The bleeding gallbladder: a rare case of acalculous cholecystitis complicated by ruptured cystic artery pseudoaneurysm and gall bladder hematoma

Background Acalculous cholecystitis is an uncommon inflammatory condition of the gallbladder, usually occurring in critically ill or immunocompromised patients. While complications such as perforation are known, vascular complications particularly cystic artery pseudoaneurysm (CAP) are exceedingly rare. Even more uncommon is the rupture of such a pseudoaneurysm into the gallbladder, resulting in an intraluminal hematoma. This case report highlights the silent presentation of such a rare complication of AC in an elderly patient with multiple comorbidities posing considerable challenges in timely diagnosis and appropriate management. Case presentation A 73-year-old male with multiple comorbidities including retroviral disease was admitted with altered sensorium and constipation. Routine abdominal ultrasonography revealed features of acalculous cholecystitis, including a distended gallbladder without calculi, gallbladder wall thickening and pericholecystic fluid along with a suspicious intraluminal gallbladder mass. Further evaluation with magnetic resonance cholangiopancreatography (MRCP) and contrast-enhanced computed tomography (CT) of the abdomen demonstrated a ruptured CAP with an associated intraluminal gallbladder hematoma. Remarkably, the patient remained hemodynamically stable throughout the course. Despite the potentially life-threatening nature of the condition, surgical intervention was deferred due to technical limitations and the patient’s comorbidities. He was managed conservatively and remained clinical stable on follow-up, without further complications. Conclusions This case illustrates an atypical, clinically occult vascular complication of AC presenting without classic symptoms. Although surgical or endovascular intervention is the standard of care, conservative management may be a feasible option in hemodynamically stable patients when invasive procedures are not viable. It also emphasizes the need for individualized treatment strategies and close clinical surveillance in managing such rare scenarios.