Anmolpreet Gurwal

While conditions like heart failure with preserved ejection fraction or chronic kidney disease could contribute to fluid overload, they do not explain the significant unintentional weight loss

Notably, the patient also had a fall leading to a gluteal hematoma can be explained by the patient's chronic anticoagulant use.

This decline seems to have started after that particular hospitalization.

While that may reflect deconditioning, it does make me wonder whether that event was a marker of an underlying process that had been evolving over time.

I also find myself in wanting to understand why the fall occurred in the first place.

Was that truly mechanical or were there features suggestive of syncope or a fall in the setting of progressive weakness?

At this stage, I'm holding two parallel hypothesis, a vascular or hepatobiliary process explaining the acute pain and a subacute systemic process possibly driving ascites and weight loss.

That's a beautiful presentation, Mukun.

Thank you very much for that.

Now, let us talk about the gallbladder.

Ultrasound is typically the first-line diagnostic test for suspected cholecystitis.

But if the findings are equivocal, a HIDA scan or hepatobiliary immunodiacetic acid scan is the sensitive test.

The ultrasound showed gallbladder wall thickening, but that is a non-specific finding, especially since this patient has ascites and volume overload.

Therefore, the thickening can occur due to venous congestion or hypoalbuminemia.

Secondly, the HIDA scan also showed non-visualization, which raises concerns for cholecystitis.

However, the study was incomplete.

False positives can occur due to impaired tracer uptake and excretion.

So taken together, I would interpret these findings cautiously rather than as definitively diagnostic.

The negative sonographic Murphy's sign also argues against cholecystitis.

Congestive states due to heart failure, patient can even develop tendered hepatomegaly which can clinically mimic cholecystitis and further confound the picture.