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An Unusual Cause of Right Upper Quadrant Pain.

Division of Gastroenterology and Hepatology, and Department of Pathology, University of North Carolina School of Medicine, Chapel Hill, North Carolina 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 Question: A 32-year-old man with a 2-year history of pain localized to the right upper quadrant was referred to our clinic for evaluation. Pain was reported as dull and constant that was exacerbated by eating. He also reported occasional nausea and vomiting, especially with severe pain. In addition, he reported diarrhea, having 5-6 bowel movements per day that were loose in consistency. He denied blood in stools. Laboratory testing was normal, including white blood cell count, liver function tests, electrolytes, and celiac serology. Previous endoscopic and radiographic tests performed by the referring physician including upper endoscopy, colonoscopy, computed tomography of the abdomen and pelvis (CT A/P), and magnetic resonance cholangiopancreatography were all unremarkable, apart from a retrocecal appendix noted on imaging. Of note, he had undergone an elective cholecystectomy 4 months prior for suspected biliary colic, but his symptoms persisted, and even worsened after this surgery. Physical examination was notable only for tenderness in the right upper quadrant with positive Murphy’s sign (despite prior cholecystectomy). Given the persistent and bothersome right upper quadrant pain, a decision was made to pursue repeat cross-sectional imaging of the abdomen and pelvis. CT A/P images with views of the right upper quadrant area are shown in Figure A (axial), Figure B (coronal), and Figure C (sagittal). What is the cause of this patient’s abdominal pain? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 100 101 102 103 Conflicts of interest The authors disclose no conflicts.