A male with postprandial abdominal pain

A 53-year-old male presented with fever and epigastric pain following breakfast. His medical history included gallbladder stones with four episodes of biliary colic over the past 3 years. The patient had declined surgical intervention. Upon arrival at our hospital, the patient reported fever, nausea, vomiting, cold sweats, and epigastric pain. Physical examination revealed tenderness in the right upper quadrant of the abdomen. Laboratory studies were unremarkable. Computed tomography (CT) of the abdomen demonstrated focal wall thickening of the gallbladder fundus with some stones present (Figure 1A, arrow), while the remainder of the gallbladder appeared normal (Figure 1A, arrowhead). Laparoscopy revealed an inflamed gallbladder with focal gangrenous changes in the fundus (Figure 1B, arrow). What is the most likely diagnosis? A CT scan of the abdomen demonstrated focal wall thickening accompanied by stones in the fundus of the gallbladder (Figure 1A). These clinical and radiological indicators pointed toward a diagnosis of acquired hourglass gallbladder with acute focal cholecystitis. Consequently, an urgent laparoscopic cholecystectomy was undertaken, which revealed an inflamed gallbladder exhibiting focal gangrenous changes in the fundus (Figure 1B, arrow). The gallbladder was found to contain multiple black muddy stones, along with areas of focal wall thickening and gangrenous alterations (Figure 2A). Additionally, a focal stenosis in the body of the gallbladder resulted in an hourglass appearance (Figure 2A, arrow). Pathological analysis revealed thickening of the muscularis layer and enlarged Rokitansky–Aschoff sinuses (Figure 2B), confirming the diagnosis of adenomyomatosis. The term “hourglass gallbladder” has been used to describe those cases with a transverse septum that divides the lumen into a proximal and distal cavity. These lesions may be congenital or acquired.1 The acquired hourglass gallbladder is related to adenomyomatosis and chronic cholecystitis. Adenomyomatosis most commonly affects the fundus but can also involve the gallbladder diffusely or segmentally.2, 3 The segmental type can cause annular wall thickening in the waist of the gallbladder, giving an hourglass appearance. The septum is composed of inflamed fibrous tissue or adenomyomatous hyperplasia. Focal or segmental adenomyomatosis may simulate gallbladder carcinoma, making differentiation challenging at times.2, 3 As in our case, when the stones impact the stenotic septum, it may lead to foal cholecystitis. Laparoscopic cholecystectomy treats focal cholecystitis and aids in differentiating it from gallbladder cancer. Ping-Hung Ko: Material support, drafting of the manuscript, critical revision of the manuscript for important intellectual content. Chia-Hsin Cheng: Material support. Chih-Wei Tseng: Material support, critical revision of the manuscript for important intellectual content. The authors declare no conflicts of interest. The study adhered to the ethical guidelines of the 1975 Declaration of Helsinki, as evidenced by the prior approval from the Ethics Committee of Dalin Tzu Chi General Hospital (approval number B11303012). Informed consent was obtained from the patient.