Ciliated foregut cysts are rare congenital lesions derived from abnormal budding of the primitive foregut and are most commonly identified in the mediastinum or liver, where they may also be referred to as bronchogenic-type cysts. Occurrence within the gallbladder is extremely uncommon, with only a limited number of cases reported in the literature. We present the case of a 29-year-old male who presented with right upper quadrant abdominal pain, nausea, and vomiting. Computed tomography and ultrasound revealed a cystic lesion adjacent to the gallbladder that was initially interpreted radiologically as a probable gallbladder diverticulum. The patient subsequently underwent laparoscopic cholecystectomy. Gross examination demonstrated a 3.5 cm subserosal cystic lesion within the gallbladder wall. Histologic evaluation revealed a cyst lined by pseudostratified ciliated columnar (respiratory-type) epithelium with mucinous differentiation, consistent with a ciliated foregut cyst. No dysplasia or malignancy was identified. The patient's postoperative course was uncomplicated. Ciliated foregut cysts of the gallbladder may mimic gallbladder diverticula or other cystic lesions on imaging, making preoperative diagnosis challenging. The cyst in the present case measured 3.5 cm and represents one of the largest reported ciliated foregut cysts of the gallbladder in the literature. This case highlights the importance of histopathologic evaluation and the need to consider a ciliated foregut cyst in the differential diagnosis of cystic lesions associated with the gallbladder.

Spontaneous hepatic rupture is a rare but life-threatening complication of Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, associated with high maternal and perinatal mortality. Its diagnosis is challenging due to a nonspecific clinical presentation and limited diagnostic resources in low-resource settings. We report a 35-year-old woman who claims 7 months of amenorrhea with the diagnosis of severe preeclampsia and HELLP syndrome, who developed sudden right upper quadrant pain and hemodynamic instability. The bedside ultrasound showed hemoperitoneum and a ruptured subcapsular hematoma. Emergency laparotomy confirmed hepatic rupture, and hemostasis was achieved with surgical intervention. This case highlights the importance of maintaining a high index of suspicion for hepatic rupture in patients with HELLP syndrome presenting with acute abdominal pain. Timely diagnosis and surgical management are critical to improving maternal outcomes.

Acute aortic dissection (AAD) is a time-critical cardiovascular emergency that classically presents with abrupt chest or back pain; however, atypical presentations may lead to misdiagnosis, delayed treatment, and worse outcomes. We report a case of AAD presenting with isolated abdominal pain and ultrasound findings mimicking acalculous cholecystitis. A 53-year-old male patient with poorly controlled hypertension and hypercholesterolemia presented with acute-onset epigastric and right upper quadrant pain associated with nausea. Lab evaluation showed direct bilirubin elevation and mild acute kidney injury. Abdominal ultrasound demonstrated gallbladder wall thickening and pericholecystic fluid without gallstones, raising a provisional concern for acalculous cholecystitis. ECG and initial troponin were unremarkable; however, serial troponin elevations prompted further assessment with transthoracic echocardiography (TTE), revealing an intimal flap in the ascending aorta with circumferential pericardial effusion. CT angiography confirmed Stanford type A dissection extending into the infrarenal abdominal aorta, associated with hemopericardium, inferior vena cava reflux, and preserved celiac perfusion. Emergent surgical repair demonstrated a contained rupture with sanguineous pericardial effusion consistent with low-grade tamponade. AAD may therefore present atypically with isolated abdominal symptoms driven by early tamponade physiology and venous congestion rather than visceral malperfusion. In patients with abrupt-onset pain and unexplained serial troponin elevations, timely consideration of dissection is paramount, even in the absence of chest pain.

Conservative management with tranexamic acid (TXA) is known in difficult-to-access pseudoaneurysms, including those of the pulmonary artery, and its broad efficacy is seen in hemorrhagic pathologies such as subarachnoid hemorrhage. We present the case of a 90-year-old woman with paroxysmal atrial fibrillation on apixaban, remote cholecystectomy, and multiple comorbidities (including hypothyroidism, interstitial lung disease, and asthma) who was admitted for right upper quadrant pain, nausea, and laboratory evidence of cholestasis (total bilirubin 3.0 mg/dL, aspartate aminotransferase 250 U/L). Computed tomography was suggestive of choledocholithiasis, and gastroenterology recommended briefly holding apixaban before endoscopic retrograde cholangiopancreatography (ERCP). On hospital day 3, ERCP was abandoned because of an upper esophageal sphincter narrowing and Zenker's diverticulum. Interventional radiology then performed a percutaneous transhepatic cholangiography with a 22-gauge Chiba needle, but nondilated intrahepatic ducts prevented drain placement. Ultimately, a laparoscopic-assisted ERCP achieved successful common bile duct stone extraction. Postprocedurally, the patient's hemoglobin declined from 13.6 to 9.4 g/dL (without transfusions), and abdominal imaging identified a 1.8-cm intrahepatic pseudoaneurysm plus a 4.1-cm peripancreatic hematoma. Diagnostic angiography demonstrated delayed pseudoaneurysm filling without a definable feeding artery suitable for embolization. Given the small lesion and occult arterial source, we administered oral TXA 1,000 mg three times daily to promote thrombosis. Within 48 hours, hemoglobin stabilized around 8.8 g/dL, and repeat CT revealed spontaneous pseudoaneurysm thrombosis. The patient was discharged uneventfully with stable hemoglobin and had no pseudoaneurysm reaccumulation at short-term follow-up. Should TXA have failed, we had discussed a potential percutaneous thrombin injection, which has shown success for endovascularly inaccessible hepatic pseudoaneurysms. This case underscores the risk of iatrogenic bleeding in patients on direct oral anticoagulants who require multiple biliary interventions and highlights how a short course of TXA can be a practical alternative when standard embolization is not feasible.

