A bag of stones found incidentally

A 91-year-old woman presented with right flank pain for two days without fever, dysuria, trauma, or recent falls. Physical examination revealed no costovertebral angle tenderness. Laboratory tests showed an elevated C-reactive protein level of 3.6 mg/dL without leukocytosis. Urinalysis demonstrated pyuria and bacteriuria. She was treated empirically for acute pyelonephritis with intravenous cefoxitin, and urine culture later grew <i>Escherichia coli</i> sensitive to cephalosporins. Abdominal computed tomography (CT) revealed rupture of a right renal cyst. Incidentally, the gallbladder was filled with multiple small, round, hyperdense calculi, producing a striking "bag of stones" appearance (image 1, arrow). These findings were consistent with asymptomatic cholelithiasis. The patient&acute;s flank pain improved after a 7-day course of antibiotics. She was discharged in stable condition, and outpatient follow-up was unremarkable. Asymptomatic gallstones are commonly detected incidentally, and most patients remain symptom-free; therefore, expectant management is generally recommended. Prophylactic cholecystectomy is reserved for selected high-risk patients, such as those with porcelain gallbladder, large gallstones (>3 cm), anomalous pancreaticobiliary ductal junctions, gallbladder adenomas, or underlying hemolytic disorders.