao-Ping Liang. Critical review and approval: All authors. Sponsor's Role: None.

Peri-aortofemoral Prosthesis Urinoma

A 75-year-old woman developed renal failure 1 week after elective aortobifemoral bypass surgery. Postoperative computed tomography showed right hydronephrosis. Tc-99m mercaptoacetyltriglycerine (MAG3) scintigraphy was performed to exclude renal obstruction or acute tubular necrosis. Planar MAG3 images demonstrated right hydronephrosis and unusual accumulation of tracer between the kidneys and the right upper quadrant of abdomen, with new areas of activity in the right lower quadrant on delayed images. SPECT/CT demonstrated MAG3 activity within fluid collections adjacent to the aorta and right iliac/inguinal arteries, consistent with a urine leak. The right upper quadrant activity represented MAG3 accumulation within the gallbladder.