Saw palmetto (SP) is a widely used herbal supplement for benign prostatic hyperplasia (BPH) and is generally considered safe. However, rare cases of SP-associated drug-induced liver injury (DILI) have been reported. We describe a case of cholestatic hepatitis attributed to SP, highlighting the diagnostic challenges associated with herbal supplement use and polypharmacy. A 70-year-old male with a history of BPH, hypertension, chronic obstructive pulmonary disease, atrial fibrillation, and cholecystectomy presented with one month of jaundice, pruritus, and pale stools. Physical examination demonstrated scleral icterus without abdominal tenderness. Laboratory evaluation revealed an alkaline phosphatase level of 215 U/L, total bilirubin of 7.3 mg/dL (direct bilirubin = 5.0 mg/dL), alanine aminotransferase of 305 U/L, aspartate aminotransferase of 133 U/L, and an international normalized ratio of 3.8 while receiving warfarin therapy for atrial fibrillation. Viral hepatitis serologies were negative. Right upper quadrant ultrasonography demonstrated mild biliary ductal prominence, and magnetic resonance cholangiopancreatography excluded biliary obstruction. Liver injury was initially attributed to congestive hepatopathy because of newly reduced left ventricular ejection fraction (34%-40%). However, the patient remained clinically euvolemic, liver biochemistries failed to improve, and progressive hyperbilirubinemia prompted further evaluation. A detailed medication history revealed over-the-counter SP use for approximately four months, discontinued two months before presentation, and a recent one-week course of trimethoprim-sulfamethoxazole for a urinary tract infection. Transjugular liver biopsy with measurement of the hepatic venous pressure gradient (6 mmHg) demonstrated cholestatic hepatitis with portal and lobular inflammation, eosinophilic infiltration, and bile duct proliferation, consistent with DILI. Right and left heart catheterization demonstrated normal filling pressures and the absence of obstructive coronary artery disease, making congestive hepatopathy unlikely. Warfarin was reversed with vitamin K and transitioned to apixaban because of concern for potential hepatotoxicity. The patient was treated with ursodiol and cholestyramine, resulting in gradual improvement in liver enzymes and bilirubin, and was discharged with close hepatology and cardiology follow-up. This case highlights SP as a rare but important suspected cause of cholestatic DILI. Although causality cannot be definitively established because of concomitant exposure to other drugs, SP was considered the most likely implicated agent based on the temporal relationship with exposure, exclusion of alternative etiologies, compatible histopathologic findings, and clinical improvement after its discontinuation. Clinicians should routinely inquire about over-the-counter and herbal supplement use when evaluating unexplained liver injury. Increased awareness, comprehensive medication reconciliation, and improved regulation of dietary supplements may facilitate earlier recognition and reduce preventable hepatotoxicity.

Although uncommon, bilateral renal infarction and renal artery thrombosis should be considered a potential cause of acute kidney injury. Its nonspecific presentation frequently contributes to delayed diagnosis, thereby compromising timely intervention and increasing the risk of irreversible injury. While embolic and thrombotic mechanisms are the predominant etiologies, idiopathic renal artery thrombosis is rare. We report the case of a 42-year-old man who presented with sudden-onset left flank pain radiating to the left upper quadrant, associated with nausea and abdominal discomfort. He had a history of tuberculosis diagnosed seven months earlier and had completed a six-month course of anti-tuberculous therapy with isoniazid, rifampin, pyrazinamide, and ethambutol. He had no history of cardiovascular disease, thrombophilia, or autoimmune disorders. Laboratory results revealed a mild elevation in serum creatinine (1.5 mg/dL), with no prior baseline for comparison. Urinalysis was unremarkable. Unexplained flank pain in association with elevated serum creatinine and lactate dehydrogenase raised clinical suspicion for renal vascular pathology. Contrast-enhanced computed tomography of the abdomen and pelvis revealed extensive thrombosis involving the left renal artery, resulting in total left kidney infarction. In addition, a small segmental infarction was seen in the mid pole of the right kidney posteriorly; however, the majority of the right kidney parenchyma is intact and enhancing. The right main renal artery was patent. A vascular surgeon was consulted, who, because of the delayed presentation, recommended conservative management rather than surgical intervention. At the time of presentation, the patient was initially treated with systemic therapeutic anticoagulation. Following clinical stabilization, anticoagulation was transitioned to oral rivaroxaban for continued anticoagulant therapy. Renal function and clinical symptoms progressively improved.

Necrotizing pancreatitis is a severe complication of acute pancreatitis that may not become radiographically evident until several days after symptom onset. Although progression from gallstone pancreatitis is well recognized, concurrent postoperative complications and Clostridioides difficile infection can obscure the clinical picture and delay diagnosis. This case adds to the literature by demonstrating how overlapping postoperative findings and concurrent infection masked the evolution of necrotizing pancreatitis despite initial clinical improvement and illustrating treatment approaches in such situations. A 61-year-old man presented with worsening right upper quadrant abdominal pain radiating to the back and was diagnosed with gallstone pancreatitis secondary to choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction followed by delayed laparoscopic cholecystectomy. After initial improvement and discharge, he returned with severe abdominal pain, nausea, vomiting, and systemic inflammatory findings. Exploratory laparotomy revealed chemical peritonitis of pancreatic origin without biliary leak or enteric perforation. During hospitalization, he developed Clostridioides difficile colitis, further complicating interpretation of persistent abdominal pain, leukocytosis, and inflammatory markers. Interval MRI ultimately demonstrated sterile peripancreatic necrosis and fluid collections consistent with necrotizing pancreatitis. The patient was managed with bowel rest, total parenteral nutrition, drainage of peripancreatic fluid, treatment of Clostridioides difficile infection, serial imaging, and multidisciplinary care involving surgery, gastroenterology, infectious disease, critical care, and internal medicine. His symptoms gradually improved, and he was discharged with outpatient surgical follow-up. This case highlights the unpredictable progression of gallstone pancreatitis to necrotizing pancreatitis despite early intervention and apparent clinical recovery. Persistent or worsening postoperative abdominal pain should prompt continued reassessment, as concurrent infections such as Clostridioides difficile may obscure an evolving pancreatic process. Serial laboratory evaluation, interval imaging, and multidisciplinary collaboration are essential for timely diagnosis and improved patient outcomes in complex cases.

