What is a porcelain gallbladder?

The porcelain gallbladder can be defined as the calcification process that occurs at the level of the respective organs. It is believed that this process is brought on by an excessive number of gallstones (the exact mechanism through which the changes occur has yet to be identified). This condition affects primarily women, with middle-age and obesity being two of the most important risk factors. The porcelain gallbladder is also known as the calcifying cholecystitis or cholecystopathia chronica calcarea. The average age at which this condition is diagnosed is 54 years, with a diagnosis age range between 38 and 70 years.

The porcelain gallbladder is considered a variant of the chronic cholecystitis, due to the characteristic morphological aspect. There are different changes that contribute to the gallbladder becoming a porcelain-like vessel, such as the inflammatory scarring that occurs at the level of the gallbladder wall or the dystrophic calcification in the same area. As you will have the opportunity to see below, the removal of the gallbladder is often the main treatment approach. This surgical intervention is known as cholecystectomy.

There are a lot of patients in which the porcelain gallbladder is associated with gallbladder cancer. It is not certain why this association occurs. The incidence of cancer is of 1-6% in all the patients who present a porcelain gallbladder. Other studies have demonstrated that 22-30% of the patients diagnosed with a porcelain gallbladder develop a gallbladder adenocarcinoma.

Causes of Porcelain Gallbladder

There are a number of predisposing factors that increase the risk for the porcelain gallbladder. Among these factors, there are: the cycling of cholesterol, hormonal factors, infections with diverse bacterial agents, sex (females > males) and geographical location.

Even though the exact cause that leads to the porcelain gallbladder is not known, some studies have incriminated the irritation of the gallbladder by the gallstones. The constant irritation seems to lead to a process of chronic inflammation, with calcium deposits appearing at the level of the gallbladder wall. Another theory has suggested that the condition is due to the obstruction of the cystic duct – it is believed that this obstruction leads to the precipitation of calcium carbonate salts. These lead to the bile stagnating in the gallbladder and thus favor the formation of the calcium deposits on the gallbladder walls. Other scientists have presented the calcification of the gallbladder as a dystrophic process, which occurs due to the chronic infection and compromised circulation. It is believed that the circulation is compromised by the presence of cystic duct stones – these can lead to a wide array of changes in the area, such as scarring and hemorrhage. In time, these changes modify the gallbladder wall, leading to the characteristic porcelain gallbladder.

What are the Symptoms of Porcelain Gallbladder?

These are the most common symptoms that appear in patients who suffer from the calcified gallbladder:

• Abdominal pain
  • The pain is especially present after the person eats
  • Most common area in which the pain appears – right upper quadrant
• Jaundice (yellow coloring of the skin and eye sclera) – often appears as the first symptom, being followed by the above-mentioned pain in the right upper quadrant of the abdomen
• Vomiting

Diagnosis

These are the most common methods used for the diagnosis of the porcelain gallbladder:

Medical history of the patient

• History of gallbladder problems (gallstones for example)
• Symptoms experience
• History of drug or alcohol abuse
• Weight loss
• Loss of appetite
• History of cancer in the family

Physical examination

• Palpation of the abdomen – most often elicits pain in the right upper quadrant

Abdominal X-ray

• Curvilinear calcification in the right upper flank (corresponding to the gallbladder)
• Variable thickness of the calcification (from thin to thick)
• Variable size of the gallbladder (most commonly – large size)
• Some patients might not present any abnormalities on the plain X-ray

Abdominal ultrasound

• Dense shadowing is present at the level of the gallbladder
• The changes identified with the help of the ultrasound can misguide the diagnosis

CT scan

• Generally used for the confirmation of the diagnosis (highest accuracy)
• Characteristic aspect – thin layer of mineralization that outlines the wall of the gallbladder
• Superior to other investigations (such as the X-rays) when it is necessary to stage the gallbladder carcinoma

MRI

• Inferior ability to detect calcification
• Not the most common imaging investigation for this health issue

Angiogram

• Recommended in case of associated malignancy, useful for the staging of the cancerous invasion.

This condition can also be diagnosed incidentally, upon performing investigations for other potential health problems. The incidental diagnosis is also made in asymptomatic patients. Based on the information provided through imaging studies, the differential diagnosis can be made with the following conditions: gallstones (wall-echo-shadow sign), emphysematous cholecystitis and pneumobilia. The early diagnosis of the porcelain gallbladder delivers the best outcome for this condition.

Treatment

The course of treatment for the porcelain gallbladder is the complete removal, due to the increased risk for gallbladder cancer. The procedure – cholecystectomy – is performed with the help of imaging studies. These are performed before and during the procedure, revealing the structure of the biliary tree and guiding the surgeon in performing the removal of the gallbladder. The cholecystectomy can be performed through the traditional, open approach or using laparoscopy, with microsurgical instruments and video guidance. It is possible that the anatomy and consistency of the gallbladder will complicate the laparoscopic intervention, requiring a switch to the open approach in the end.

Upon intervening surgically to remove the porcelain gallbladder, the surgeon will notice the blue discoloration, as well as the brittle consistency of the gallbladder wall. All of these changes are due to the extensive calcium encrustation that occurs at the level of the gallbladder wall. The surgical intervention should not be eliminated as a course of treatment, just because the patient is asymptomatic (the risk of developing gallbladder cancer is just as high in these patients).

After the porcelain gallbladder is removed, a sample will be sent to the laboratory for the routine histopathological examination. This examination will demonstrate whether the gallbladder presented a neoplasm component or not.

What is basal ganglia hemorrhage?

