A Phrygian Cap
An 81-year-old man visited the gastroenterologist because he had been suffering from iron deficiency anaemia without obvious blood loss for a few months. Apart from intermittent pain in the right upper abdominal region, there were no other symptoms. His weight remained constant and he did not lose his appetite. Defecation was regular, once a day. His medical record consisted of diabetes mellitus type II, hypertension, impaired renal function and an ear operation many years before. He had no history of gastrointestinal problems. Family history revealed two brothers who had died of colorectal cancer at old age. With a body mass index of 28 he was overweight. Examination of the abdomen did not reveal any unusual findings. No abnormality was palpated during digital rectal examination. A complete blood count revealed anaemia (Hb 6.7 mmol/l) and iron deficiency (9 µmol/l).\nThe patient underwent colonoscopy. Diverticulosis was seen in the sigmoid. Three polyps were removed during the colonoscopy. A bleeding tumour was found in the ascending colon, 80 cm from the anal sphincter. Definitive pathology revealed an adenocarcinoma in the ascending colon. An abdominal CT scan confirmed the presence of a process in the ascending colon. It also showed a liver lesion with a diameter of 9 mm, suspicious of liver metastasis. The CT scan did not reveal any other unusual findings. Ultrasonography of the upper abdomen confirmed a liver lesion, with a diameter of 13 mm, suspicious of liver metastasis with an atypical hepatic haemangioma in the differential diagnosis. MRI scan showed a liver lesion in segment V, suspicious of liver metastasis.\nThe patient underwent simultaneous right hemicolectomy and wedge resection of the liver lesion. During perioperative inspection of the upper abdomen, a gallbladder deformity was seen (fig. ). The fundus of the gallbladder was folded like a cap. The patient underwent cholecystectomy to make the wedge resection of the liver metastasis in segment V easier to perform. The surgery proceeded without complications. Pathological examination confirmed the presence of both an adenocarcinoma in the ascending colon and a liver metastasis. There were slight inflammatory changes in the gallbladder, but it did not show stones or a tumour. The patient recovered from surgery without any problems and was discharged after 12 days. The deformity of the gallbladder was, in retrospective, detected on the preoperative MRI scan (fig. ).