Episode two covers the less common gallbladder presentations, and the thread running through all of them is the same: chronic inflammatory remodeling around the gallbladder distorts the anatomy enough to change either the operation, the cancer risk, or the diagnostic frame. Stone-driven inflammation at Calot's triangle either compresses the bile duct from outside in Mirizzi, calcifies the wall in porcelain gallbladder, or erodes into bowel in gallstone ileus and Bouveret. The Csendes stage sets the reconstruction, the calcification pattern sets the cancer indication, and the level of stone impaction sets endoscopy versus surgery. Polyps test on a clean size rule with risk-factor modifiers, and functional gallbladder disorder tests on the discipline not to operate, because the failure mode is over-treating a heterogeneous category. Topics covered Mirizzi syndrome and the Csendes classification MRCP staging and open conversion risk Porcelain gallbladder and calcification pattern Cholecystenteric fistula and gallstone ileus Bouveret syndrome and gastric outlet obstruction Gallbladder polyps and the size threshold Gallbladder adenocarcinoma biology Pancreaticobiliary maljunction Functional gallbladder disorder and over-treatment Key decisions In Mirizzi syndrome the Csendes stage dictates the operation: external compression or a small fistula allows cholecystectomy or primary repair over a T-tube, while destruction of two-thirds or more of the duct wall requires hepaticojejunostomy. MRCP is the study of choice in suspected Mirizzi because it shows the stone, duct compression, and any fistula without instrumenting, and dense inflammation at Calot's triangle mandates open conversion with intraoperative cholangiography. Mucosal, incomplete, or focal porcelain gallbladder calcification remains an indication for prophylactic cholecystectomy, while complete circumferential transmural calcification can be observed in selected high-risk surgical patients. Gallstone ileus is managed with enterotomy and stone extraction, and a staged approach that defers fistula takedown lowers perioperative mortality in elderly comorbid patients; Bouveret syndrome is treated first-line with endoscopic lithotripsy because the duodenal stone is within endoscopic reach. Gallbladder polyps at or above ten millimeters warrant cholecystectomy regardless of other features, and six-to-nine-millimeter polyps warrant surgery if any risk factor is present, with documented growth of two millimeters or more the highest-yield malignancy signal. Primary sclerosing cholangitis drops the polyp threshold so that any polyp, or one at eight millimeters, warrants cholecystectomy, with annual ultrasound surveillance. Functional gallbladder disorder demands strict selection: fully met biliary pain criteria, structural disease excluded, functional GI disease optimized first, and explicit counseling that even low-ejection-fraction patients improve only about sixty percent of the time. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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