FINAL DIAGNOSE CASE-31

Radiology case- 31 ( FB and INSTA) POST ANALYSIS


Patient Clinical History:
Patient presents with pain in right hypochondriac region and loss of appetite.

Examination:
CECT Whole Abdomen (Coronal sections)


Findings:

  1. Gallbladder:

    • Presence of multiple hyperdense calculi within the gallbladder lumen.
    • Findings are consistent with cholelithiasis.
    • No obvious signs of gallbladder wall thickening or pericholecystic fluid to suggest acute cholecystitis.
  2. Common Bile Duct (CBD):

    • The CBD is dilated (as marked in image).
    • No definite intraluminal hyperdense calculus seen on this section; however, possible distal obstruction or choledocholithiasis cannot be ruled out.
  3. Liver and Intrahepatic Biliary Tree:

    • Mild intrahepatic biliary radicle dilatation may be present secondary to distal biliary obstruction.
  4. Kidneys:

    • A well-defined, non-enhancing, fluid-attenuation lesion is seen in the right kidney cortex – suggestive of a simple renal cyst.
    • No hydronephrosis, renal calculi, or suspicious masses noted.
  5. Pancreas, Spleen, Adrenals, and GI Tract:

    • Appear normal in the visualized sections.
    • No obvious mass or lymphadenopathy seen.
  6. Urinary Bladder and Pelvic Organs:

    • Appear unremarkable.
    • No free fluid or abnormal pelvic mass detected.

Impression:

  • Cholelithiasis
  • Dilated Common Bile Duct – likely due to distal obstruction; clinical correlation and further evaluation (e.g., MRCP or ERCP) may be considered to rule out choledocholithiasis.
  • Simple cyst in right kidney – benign, no clinical concern.
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