The liver in this patient presented a significantly dilated gallbladder with echogenic, suspended, largely immobile debris and thickened gallbladder wall. The gallbladder measured 3.9 x 3.0 cm. Cystic duct and common bile duct were dilated. Lobar ducts were also dilated indicating an obstruction for at least 4 days. The liver itself was coarse with increased portal markings. The common bile duct prior to the duodenal papilla measured 0.8 cm in width with echogenic inflammatory pattern around the common bile duct. Heterogenous, hyperechoic hepatic changes were present and may represent metastatic disease such as that of adenocarcinoma. However, in my experience biliary adenocarcinoma, which is primarily suspected in this case, can present isoechoic, metastatic lesions. Exploratory surgery with expectations towards direct examination of the liver for metastatic lesions as well as bile duct deviation and gallbladder removal. At that time a liver biopsy would also be indicated. The deep right liver lobe presented heterogenous, hyperechoic lesion. This is suggestive for metastatic disease.