A 14-year-old boy presented with abdominal pain and hematemesis, following two years of occasional vague epigastralgia. Radiographs showed no evidence of perforation; hepatobiliary ultrasound showed an inflamed gallbladder (GB) and a hypoechoic ill-defined mass shadow. CT revealed a distinct air bubble in the edematous GB, suspicious for a biliary-enteric fistula (BEF). Upper endoscopy showed cobblestone mucosa with ulcerations in the antrum and duodenum (Figure 1). Helicobacter pylori test was negative.Symptoms persisted despite proton-pump inhibitor. MRCP demonstrated a stretching appearance of the cystic duct, fluid accumulation in the GB fossa, and wall thickening and luminal narrowing in the preand post-pyloric region. Exploratory laparoscopy elucidated severe adhesions between the pylorus, duodenum and GB, but no fistula. The sonographic mass appeared to be localized fibrosis due to chronic
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