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms characterized by the coexistence of melanocytic and smooth muscle differentiation, with hepatic involvement being exceptionally uncommon. We present the case of a 60-year-old man with no relevant past medical history, who presented with right upper quadrant pain, without constitutional symptoms or significant laboratory abnormalities. Abdominal ultrasound revealed a hepatic mass in the right lobe. Further evaluation with contrast-enhanced computed tomography and dynamic liver magnetic resonance imaging demonstrated a hypervascular lesion in segments VI-VII, with imaging features suggestive of malignancy. The main differential diagnosis considered was mass-forming intrahepatic cholangiocarcinoma. Tumor markers, including alpha-fetoprotein and CA 19-9, were within normal limits. Given the diagnostic uncertainty, a percutaneous liver biopsy was performed. Histopathological and immunohistochemical analysis showed a mesenchymal proliferation with a myomelanocytic immunophenotype, with co-expression of HMB-45 and smooth muscle actin, consistent with hepatic PEComa. Following multidisciplinary team discussion, surgical treatment was decided. This case highlights the importance of considering hepatic PEComa in the differential diagnosis of hypervascular liver masses, particularly when presenting as a solitary lesion in a non-cirrhotic liver and with normal tumor markers.

Hypervirulent Klebsiella pneumoniae (hvKp) is an emerging cause of community-acquired pyogenic liver abscess (PLA), classically described in East and Southeast Asia. We report two cases of hvKp-associated PLA in Caucasian women of American origin with no history of international travel, animal exposure, or Asian food consumption. Both patients presented with fever and right upper quadrant abdominal pain and were found to have solitary hepatic abscesses on imaging. Blood and abscess cultures confirmed K. pneumoniae with a positive string test (> 5 mm), K2 capsular serotype, and rmpA gene, establishing the hypermucoid phenotype. While one patient had diabetes mellitus, the other had no major underlying health condition apart from the bacterial infection reported here. Both patients were successfully treated with intravenous antimicrobial therapy, initially broad-spectrum and subsequently de-escalated based on susceptibility results, in combination with image-guided percutaneous drainage. Neither patient developed metastatic complications. These cases suggest a broader geographic and demographic distribution of hvKp-associated PLA than previously recognized. The string test served as an early diagnostic clue, facilitating timely intervention. Given the potential for rapid clinical progression, early recognition and aggressive management, including antimicrobial therapy and source control, remain essential to reducing morbidity associated with hvKp PLA.

Acute acalculous cholecystitis (AAC) is an inflammatory condition of the gallbladder that occurs in the absence of gallstones and is increasingly recognized among medically complex and long-term care populations. Patients receiving chronic enteral nutrition via gastrostomy tubes may be at risk for biliary complications related to impaired gallbladder emptying or mechanical factors. We describe an 81-year-old female nursing home resident with a previous medical history of hypertension, diabetes mellitus, Alzheimer's dementia, hypothyroidism, and gastrostomy tube dependence who presented with five days of malaise, nausea, vomiting, and right upper quadrant pain. Laboratory evaluation demonstrated a cholestatic liver enzyme pattern without leukocytosis. Bedside ultrasonography revealed gallbladder dilation without gallstones. Contrast-enhanced computed tomography of the abdomen and pelvis demonstrated migration of the balloon-retained gastrostomy tube into the proximal duodenum, causing extrinsic compression of the distal common bile duct, with associated gallbladder distention and intra- and extrahepatic biliary dilatation. Magnetic resonance cholangiopancreatography confirmed obstructive physiology without choledocholithiasis. The gastrostomy tube was deflated, removed, and repositioned, resulting in rapid clinical and biochemical improvement with conservative management. In patients receiving long-term enteral nutrition, reduced physiologic gallbladder stimulation may predispose to bile stasis, creating vulnerability to obstruction when tube malposition occurs. Imaging plays a central role in diagnosis, and early recognition with prompt tube repositioning can reverse obstruction and prevent progression to more severe gallbladder injury. Clinicians should be aware that, in patients with gastrostomy tube dependence, unexplained cholestatic liver enzyme elevation should prompt assessment of tube position and evaluation for possible device-related biliary obstruction.

