67-year-old male admitted with acute on chronic systolic heart failure and persistent hypotension. Evaluate for occult intra-abdominal source.

None available.

Helical CT of the abdomen and pelvis was performed in the portal venous phase following intravenous administration of 100 mL Omnipaque 350. Multiplanar reformations were generated.

Bibasilar dependent atelectasis. Small bilateral pleural effusions, right greater than left, in keeping with the patient's known volume status.

Diffusely decreased hepatic parenchymal attenuation relative to the spleen, consistent with mild hepatic steatosis. No focal hepatic lesion. The hepatic veins and intrahepatic IVC are mildly distended without thrombus, compatible with the patient's clinical state. No intrahepatic biliary ductal dilatation.

The gallbladder is unremarkable. No cholelithiasis or pericholecystic fluid. The common bile duct measures 5 mm.

Normal in size and attenuation. No ductal dilatation. No peripancreatic stranding.

Normal in size and homogeneous in attenuation.

There is a 3.2 cm rounded mass arising from the medial limb of the right adrenal gland, demonstrating soft-tissue attenuation of approximately 32 HU on the post-contrast acquisition. The lesion is indeterminate by this study alone; adenoma cannot be confidently distinguished from other adrenal etiologies. The left adrenal gland is unremarkable.

A 1.4 cm simple cyst arises from the lower pole of the left kidney (Bosniak 1), incidental. Both kidneys otherwise enhance symmetrically without hydronephrosis. No perinephric stranding.

Nondistended loops of small and large bowel without wall thickening or pneumatosis. No free intraperitoneal air or fluid. The appendix is normal.

Atherosclerotic calcification of the abdominal aorta without aneurysm. No active extravasation. No mesenteric or portal venous thrombus.

Multilevel degenerative changes of the lumbar spine, most pronounced at L4–L5. No suspicious osseous lesion.

Unremarkable.

1. No acute intra-abdominal or intrapelvic process to account for hypotension. No active hemorrhage, bowel perforation, or focal solid-organ injury. 2. 3.2 cm indeterminate right adrenal mass. Recommend dedicated adrenal protocol CT with washout, or chemical-shift MRI, for further characterization. 3. Small bilateral pleural effusions and mild IVC/hepatic venous distension, compatible with the patient's known heart failure. 4. Additional incidental findings, no follow-up required: mild hepatic steatosis, simple left renal cyst, multilevel lumbar degenerative change.