I have pain in the upper-right-quadrant

Clinical summary

Patient identification: male, 57-years-old.

Present diagnosis: metastatic prostate cancer (bones) , under hormonal treatment.Signs and symptoms: upper-right-quadrant pain, with fever, nausea, in the last week. Physical examination: pain in the upper-right-quadrant ; no organomegaly. Blood test: leuokocytosis with neutrophilia. Bilirubin and amylasemia levels were normal.

Clinical reasoning

In a male with a diagnosis of metastatic prostate cancer and pain in the upper-right-quadrant, the first clinical suggestion would be a problem associated with the prostate cancer,  possibly metastases. At the same time we have to think in toxicity associated with the hormonal treatment, but this event is not common.

Imaging

The MR showed a normal liver parenchyma

The image shows a gallbladder with a thickened wall and calculi. One of the stones was impacted in the cystic. A retrograde cholangiography was performed to remove the stone.

Final comment

When a patient is diagnosed with an important disease, the presence of new sign or symptom is generally associated with this first diagnosis. But, as it is the case shown here, we have to set up a wider differential.