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare and aggressive primary hepatic mesenchymal malignancy, predominantly affecting children aged 6-10 years but occasionally arising in young adults. Diagnosis is clinically challenging owing to paradoxical and nonspecific imaging features that vary across modalities, contributing to misdiagnosis rates of up to 23.5%. We report a 23-year-old woman who presented with a 6-week history of right upper quadrant pain, normal liver function tests, and unremarkable tumor markers. Abdominal ultrasound demonstrated a solid-appearing, heterogeneously echoic hepatic mass, while computed tomography and magnetic resonance imaging revealed a predominantly cystic lesion with enhancing internal septations, serpiginous peripheral vessels, intertumoral hemorrhage, fluid-fluid levels, and restricted diffusion-a characteristic cross-modal discordance typical of UESL. Following multidisciplinary team review, the patient underwent right hemi hepatectomy without preoperative biopsy. Histopathology confirmed UESL with classic spindle and stellate cells in a fibro myxoid background, diastase-resistant periodic acid-Schiff-positive eosinophilic globules, and an immunohistochemical profile consistent with primitive mesenchymal origin. Adjuvant chemotherapy with ifosfamide and epirubicin was administered, and 12-month surveillance imaging demonstrated no recurrence. This case illustrates that cross-modal imaging discordance in a young adult with a large complex hepatic lesion and normal tumor markers should raise suspicion for UESL, and supports upfront surgical resection as the cornerstone of management.

For patients with high-level malignant biliary obstruction-confirmed following initial percutaneous transhepatic cholangiography drainage (PTCD) performed for preoperative bilirubin reduction and subsequently determined to be unresectable-biliary stent placement via the existing PTCD tract represents a straightforward, minimally invasive, and clinically feasible therapeutic strategy. However, the procedure may be technically challenging if the catheter tract is tortuous. This case report describes a refined interventional technique to overcome such limitations. A 56-year-old man was admitted due to right upper quadrant abdominal pain and progressive jaundice involving both the skin and sclera. Initial PTCD was performed to achieve rapid biliary decompression and reduce serum bilirubin levels. Subsequently, comprehensive imaging and histopathological evaluation established the diagnosis of unresectable hilar cholangiocarcinoma with intrahepatic and multiple osseous metastases. Given the patient's unresectability and need for durable biliary drainage, stent placement through the preexisting PTCD tract was selected as the optimal palliative intervention. During the procedure, a hydrophilic guidewire was advanced through the indwelling PTCD catheter into the duodenum through the obstructed hepatic portal bile duct and common bile duct; the catheter was then withdrawn over the wire, and a vascular sheath (size similar to the original PTCD tract) was inserted coaxially over the guidewire. This maneuver effectively straightened the access pathway and provided mechanical support for subsequent device delivery. A self-expanding metallic biliary stent was then successfully deployed along the PTCD tract. Postprocedural cholangiography confirmed complete stent apposition, unobstructed bile flow into the duodenum, and absence of procedural complications. This case demonstrates that the judicious use of a vascular sheath during PTCD tract-based stent placement enhances procedural safety, efficiency, and technical success-while minimizing procedural complexity and patient discomfort-and represents a practical, reproducible refinement for biliary stent deployment in anatomically challenging high-grade malignant biliary obstruction.

Titanium is widely regarded as a biocompatible and inert material commonly used in surgical implants. Despite this reputation, hypersensitivity reactions to titanium, though rare, can lead to persistent and unexplained postoperative symptoms. We report the case of a 76-year-old woman who developed progressive right upper quadrant abdominal pain, burning sensations, neuropathic symptoms, and fatigue three months after laparoscopic cholecystectomy in which titanium clips were used. Her history included documented systemic intolerance to a titanium dental implant 10 years earlier, which had required removal. Extensive laboratory and imaging evaluation was unremarkable. Titanium hypersensitivity was clinically suspected based on the temporal association between clip placement and symptom onset, along with systematic exclusion of alternative causes. MELISA® (memory lymphocyte immunostimulation assay) testing was discussed, but declined due to cost and extended turnaround time. Following diagnostic laparoscopy and removal of the four titanium clips approximately three months after symptom onset, the patient experienced complete symptom resolution within one week. She remains asymptomatic at six-month follow-up. This case highlights the importance of considering metal hypersensitivity in patients with unexplained postoperative symptoms and prior exposure to implants. Increased awareness and selective preoperative screening, particularly evaluation for prior metal intolerance, may help prevent unnecessary morbidity and repeated interventions.