Mukund

A reticulant stain highlights mild attenuation of the hepatic trabecula in the perivenular parenchyma, indicative of altered perfusion of the perivenular hepatocytes.

A PAS stain is negative for intracytoplasmic alpha-1 antitrypsin.

And in summary, the pathologist says these findings are compatible with a chronic inflow-outflow impairment, and that given the presence of perisinusoidal fibrosis in the territory the biopsy was obtained, a diagnosis of nodular regenerative hyperplasia cannot be established on this particular biopsy sample.

Anmol, I think you have the most difficult job of this episode so far.

Very, very complicated case.

And unfortunately, there really was no unifying diagnosis in the end.

So all we can do is speculate.

As the workup became more and more complex, and we started to talk about doing repeat paracentesis to trend ascites fluid white blood cell counts, the patient was just exhausted.

He ultimately elected to transition to hospice care, where he passed peacefully shortly thereafter in the company of his family.

We were never able to ultimately determine what exactly was going on with him.

I think what I'll do is try and give you an overview of each phase of his case as we thought about it, because there were a couple of twists and turns throughout.

So initially he comes in, he gets CT scanned.

His gallbladder is thickened.

There's some pericholecystic fats trending.

And while the read of the CT is that this could be in the setting of volume overload, of course, everyone starts to think about cholecystitis in the setting of a right upper quadrant pain.

Biliary workup was kind of the first arc of his case.

And particularly before we could get the paracentesis fluid while he was in the emergency department, the focus was entirely on is this or is this not cholecystitis?

And it ended up actually being extremely nuanced because symptoms that weren't really compatible with cholecystitis, he had a negative Murphy's, a negative sonomurphy's, abdominal pain that initially I think on presentation was in the right upper quadrant.

But when we actually examined him was kind of all over the place.

A HIDA was done that showed decreased uptake in the gallbladder.