A Male Patient with Severe Pain in the Right Hypochondrium

SECTION 2 – ANSWER Case A 45-year-old nondiabetic male presented with complaints of pain in the right hypochondrium for 6 months, which was aggravated in the last 10 days. There was no history of trauma. Ultrasound and computed tomography (CT) evaluation of the abdomen was performed [Figures 1-3].Figure 1: Grayscale ultrasonography image of the liver and gallbladder showing multiple calculi in the lumen of the gallbladder which shows posterior acoustic shadowingFigure 2: Grayscale ultrasound image showing the defect in the wall of gallbladder (sonographic hole sign)Figure 3: Computed tomography image showing defect in the gallbladder wall (sonographic hole sign) and pericholecystic collectionInterpretation Ultrasound and CT images of the abdomen showed a defect in the wall of the gallbladder with pericholecystic fluid collection [Figures 2 and 3]. Hence, the diagnosis, here, is gallbladder perforation. Furthermore, we can see a hyperechoic focus in the lumen of the gallbladder showing posterior acoustic shadowing [Figure 1], which is consistent with the diagnosis of cholelithiasis. Perforation of the gallbladder is a rare entity with devastating consequences and risk to life. Various causes of perforation include idiopathic, traumatic, iatrogenic, cholelithiasis, infections, steroid use, and uncontrolled diabetes. These patients are predisposed to this condition.[1] Patients with gallbladder perforation present with acute pain without any known cause. The pain is usually starts in the right hypochondrium and then spreads to whole of the abdomen. The pain aggravates on movement and relieved by rest. The patient also has tenderness, rigidity, and guarding which are also the signs of peritonitis. Other symptoms with which patient can present include nausea and vomiting. Spectrum of ultrasound finding includes gallbladder distension, pericholecystic fluid, and sonographic hole sign which has a very high specificity for diagnosis.[2] CT is considered a superior modality than ultrasound due to its ability to show focal wall defect. It also shows extraluminal gallstones as well as Mercedes-Benz sign (gas within gallstones) along with location and extent of abscess due to perforation.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and the initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.