Dropped gallstones mimicking omental nodules

Case contributed by Dr Paul Simkin

Presentation

Upper abdominal nodules noted incidental on CT chest.

Patient Data

Age: 50 years
Gender: Male

The previously identified enlarged gastrocolic nodules remain unchanged with the largest measuring 20 mm in diameter. Portocaval lymph node and several mesenteric lymph nodes are visible, but not definitely enlarged according to size criteria.

Hypodense lesion in the posterior aspect of the pancreatic head measures 13 mm, has a density of HU 19, without significant mass effect on adjacent structures. Trace calcification in its wall on the right. The pancreatic duct and common bile ducts are not dilated. No pancreatic duct calcification. The liver, spleen, adrenals large and small bowel appear unremarkable. Oral contrast is seen in the lumen of the ileum, ascending and transverse colon; no abnormal bowel wall thickening or stenoses identified. The stomach also appears unremarkable. No free intra-abdominal fluid or gas. Minor bilateral cortical renal scarring. Previous cholecystectomy clips noted. Small bilateral fat containing indirect inguinal hernias. Large left pleural effusion as seen on previous chest CT, and adjacent left lower lobe atelectasis has worsened. No suspicious osseous lesions; mild lumbar spine degenerative disc disease.

Conclusion:

1. Several enlarged gastrocolic nodules may represent metastatic deposits. A primary lesion is not definitely identified on today's CT. The hypodense lesion in the pancreatic head may represent a pancreatic cyst or cystic neoplasm. Further investigation with MRI would help to characterize this lesion if clinically indicated.

2. Unilateral left pleural effusion and worsening left lower lobe atelectasis is also concerning for malignancy.

Aseptic technique. Local anesthetic. Using real-time ultrasound guidance a 17 gauge outer coaxial needle was inserted into the soft tissue nodule. Three 18 gauge core biopsies obtained. Samples placed in formalin. No immediate post procedure complication.

Multiple cystic lesions are demonstrated in the pancreas, largest at the uncinate process measuring 17 mm and in the tail of pancreas measuring 19 mm. Other cystic lesions are less than 5 mm. There are no enhancing or solid components associated with the cystic lesions. No solid lesions in the pancreas. The pancreatic duct is not dilated, measuring 2 mm at the head of pancreas. The common bile duct is unremarkable. Previous cholecystectomy. In segment 8 of the liver, there is a 16 mm T2 hyperintense, high DWI signal lesion. This is just outside the FOV on the post-contrast imaging. It is most likely benign, such as a hemangioma. The previously demonstrated omental (gastrohepatic ligament) nodules are unchanged in size and show no enhancement, demonstrate central star shaped. There is also a stable 9 mm portocaval node. Moderate to large left pleural effusion.

Conclusion:

1. Pancreatic cystic lesions are most likely pseudocysts, and correlation with any history of pancreatitis should be made. These are not adenocarcinomas and less likely to be benign mucinous neoplasms.

2. The gastrohepatic ligament nodules are consistent with dropped gallstones and do not require any further follow-up.

3. Small periportal lymph nodes are non-specific, and remain stable. No biliary lesion is detected.

4. Small liver hemangioma segment VIII.

Case Discussion

The biopsy shows lobules of fat partially lined by mesothelium and areas of fat necrosis surrounded by fibrosis and associated with a chronic inflammatory cell infiltrate and golden yellow pigment. There is no evidence of malignancy. DIAGNOSIS: Omental nodule biopsy: Fat necrosis.
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Case information

rID: 51245
Published: 8th Aug 2018
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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