How should I evaluate and manage a 55‑year‑old man with mild hepatomegaly, a 9.6 × 21.5 mm non‑calcified gallbladder hypodensity (possible stone or sludge), bilateral simple renal cortical cysts (1.4 cm right, 2.3 cm left), an enlarged heterogeneous prostate protruding into the bladder base, a 1.6 cm umbilical hernia containing non‑dilated small bowel, a small right inguinal fatty hernia, and degenerative changes of the spine, sacroiliac and hip joints?

Management of a 55-Year-Old Man with Multiple Incidental CT Findings

For this asymptomatic 55-year-old man, the priority is evaluating the enlarged heterogeneous prostate and confirming the benign nature of the renal cysts, while the hepatomegaly, gallbladder hypodensity, and hernias require only selective follow-up based on symptoms.

Immediate Priority Actions

1. Prostate Evaluation (Highest Priority)

• Obtain serum PSA immediately to assess malignancy risk, as the enlarged heterogeneous prostate protruding into the bladder base raises concern for prostate cancer or significant benign prostatic hyperplasia 1
• Refer to urology for digital rectal examination and consideration of multiparametric MRI if PSA is elevated (>4 ng/mL) or age-adjusted abnormal 1
• The heterogeneous attenuation pattern on CT is non-specific but warrants further characterization to exclude malignancy 1

2. Renal Cortical Hypodensities

• No follow-up imaging is required for these bilateral cortical hypodensities (1.4 cm right, 2.3 cm left), as they are consistent with simple renal cortical cysts 2
• The EASL guidelines provide a strong recommendation (96% consensus) against following asymptomatic patients with simple cysts, regardless of size 2, 3
• Only perform ultrasound if symptoms develop (flank pain, hematuria, or signs of infection) 2, 3

Critical pitfall to avoid: Do not order surveillance imaging for these asymptomatic renal cysts based on size alone, as this leads to unnecessary healthcare utilization without improving outcomes 3

Secondary Evaluations

3. Mild Hepatomegaly (17.5 cm)

• Obtain liver function tests (AST, ALT, alkaline phosphatase, bilirubin, albumin, INR) to assess for underlying liver disease 2
• Check hepatitis B and C serologies, fasting glucose, lipid panel, and consider iron studies if metabolic syndrome is suspected 2
• If liver function tests are normal and the patient is asymptomatic, no further imaging is needed 2
• The hepatomegaly may be related to fatty liver disease, which is common in this age group and does not require specific intervention beyond lifestyle modification if confirmed 2

4. Gallbladder Hypodensity (9.6 × 21.5 mm)

• No intervention is required for this asymptomatic finding consistent with either a non-calcified stone or biliary sludge 4
• Asymptomatic patients with gallbladder sludge or stones require no therapy 4
• Only pursue further evaluation if biliary symptoms develop (right upper quadrant pain, nausea after fatty meals, jaundice) 5, 4
• The absence of gallbladder wall thickening or pericholecystic fluid makes acute cholecystitis unlikely 5

Important caveat: Biliary sludge can cause complications including biliary colic, acute cholangitis, and acute pancreatitis in <1% of cases annually, but prophylactic cholecystectomy is not indicated in asymptomatic patients 5, 4

5. Umbilical and Inguinal Hernias

• The 1.6 cm umbilical hernia containing non-dilated small bowel requires elective surgical consultation for consideration of repair, as umbilical hernias in adults do not spontaneously resolve and carry risk of incarceration 1
• The small right inguinal fatty hernia (likely lipoma of the cord) can be observed if asymptomatic 1
• Educate the patient on warning signs of incarceration: sudden severe pain, nausea, vomiting, inability to reduce the hernia, or overlying skin changes 1
• Elective repair is preferred over emergent repair, which carries significantly higher morbidity and mortality 1

6. Degenerative Joint Changes

• The degenerative changes of the spine, sacroiliac joints, and hips with bilateral os acetabuli and periarticular loose bodies are incidental age-appropriate findings 1
• Only pursue orthopedic evaluation if the patient has limiting pain or functional impairment 1
• The loose bodies around the right hip may cause mechanical symptoms (catching, locking) that would warrant arthroscopic removal 1

Recommended Follow-Up Algorithm

Immediate (within 2 weeks):

• Serum PSA
• Liver function tests (AST, ALT, alkaline phosphatase, bilirubin, albumin, INR)
• Hepatitis B and C serologies
• Fasting glucose and lipid panel

Based on PSA result:

• If PSA >4 ng/mL or age-adjusted abnormal: urgent urology referral for DRE and consideration of prostate MRI/biopsy 1
• If PSA normal: routine age-appropriate screening per USPSTF guidelines 1

Based on liver function tests:

• If abnormal: further hepatology workup including ultrasound elastography or FibroScan to assess for fibrosis 2
• If normal: reassurance and lifestyle counseling (weight management, alcohol moderation, exercise) 2

Surgical consultation:

• Non-urgent referral for umbilical hernia repair discussion 1
• Patient education on incarceration warning signs 1

No further action needed for:

• Renal cortical cysts (unless symptoms develop) 2, 3
• Gallbladder hypodensity (unless biliary symptoms develop) 5, 4
• Inguinal fatty hernia (unless symptomatic) 1
• Degenerative joint changes (unless symptomatic) 1
• Colonic diverticulosis (routine colonoscopy per age-appropriate guidelines) 1