Gallbladder agenesis is a rare congenital malformation that can present itself with comparable symptoms as any case of cholelithiasis. We present a case of a 76-year-old male patient without any medical background of significance who presented at the ER complaining of sudden abdominal pain that started two hours prior to his arrival. Laboratory tests were ordered and an increase in total bilirubin was noted, showing a cholestatic pattern. An abdominal ultrasound was performed where the gallbladder could not be found; therefore, an abdominal CT and an MRI were ordered, which later confirmed gallbladder agenesis. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed with sphincterotomy and the patient was discharged 24 hours later without any complications noted. Gallbladder agenesis is a rare but important diagnosis that general surgeons must have in their diagnostic repertoire because of its ability to mimic acute cholecystitis or cholelithiasis. The objective of this report is to summarize the principal details of this entity.

Gallbladder agenesis (GA) is a rare congenital malformation with less than 500 reported cases. Often an incidental finding intraoperatively or in postmortem autopsies, the first reported case dates back to 1701. We discuss the case of a 21-year-old female presenting with classic biliary symptoms who, on imaging, failed to have a visualizable gallbladder. Initial ultrasound (US) reported a non-visualized gallbladder with gallbladder contraction as a possible explanation. More advanced imaging allowed for the preoperative diagnosis, thus preventing an unpleasant intraoperative surprise. As imaging techniques continue to advance, unnecessary operations can hopefully be avoided, albeit a difficult diagnosis to make.

Gangrenous cholecystitis is a potentially fatal complication of acute cholecystitis that presents with right upper quadrant pain and sepsis. Due to the overlap in clinical features with ascending cholangitis, gangrenous cholecystitis can be easily misdiagnosed, resulting in treatment delay. While the gold standard of diagnosis of gangrenous cholecystitis is direct visualization during surgery and tissue sampling to pathology, some imaging features can guide the diagnosis to appropriate early surgical treatment of gangrenous cholecystitis. A 78-year-old female presented to the emergency department with right upper quadrant pain, sepsis, and altered mental status. Imaging findings on ultrasound and CT were suggestive of gangrenous cholecystitis. However, clinically the patient presented with ascending cholangitis symptoms. Instead of an emergent cholecystectomy, percutaneous cholecystostomy (PTC) was performed. After the PTC, the patient worsened clinically and despite surgical intervention, the patient expired due to septic shock and multiple organ failure.