Abdominal pain is a common presentation in the emergency department (ED). Ultrasound is the first-line diagnostic imaging modality for right upper quadrant pain. Point-of-care ultrasound (POCUS) is a focused examination that can be performed at the patient's bedside to evaluate acute and emergent biliary pathology. The advantages of POCUS include avoiding the potential safety risks associated with transporting critically ill patients, no exposure to ionizing radiation, potentially reduced costs, and rapid diagnosis. This narrative review synthesizes key sonographic findings and techniques for emergent and non-emergent biliary diseases that physicians should recognize at first glance. We present significant and interesting images of cholelithiasis, acute cholecystitis, emphysematous gallbladder, choledocholithiasis or sludge, Mirizzi syndrome, post-operative biliary obstruction, gallbladder polyps, biliary neoplasms, and malignant-appearing lesions or masses. Finally, this review integrates POCUS into clinical pathways to guide decisions regarding additional abdominal imaging, such as computed tomography or radiology-performed ultrasound, and surgical consultation.

Traumatic diaphragmatic rupture (TDR) is a rare but serious injury. It most commonly results from high-impact blunt trauma. Right-sided ruptures are particularly uncommon due to the protective effect of the liver. Delayed presentation can cause diagnostic challenges, as the injury may remain clinically silent for years before complications such as organ herniation. We report a case of a 65-year-old male who presented with progressive dyspnea, right-sided chest pain, and right upper quadrant abdominal discomfort 4 years after a severe motor vehicle accident. Chest radiography revealed a heterogeneous opacity in the right hemithorax, and contrast-enhanced CT confirmed right hemidiaphragmatic rupture with intrathoracic herniation of the liver. The patient underwent urgent surgical repair. A large diaphragmatic defect was identified and repaired with a Prolene mesh in a tension-free fashion. The postoperative course was uneventful, with complete resolution of symptoms. This case highlights the importance of maintaining clinical suspicion for delayed diaphragmatic rupture in patients with a remote history of blunt trauma, even when initial imaging was normal. Contrast-enhanced CT remains the diagnostic standard, and Prolene mesh repair is a surgical solution for large diaphragmatic defects.

Wünderlich syndrome, or spontaneous non-traumatic renal hemorrhage, is a rare and potentially life-threatening condition. We report the case of a 52-year-old woman presenting with right upper quadrant pain radiating to the lumbar region, bilious vomiting, and positive Murphy's and Giordano's signs, initially suggesting acute biliary disease. Ultrasonography demonstrated cholelithiasis and suspected choledocholithiasis; however, computed tomography urography revealed a large right-sided subcapsular and perirenal hematoma associated with a renal pelvic calculus. Because of the hematoma volume and suspicion of malignancy, nephrectomy was performed. Histopathological examination demonstrated an organized subcapsular hematoma with chronic inflammatory changes and no evidence of neoplasia. This case highlights the diagnostic challenge posed by atypical presentations of Wünderlich syndrome and underscores the essential role of computed tomography in distinguishing spontaneous renal hemorrhage from more common causes of acute abdominal pain.

Gallbladder agenesis and hypoplasia are rare diseases that are often asymptomatic but can present as biliary colic in the 5[th] or 6[th] decade of life. The incidence of gallbladder agenesis and hypoplasia has not been well documented in the pediatric population, and concomitant congenital anomalies can result in a complex clinical presentation. This is a case report of a 20-year-old male with Apert disease with a 6-month history of chronic right upper quadrant (RUQ) pain with imaging that demonstrated both gallbladder hypoplasia and malrotation without volvulus. He underwent both a cholecystectomy and a Ladd's procedure upon intraoperative identification of a hypoplastic gallbladder and had complete resolution of pain. The etiology of this patient's abdominal pain cannot be conclusively identified due to the multiple procedures performed, but prior studies indicate that it may be more attributed to the gallbladder hypoplasia. This case highlights the difficulty of both gallbladder hypoplasia diagnosis and its surgical management. Gallbladder hypoplasia is exceedingly rare, and a high clinical suspicion is needed to diagnose its presence in patients with genetic predispositions for biliary disease. While there is no gold standard for its management, initial recommendations are to proceed with conservative treatment with antispasmodics before operative intervention. In the case of operative intervention, surgeons must understand the high risks of operating in these patients due to the degree of fibrosis.

Situs inversus totalis is a rare congenital anomaly in which the thoracic and abdominal viscera are transposed in mirror image, placing the gallbladder in the left upper quadrant. Laparoscopic cholecystectomy is consequently demanding for the right-hand-dominant surgeon, who, using a conventionally mirrored setup, would be required to dissect with the non-dominant hand, accept crossing of the operating instruments, or delegate retraction to an additional assistant. We describe a woman in her 40s with situs inversus totalis and symptomatic cholelithiasis who underwent an elective laparoscopic cholecystectomy using a configuration in which the surgeon operated from the patient's left with both working ports placed subcostally. This allowed dominant-hand dissection while the surgeon retained infundibular retraction, enabling the procedure to be completed safely with a single assistant. The critical view of safety was achieved and the patient's recovery was uneventful. An annotated operative video accompanies this report as a teaching resource.