A 62-year-old male with a history of dyspepsia and prior appendectomy presented to the ED with complaints of diffuse abdominal cramping. He reported that his symptoms started about 1 month prior to presentation with the pain located in his epigastrium. He initially tried tums and Pepcid for the discomfort without relief. The cramping moved from the epigastrium and became more diffuse over the course of a few weeks. He denied nausea, vomiting, diarrhea, constipation, blood in the stool, and fever. He recently had a colonoscopy that revealed a few benign polyps. He did report daily bowel movements, but they were usually small and hard.


Initial VS: BP 130/86, HR 127, T 37 °C (98.6 °F), RR 22, SpO2 99% on RA


Physical exam revealed an abdomen that was soft and non-distended with diffuse tenderness without any real localization. There was no rebound or guarding.


The differential was broad and included partial small bowel obstruction, constipation, biliary colic, gastritis, PUD, GERD, nephrolithiasis, and pancreatitis.


The ED team decided to start a work-up with a CBC, chemistry panel, liver function tests, lipase, and a RUQ ultrasound to look for gallstones as the cause.


Here are the first clips of the gallbladder:


What do you see?


Here is the wall measurement:

liver mets GB


The gallbladder appears to be normal in size. There are no obvious gallstones present. There is no pericholecystic fluid. The wall measures normal in size. But…did you see the surrounding liver? Normally the liver has a homogenous echotexture, but this liver does not. There are hypoechoic areas throughout the liver.


Here are a few more clips through the liver:



The providers taking care of the patient realized that the liver appeared abnormal and were concerned that this could represent malignancy. A CT of the abdomen and pelvis was then obtained. See images below:

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Radiology interpreted the CT scan as having a lobulated intramural mass in the lesser curvature of the stomach consistent with gastric carcinoma along with multiple liver lesions representing metastasis.


Of note, the laboratory tests were all normal except an alkaline phosphatase that was just slightly elevated.


He was admitted to the hospital and underwent a biopsy of the stomach that revealed adenocarcinoma. Oncology felt that the cancer was terminal and recommended chemotherapy for palliation.

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