Dilated Gallbladder Causing Right Iliac Fossa Pain in a Patient with Advanced Pancreatic Cancer: A Diagnostic and Symptom Management Challenge at End of Life.

Introduction: Gallbladder distension secondary to malignant biliary obstruction is an under-recognized cause of abdominal pain in advanced pancreatic cancer and may present atypically outside the right upper quadrant. Pain assessment can be further complicated in older adults with cognitive impairment and superimposed delirium. Case Presentation: We present an 83-year-old female with locally advanced pancreatic adenocarcinoma and baseline cognitive impairment, admitted to an acute tertiary hospital with painless jaundice. She subsequently developed persistent right iliac fossa pain that was poorly responsive to escalating opioid therapy despite empirical treatment for urinary tract infection and constipation. The inpatient palliative care team was consulted to assist with symptom control. Delirium on a background of cognitive impairment complicated pain assessment. Imaging performed to clarify the cause of escalating pain revealed a grossly dilated gallbladder extending into the mid abdomen, likely due to malignant biliary obstruction. Following multidisciplinary discussions and conversations with family regarding goals of care, invasive interventions were deferred. Pain control improved with opioid titration and the addition of antispasmodic therapy. The patient later developed sepsis and died during the admission. Discussion: This case highlights key learning points for palliative care practice. Atypical and opioid-refractory pain should prompt reconsideration of pain etiology rather than reflexive opioid escalation. Cognitive impairment and delirium necessitate iterative, multimodal assessment, while caregiver concerns regarding opioid use require proactive engagement. Opioids alone may be insufficient for colicky biliary pain, underscoring the importance of mechanism-based adjuvant strategies. When aligned with goals of care, judicious use of imaging at the end of life can clarify pain etiology and guide proportionate, comfort-focused management. Conclusion: In advanced cancer, particularly in patients with cognitive impairment and delirium, careful assessment of pain mechanisms, caregiver engagement, and proportionate investigations are essential to optimize comfort and support individualized end-of-life care.