1319 The Elephant in the Room: A Rare Cause of Gastric Outlet Obstruction

Abstract

INTRODUCTION: Gastric outlet obstruction (GOO) is characterized by the inability of the gastric contents to pass beyond the proximal part of duodenum. We describe an unusual case of GOO caused by compression of the duodenum by gall bladder hydrops (also called gallbladder mucocele). This is only the fourth such case reported in literature. CASE DESCRIPTION/METHODS: The patient is a 59-year-old healthy Caucasian male who presented to the ER with complaints of persistent nausea and non-bilious vomiting for 2 weeks. He also had mild but persistent abdominal pain for the same duration and retrosternal burning pain for over 1 week. The patient had no previous medical or surgical history except for chronic gastroesophageal reflux disease treated with Prilosec. On physical examination, the patient had right upper quadrant tenderness with positive Murphy's sign. His routine lab workup revealed a high WBC count. Other lab values were normal. He underwent ultrasonogram which showed a distended gallbladder measuring 10 cm. CT scan revealed the enlarged gallbladder appearing to compress the duodenum. His upper gastrointestinal endoscopy showed LA grade C erosive esophagitis and a normal looking second portion of duodenum. He subsequently underwent laparoscopic cholecystectomy. The surgery specimen showed distended gallbladder measuring 12 cm in length with thinning of the walls and a 1 cm stone in the body. He had complete resolution of his symptoms after surgery and remained asymptomatic during his follow-up two weeks later. DISCUSSION: Gall bladder mucocele is most commonly due to prolonged obstruction of the cystic duct by gallstones. Acalculous cholecystitis can also lead to mucocele formation. Long-standing gallbladder outlet obstruction can lead to the collection of bile. Resorption of bile salts by gall bladder mucosa occurs over time, resulting in accumulation of clear watery and mucoid residue. Ultrasonography is extremely sensitive for diagnosis. The standard treatment is laparoscopic cholecystectomy, with open cholecystectomy an alternate in large-sized gallbladders. In poor surgical candidates, percutaneous drainage of the gallbladder may be considered. Among the three previously reported cases where the distended gallbladder caused GOO, one was treated with percutaneous biliary drainage as the patient was unfit for surgery and one other case was treated with laparoscopic cholecystectomy. The third case was treated initially with medical therapy leading to resolution of symptoms followed by cholecystectomy.