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Age: 55

Sex: Male

Indication: Right upper quadrant pain

Sonographic Murphy sign: Negative

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Case #20


  • Several hypoechoic lesions in the left hepatic lobe measuring up to 3 cm with irregular, thick margins and posterior acoustic enhancement
  • Surrounding areas of increased hepatic parenchymal echogenicity
  • Gallbladder is distended (measuring up to 6 cm in transverse diameter) with marked mural thickening and layering sludge
  • Mild intrahepatic biliary duct dilation
  • Extrahepatic duct measures up to 1.4 cm in diameter with no obstructing lesion seen, though the distal common bile duct and insertion of the cystic duct are not visualized
  • The visualized portal and hepatic veins are patent with antegrade flow
  • Multiple echogenic foci in the spleen, likely calcified granulomas
  • Normal appearance of the kidneys
  • Visualized portions of the pancreas are normal
  • Urinary bladder is mildly distended with a catheter present
  • Visualized segments of the abdominal aorta are normal in caliber


  • Hepatic abscesses
  • Biliary obstruction

Sample Report

Intrahepatic and extrahepatic biliary duct dilation with nonvisualization of the distal common bile duct. Findings raise concern for a distal biliary obstruction, possibly relating to a gallstone or neoplasm. Recommend MRCP or ERCP for further assessment.

Multiple irregular hypoattenuating lesions in the left hepatic lobe measuring up to 3 cm, concerning for abscesses.

Distended gallbladder with wall thickening and layering sludge. Despite a negative sonographic Murphy sign, these findings could relate to cholecystitis. Alternatively, a common bile duct stone/obstruction or a cystic duct stone obstructing the common hepatic duct (Mirizzi syndrome) could be the etiology for these findings. Again, MRCP or ERCP could further evaluate.


  • The distal common bile duct is often difficult to assess by ultrasound, so biliary duct dilation usually requires another test to evaluate the common bile duct in its entirety
  • Don’t forget Mirizzi syndrome as a cause for biliary and gallbladder distension – a stone in the cystic duct can obstruct drainage of the gallbladder while also exerting mass effect on the common hepatic duct, impairing drainage
  • Hepatic abscesses need imaging followup to resolution given the potential imaging overlap with necrotic neoplasms

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