What is the best course of management for a patient with a history of appendectomy and previous spinal surgery, presenting with liver focal hypodensity, a calcified nonobstructive kidney stone, small hiatal hernia, moderate colonic stool burden, mild anasarca, and circumferential urinary bladder wall thickening?

Management of CT Abdomen/Pelvis Findings in Post-Surgical Patient

The focal liver hypodensity adjacent to the falciform ligament requires no intervention as it represents benign focal fat or perfusion anomaly, the nonobstructive kidney stone needs conservative management with hydration and monitoring, and the circumferential bladder wall thickening warrants urologic evaluation to exclude chronic inflammatory conditions. 1, 2

Liver Hypodensity - No Action Required

• Focal hypodensity adjacent to the falciform ligament is a characteristic location for benign focal fatty infiltration or perfusion anomaly and does not require further imaging or intervention. 1, 3

• The American College of Radiology confirms that when a CT scan images the kidneys, the liver is routinely included in the field of view and should be evaluated as part of standard radiologic interpretation. 3

• For indeterminate liver lesions >1 cm in normal liver, multiphase CT or MRI with contrast would be appropriate for further characterization, but the radiologist's description of this as "common reason for fatty infiltration or perfusion anomaly" indicates this is a recognized benign finding. 1

• No follow-up imaging is needed for this liver finding unless it was incompletely characterized on the initial scan. 1, 4

Nonobstructive Kidney Stone - Conservative Management

• The calcified nonobstructive left renal stone requires conservative management with increased hydration and periodic monitoring, not immediate intervention. 1

• The European Association of Urology (2025) recommends that asymptomatic, nonobstructing kidney stones should be managed conservatively with hydration and lifestyle modifications. 1

• NSAIDs (diclofenac, ibuprofen, or metamizole) are first-line treatment only if the patient develops renal colic; opioids are second-choice analgesics. 1

• Medical expulsive therapy with alpha-blockers is most beneficial for stones >5 mm in the distal ureter, not for nonobstructing renal stones. 1

• Follow-up imaging should be performed at least yearly for patients with known kidney stones to monitor for stone growth, new stone formation, or development of obstruction. 1

• Ultrasonography is the most commonly used imaging modality for follow-up, though non-enhanced CT may be more sensitive for identifying renal calculi. 1

Common Pitfall to Avoid

• Do not pursue aggressive intervention (ESWL, ureteroscopy, or PCNL) for asymptomatic nonobstructing stones unless they are causing recurrent symptoms or progressive obstruction. 1

Bladder Wall Thickening - Requires Urologic Evaluation

• Circumferential urinary bladder wall thickening on CT warrants urologic evaluation to exclude chronic inflammatory conditions such as interstitial cystitis/bladder pain syndrome, chronic infection, or less commonly, malignancy. 2

• Recent evidence (2025) demonstrates that bladder wall thickness on CT reflects chronic inflammation of the bladder wall and correlates with severity of bladder pathology. 2

• Diffuse bladder wall thickening is associated with more severe uroepithelial denudation, plasma cell infiltration, inflammatory cell infiltration, and nerve bundle hyperplasia compared to focal thickening. 2

• The patient should undergo cystoscopy and urodynamic evaluation if symptomatic (urgency, frequency, pelvic pain) or if there are risk factors for bladder pathology. 2

• If the patient is asymptomatic and has no urinary symptoms, close clinical follow-up with repeat imaging in 3-6 months is reasonable, but urologic consultation should still be considered. 2

Other Findings - Routine Management

• The small hiatal hernia requires no specific intervention unless the patient has symptomatic gastroesophageal reflux disease.

• Moderate colonic stool burden should be addressed with increased fiber intake, hydration, and consideration of stool softeners or osmotic laxatives to prevent constipation-related complications.

• Mild anasarca (subcutaneous edema) and trace pelvic free fluid suggest volume overload or hypoalbuminemia and warrant basic metabolic panel, albumin level, and clinical assessment for heart failure, liver disease, or renal dysfunction.

• The cervical and ovarian findings (nabothian cyst, benign-appearing ovarian cyst) are incidental benign findings requiring no intervention unless symptomatic. 1

• The sclerotic T12 vertebral body lesion is nonspecific but in the context of prior spinal surgery likely represents degenerative change; however, if there is concern for metastatic disease based on clinical context, bone scan or MRI spine could be considered. 1

Summary Algorithm

1. Liver hypodensity → No action needed 1, 3
2. Kidney stone → Hydration, yearly imaging follow-up, NSAIDs only if symptomatic 1
3. Bladder wall thickening → Urologic referral for evaluation, consider cystoscopy 2
4. Stool burden → Bowel regimen with fiber and hydration
5. Anasarca/free fluid → Metabolic workup (BMP, albumin, clinical assessment)
6. Other findings → Routine follow-up as clinically indicated