Gallbladder Cancer Eroding Into the Duodenum Causing Gastric Outlet Obstruction

Abstract

SymbolIntroduction: Gallbladder cancer (GBC) is an uncommon but fatal malignancy mostly because of its late presentation. The nonspecific symptoms and advanced stage at presentation contribute to the poor prognosis. We present a case of even rarer type of gall bladder cancer presenting in an uncommon way.SymbolCase Report: 66-year-old Korean male with no significant medical history presented to us with 4 week history of vague right upper quadrant abdominal pain along with nausea with progressive symptoms for past 5 days with now inability to tolerate PO due to post-prandial emesis. Labs on admission were remarkable for white blood cell count of 15 with a left shift; mild elevation in alkaline phosphatase at 181; the rest of the labs were normal. CT scan of the abdomen showed a large cavitary mass within the gallbladder with invasion of the surrounding portal vasculature and erosion into the second portion of the duodenum forming a fistula. An upper endoscopy showed a normal appearing duodenal bulb with the duodenal sweep leading into a cavity with exudative mucosa; the cavity contained bile. A large gallstone was noted in the cavity. The endoscope was unable to be advanced to the descending duodenum. This was thought to be the fistulous tract leading from the duodenum into the gallbladder mass. Biopsy of the cavity revealed invasive squamous carcinoma on histopathology. During the next few days, patient was not able to tolerate any PO intake. He underwent a palliative venting gastric tube along with a feeding jejunal tube and was discharged on home hospice. He subsequently expired 4 weeks later at home. Discussion: GBC is an uncommon GI malignancy with less than 5000 cases a year diagnosed in the US. More than 90% of cases GBC are adenocarcinoma. In our patient, the pathology showed squamous cell cancer, which although rare has been reported. Gallstones amongst other things appear to confer a risk factor for development of GBC especially when larger than 3 cm. Our patient had a gallstone seen on imaging and endoscopy measuring 1.8 cm. The nonspecific symptoms often lead to late diagnosis and despite advanced imaging, only 50% of GBC are recognized pre-operatively. Duodenal obstruction is rarely a presenting symptom, unlike in our patient where the GBC eroded into the duodenum and caused gastric outlet obstruction. Conclusion: GBC is an uncommon malignancy in the United States with variable presentation and vague non-specific symptoms. We describe a case of even rarer form of GBC (squamous cell cancer) presenting as gastric outlet obstruction from erosion of the cancer into the duodenum. The risk factor in our patient may have been presence of a gallstone.