The answer
This image is a further section from an IV contrast enhanced CT scan taken
through the upper abdomen. There is considerable ascitis present. The ascitis
appears to compress the liver and inferior vena cava. There is a wedge shaped
area in the spleen that does not enhance, this is in keeping with a splenic
infarct. The stomach appears quite full. The most likely reason for the
patient being unwell is a bile leak following the cholecystectomy. A large
amount of bile has built up and this is causing a haemodynamic effect due to
compression of the liver and inferior vena cava.
What the student may say
This is a futher image from the CT scan taken on the patient. This section
again shows the upper abdomen. The patient has received intra-venous contrast
but no oral contrast. Again there is considerable fluid present.
This is seen around the liver and also around the spleen. The liver and
inferior vena cava appear to be compressed by the large amount of fluid.
We can also see in this scan that there is a wedge shaped area of the
spleen that does not enhance, this most likely represents a splenic infarct.
The infarct may relate to the present problem or may be old due to the
previous episode of pancreatits, or another condition.
The most likely reason that this patient is unwell three to four days
after a cholecystectomy with the scans showing a large amount of ascitis is a
bile leak.
Small print
While accessory spleens (splenucli) are common, none can be seen in this
image.
There is no evidence of portal vein thrombosis on this image. The vessels
visible in the liver may be branches of the portal vein bringing blood to the
liver or the hepatic veins carrying the blood from the liver back into the
vena cava. The portal vein would be best seen on images lower than this
outside the liver. If there is doubt about flow in the portal vein then a
duplex ultrasound would be the best investigation.
The stomach does appear full on this image but the consistency is regular
and more in keeping with ordinary gastric fluid. There is no evidence that
there is a large collection of hair (tricho-beezoar) or vegetable matter
(phyto-beezoar) in the stomach.
The liver secretes from 250 - 500 ml of bile a day. Thus it takes several
days for enough bile to build up in the abdomen to cause a problem. Bile is
very slippy so that it will leak out of any small hole.
