A mass more ordinary.

To cite: Edlin JC, AlfaWali M, Bond A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015209409 DESCRIPTION An 88-year-old woman presented with sudden onset sharp upper abdominal pain associated with anorexia, vomiting and weight loss. Examination revealed a tender palpable mass in the epigastrium without any abnormal blood tests. A CT scan showed a 12 cm cystic mass in the epigastrium with the gallbladder not identified, and separate from the liver and pancreas (figure 1). Ultrasound confirmed the cystic lesion as the gallbladder with sludge. A cholecystostomy was initially performed, draining 600 mL bile-stained and blood-stained fluid. The patient subsequently underwent a laparoscopic cholecystectomy 6 weeks later without any complications. Histopathology showed chronic inflammatory changes of cholecystitis. Intra-abdominal cystic structures can have several origins, including gallbladder, biliary tree, pancreas, kidney, adrenal, omentum, mesentery, appendix vermiformis and ovaries. The upper limit of gallbladder volume is usually 60 mL. Moderately enlarged gallbladders containing 200–300 mL are encountered in surgical practice. Giant gallbladders have been reported to contain between 1.5 L and 5 L with dimensions from 18×4 cm to 43×21 cm. Their aetiology includes congenital, gallstones or sludge or tumour or a ‘wandering’ gallbladder, where the gallbladder is attached to surrounding structures only by the cystic duct and its mesentery, making it prone to torsion. Irrespective, the drainage of bile is impaired and the gallbladder distended. Large or giant gallbladders require special surgical consideration. In our case, the gallbladder was successfully drained via cholecystostomy and subsequently removed by a laparoscopic cholecystectomy. Some authors report open cholecystectomy without preoperative drainage, taking special consideration of adhesions to adjacent structures. 3