From the Guidelines
For this 76-year-old male with abdominal pain, I recommend scheduling a contrast-enhanced CT scan of the abdomen to further evaluate the findings, particularly the variant-appearing cyst in the left kidney. The ultrasound findings suggest cholelithiasis (gallstones) with biliary sludge, which could be causing his abdominal pain, though the absence of gallbladder wall thickening or biliary duct dilation suggests this may not be acute cholecystitis. The renal findings require follow-up imaging to rule out any concerning lesions. While waiting for the CT scan, the patient should be managed with pain control using acetaminophen 500-1000mg every 6 hours as needed, avoiding NSAIDs due to potential renal issues, as suggested by studies such as 1. If gallstones are determined to be symptomatic, surgical consultation for possible cholecystectomy would be appropriate. The echogenic renal cortex suggests underlying chronic kidney disease, so baseline renal function tests (BUN, creatinine, eGFR) should be ordered, and nephrology consultation considered depending on results. Some key points to consider in the management of this patient include:
- The importance of further imaging to characterize the renal cyst, as emphasized by studies such as 1 and 1.
- The potential benefits and limitations of different imaging modalities, including CT and MRI, as discussed in studies such as 1, 1, and 1.
- The need for careful consideration of the patient's renal function and potential contraindications to contrast agents, as noted in studies such as 1 and 1. If the patient has contraindications to contrast (such as significant renal impairment), a non-contrast MRI would be an acceptable alternative for evaluating the renal cyst, as suggested by studies such as 1 and 1. The patient should be advised to maintain adequate hydration and report worsening symptoms such as fever, severe pain, jaundice, or vomiting.
From the Research
Gallbladder Findings
- The patient has small gallstones mixed with isoechoic gallbladder sludge, but no wall thickening or biliary dilatation is present 2, 3.
- The presence of gallstones can lead to various complications, including acute cholecystitis, choledocholithiasis, and gallstone pancreatitis 2, 4.
- Further evaluation with CT or MRI is recommended to characterize the gallbladder findings and rule out any potential complications 5, 4.
Renal Findings
- The patient has multiple renal cysts, with a slightly variant appearing cyst in the left central kidney 6.
- The mildly echogenic renal cortex bilaterally suggests an underlying medical renal disease 6.
- The Bosniak classification system can be used to categorize cystic renal lesions, but it may not provide information on the underlying pathophysiology 6.
- CT or MRI can help further characterize the renal cysts and determine the need for additional evaluation or follow-up 6, 5.