Gallbladder agenesis (GA) is a rare congenital malformation of the biliary tract. While most patients are asymptomatic, approximately half exhibit symptoms resembling gallstone-related biliary pain. The initial diagnostic evaluation for suspected biliary pathology relies on hepatobiliary ultrasound, which has limited effectiveness in detecting malformations of the biliary tree. GA is frequently misdiagnosed as other hepatobiliary conditions, such as scleroatrophic gallbladder, resulting in avoidable and potentially risky surgical procedures. Despite significant advancements in imaging technology, many patients still undergo unnecessary surgery, during which the diagnosis is ultimately confirmed. We report the case of a young woman with a familial history of GA who presented with intermittent epigastric and right hypochondrial pain. Ultrasound findings suggested one of three possible diagnoses: porcelain gallbladder, multiple gallstones, or limy bile. Magnetic resonance cholangiopancreatography was inconclusive. During exploratory laparoscopy, the gallbladder fossa was thoroughly examined, and GA was confirmed. When imaging fails to visualize the gallbladder, performing laparoscopy before proceeding to laparotomy may help minimize surgical stress.
Secondary Aortic graft-enteric fistula (GEF) is a rare but life-threatening complication following aortic reconstructive surgery. Early diagnosis is challenging, and urgent intervention is mandatory. This is the case report of a 67-year-old male with prior aorto-popliteal bypass surgery presented with recurrent melena and severe anemia. Computed tomography angiography demonstrated contrast extravasation from the distal aortic graft stump into an adjacent proximal small-bowel loop, with perigraft air suggestive of secondary GEF. Positron emission tomography–computed tomography findings supported underlying graft infection. As the distal graft was chronically occluded and non-functional, endovascular embolization of the graft stump was performed to control hemorrhage. Initial coil embolization achieved temporary hemostasis; however, rebleeding occurred 15 days later due to coil migration and persistent stump perfusion. Repeat embolization was done using additional coils, glue, and deployment of an Amplatzer vascular plug which achieved complete exclusion. At 5-month follow-up, the patient remained clinically stable without recurrent bleeding. Staged endovascular therapy can provide life-saving hemorrhage control in high-risk patients with secondary GEF involving a non-functional graft. However, recurrence due to device migration and persistent infection remains a limitation, requiring meticulous technique and close follow-up.
Gallstones are a very common condition in developed countries, affecting approximately 10%–15% of patients who also suffer from bile duct stones. Bile duct stones can occur even in the absence of gallstones. Current guidelines recommend stone extraction for all patients with common bile duct stones, whether symptomatic or not, provided they are fit enough to tolerate the intervention. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for biliary stones; however, it can be challenging in patients with a history of biliary surgery or distorted anatomy. Percutaneous biliary stone removal is an effective alternative for patients who are not suitable for or have failed ERCP. This article discusses various techniques for percutaneous biliary stone removal, ranging from simple to more advanced methods.
