Rare cause of gastric outlet obstruction: xanthogranulomatou
The present case has been published in BMJ. A 62-year-old female patient presented with right upper quadrant pain and multiple episodes of vomiting for 10 days.

Routine investigations revealed presence of anaemia (haemoglobin 9.1 g/dL), raised total leucocyte counts (17 x10^9/L) and hypokalaemia (2.8 mEq/L). Patient was stabilised with intravenous fluids, antibiotics and other supportive management. Imaging with ultrasound (USG) was suboptimal due to the massive intestinal gas and uncooperative nature of the patient.

A collapsed gallbladder (GB) and a mass with a smooth curvilinear surface and posterior acoustic shadowing in the distal part of the duodenum were the only distinguishable findings. Due to repeated episodes of vomiting, the patient underwent an upper gastrointestinal endoscopy, which was suggestive of pyloric obstruction. For the further evaluation of GB mass in the USG report, the patient underwent an abdominal CT examination.

Non-enhanced axial CT images revealed mass-like thickening of the GB wall (maximum thickness 18 mm) with multiple intramural hypoattenuated nodules; the postcontrast images showed luminal surface enhancement at the lesion site and focal discontinuity at some places. Additionally, there was thickening and inflammation noted in the antropyloric region and the first part of the duodenum.

Due to the persisting upper gastrointestinal tract obstruction, surgery was planned on the seventh day from the admission. Intraoperatively, the GB mass was adherent to the duodenum and colon, there was thickening and narrowing present at the gastric outlet obstruction. The decompressed and oedematous GB was seen to be fistulised to the second part of the duodenum.

The patient underwent partial cholecystectomy, primary repair of fistula over a T-tube and retrocolic gastrojejunostomy. Histopathological examination of the GB came out to be xanthogranulomatous cholecystitis (XGC). The patient had an uneventful postoperative recovery.

Learning points
• Xanthogranulomatous cholecystitis (XGC) can mimic gallbladder carcinoma on clinical examination and imaging.

• XGC can rarely present with gastric outlet obstruction.

• Diagnosis of XGC can be made on histopathological examination only.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-226580.full