Resolution
Diagnosis
The patient has asymptomatic cholelithiasis. Note the 3.6-cm lamellated gallstone in the right upper quadrant (circle, Figure 2). A subsequent computed tomography scan confirmed the presence of a 3.3-cm gallstone and revealed bilateral uncomplicated fat-containing inguinal hernias.
Learnings
Gallstones are rarely appreciated on plain film because most do not contain enough calcium for visualization. Prophylactic cholecystectomy is not usually indicated for asymptomatic gallstones, with the following exceptions:
- Gallstones >2 cm in diameter
- Patients at risk for gallbladder carcinoma
- Patients with spinal cord injuries or sensory neuropathies affecting the abdomen
- Patients with comorbidities (sickle cell anemia, cirrhosis, portal hypertension) or who have undergone transplantation
- Children, pregnant women, and patients with diabetes, all of whom require close follow-up
Future complications of gallstones >2 cm in diameter include possible biliary-enteric fistulas, as in gallstone ileus with coexisting Mirizzi syndrome.
Acknowledgment: Case presented by Linda-Michelle Ledesma, DO, Urgent Care Extra, Phoenix, Arizona.