S3497 Late-Presented Biliary Carcinoma Following Chronic Cholelithiasis: Surgical and Public-Health Lessons From Guatemala’s Highlands

Introduction: Liver and biliary malignancies account for roughly one-fifth (≈ 20%) of all cancer-related deaths in Guatemala, compared with ∼8% worldwide. Gallbladder cancer—strongly associated with chronic cholelithiasis—remains a leading cause of cancer mortality among Guatemalan women (14 deaths per 100,000). Outside major cities, access to screening ultrasound and prophylactic cholecystectomy is scarce, so patients frequently present with complications and experience stage migration to unresectable disease. Case Description/Methods: A 53-year-old farmer from Chicamán in the Guatemalan highlands presented with 1-week right upper quadrant pain, fever, and profound weight loss. He had had untreated gallstones for more than 2 years. Examination revealed cachexia and localized peritonism. Contrast computed tomography demonstrated a 337-cc subhepatic abscess around a perforated, stone-laden gallbladder and several firm lesions in hepatic segments VI–VIII. Emergency laparotomy evacuated 200 cc of purulent fluid, retrieved 2 free intraperitoneal calculi, and achieved partial cholecystectomy with drainage. Core biopsies of the hepatic masses were obtained. Histopathology revealed a moderately differentiated adenocarcinoma of gallbladder origin with direct hepatic invasion. Broad-spectrum antibiotics produced clinical recovery; staging computed tomography confirmed unresectable metastatic biliary carcinoma, and the patient was referred for systemic therapy. Discussion: This case illustrates the well-described carcinogenic sequence of chronic gallstone–induced inflammation progressing to gallbladder cancer, amplified by limited surgical access in rural Guatemala. Missed elective cholecystectomy and absent surveillance allowed silent malignant transformation until catastrophic perforation forced emergent care. Earlier ultrasound screening and subsidized referral pathways could have intercepted disease at a curable stage. National programs that prioritize rural hepatobiliary screening—especially for symptomatic cholelithiasis—are essential to reduce a preventable cancer that remains a disproportionate killer in Guatemala.