Male 82 years old Reason: Eval for clearance of biliary stones, s/p ERCP on 2/12. Please perform study on Monday 2/15 (3 days post-procedure) History: jaundice, abd pain ABDOMEN:LIVER, BILIARY TRACT: Liver is normal in morphology. No suspicious hepatic lesions. Hepatic and portal veins are patent. There is mild central intrahepatic biliary ductal dilatation. Status post cholecystectomy there is small amount of debris remaining in the residual cystic duct which has low insertion. No definite debris within the common bile duct. Small foci of signal hypointensity along the anterior aspect of the duct suggests small air bubbles.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Lateral renal cysts. No hydronephrosis.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Mild inflammation in the right upper abdomen adjacent to the colon. There is a fluid collection with a fluid fluid level anterior to the hepatic flexure with a neck that extends near the porta hepatis and duodenal bulb. This has wall enhancement and has restricted diffusion and is suspicious for a collection possibly representing an abscess or biloma. The small bowel in the area have a mildly thickened wall. There is a mild generalized ileus. There is mild hyperenhancement of the peritoneum in the right upper abdomen.BONES, SOFT TISSUES: Postsurgical changes in the abdominal wall with mild body wall edema and trace ascites.OTHER: No significant abnormality noted.
1.Status post cholecystectomy with small amount of debris within the cystic duct. Mild central intrahepatic biliary duct dilatation.2.3.4 x 1.5 cm fluid collection anterior to the hepatic flexure representing either an abscess or biloma.Findings discussed with Dr. Krishnamoorthi at the time of dictation