The basal ganglia hemorrhage can be defined as a form of hemorrhage that occurs inside the brain, being primarily caused by a hypertension that was poorly kept under control. The patients who suffer from this form of hemorrhage also present the signs of chronic hypertensive encephalopathy. It is important to remember that the hemorrhages caused by hypertension can appear in other areas of the brain as well, such as the pons or the cerebellum.

When a bleeding occurs at the level of the basal ganglia, this means that the area of the brain that is responsible for the movements of the body, sensation, speech and personality has suffered. The basal ganglia hemorrhage is one of the most frequent hemorrhages that occur at the level of the brain. The accumulation of blood at the level of the brain can actually lead to compression, followed by the damage of the brain tissue. High blood pressure remains the main cause why the arteries at the level of the basal ganglia burst, leading to hemorrhage.

Anatomy of the Basal ganglia (in Pictures)

Picture 1 showing Basal ganglia and related structures of the brain : Globus pallidus, Basal ganglia, Thalamus, Substantia nigra and Cerebellum.

Pathophysiology

If a person suffers from chronic hypertension and this is not properly kept under control, this will lead to a number of pathological changes at the level of the blood vessels (including those at the level of the brain).

Microaneurysms can occur at the level of perforating arteries, these being also known as the Charcot-Bouchard aneurysm. These have a small diameter, often occurring on arteries that are small in diameter as well. Upon a close analysis, it seems that the microaneurysms have a similar location with the actual hypertensive hemorrhage – 80% lenticulostriate, 10% pons and 10% cerebellum. These are found in patients who suffer from chronic hypertension – it is possible that they thrombose or rupture. In case of leakage, the patient can suffer from what is known as a cerebral microhemorrhage.

Apart from the microaneurysms, it is possible that the larger vessels are affected by the atherosclerosis process. Arteriosclerosis is present in two different forms, meaning the hyaline and the hyperplastic ones. The latter is most often encountered in severe cases.

The basal ganglia is a very important of the brain, being located at the level of the cerebrum and playing an essential role in the following areas: cognitive function, eye movement, procedural learning and motor control. There are three major functions that the basal ganglia is responsible of, meaning: suppression of undesired movements, regulation of muscle tone and movement control (the basal ganglia contributes to the initiation and termination of body movements).

While the hypertension is known as a precipitating factor, there are other factors that are known as “predisposing”. Among these factors, there are: leading a sedentary lifestyle, eating an unhealthy diet, age, gender, hereditary and choosing self-medication. Due to all of these factors, a chronic process of vasoconstriction appears. This in turn leads to the blockage of the blood vessels, with a reduction in the oxygen and nutrient supply. Once the brain does not receive what it needs, the cerebral perfusion is going to be altered and reduced. The alteration of the perfusion is responsible for the basal ganglia hemorrhage, with the blood irritating both the nerves and the tissues in the area.

It is also possible that, due to the basal ganglia hemorrhage, a blood clot will form in the area. This will cause the compression of the brain tissues in the area, with the patient suffering from specific symptoms.

Symptoms

The symptoms caused by the basal ganglia hemorrhage are present at different levels, as you will have the opportunity to see below:

Body movement

• Difficulties swallowing, smiling or speaking
• Ataxia
• Tremor
• Loss of movement/rigid movements
• Paralysis or hemiparesis

Cognitive function

• Difficulties in processing information or taking decisions
• Memory problems (memory loss, forgetfulness)
• Language difficulties (spoken and written)
• Attention deficit or short span of attention

Vegetative symptoms

• Nausea and vomiting
• Headaches
• Loss of consciousness (various degrees)

Changes in relation to the personality

• The patient presents difficulties in understanding information
• Frustration or anxiety
• No longer feels motivated, losing the interest for daily activities or work
• Mood swings – laughs or cries for no reason
• Feelings of depression or anger.

Diagnosis

These are the most common used methods for the diagnosis of the basal ganglia hemorrhage:

Imaging studies

• CT scan
  • Hyperdensity identified at the level of the basal ganglia or thalamus
  • The hemorrhage can extend to the brain ventricles (small parenchymal component)
• MRI
  • Identification of the hemorrhage that has occurred at the level of the basal ganglia.

Treatment and Prognosis

In general, one of the main objectives of the treatment is keeping the hypertension under control, in order to prevent the basal ganglia hemorrhage in the future. If the hemorrhage has occurred, with hydrocephalus being also present at the level of the brain, CSF drainage might be required (along with the extra-ventricular drain). The evacuation of the clot is only recommended only in the large hemorrhages (over 60 ml). Pain medication can be administered to bring the necessary pain relief (often the pain appears as the result of immobilization).

Physical therapy is essential during the recovery period for the patient. It is based on exercises that are meant to strengthen the muscles and also on movements destined to increase the range of motion. The physical therapist will include exercises that are both active and passive; some of them will concern the improvement of the balance and coordination, while others address the problems related to sensory organization. Locomotion training is going to be performed, with or without walking aids or other specialized equipment. Some patients might need to learn how to use a wheelchair – the physical therapist will also provide assistance when it comes to making the necessary transfers. The occupational therapist will work hand in hand with the physical therapist – he/she will be responsible for teaching the patient how to handle the activities of daily living with the current abilities.

What is Mycotic aneurysm?

The mycotic aneurysm is a type of aneurysm that appears as the wall of certain arteries suffers from a bacterial infection. This medical condition is often perceived as a complication of the infection – the bacteria travels from the heart, the hematogenous spread being responsible for the mycotic aneurysm.

This condition is also known as microbial arteritis, having been identified for the first time by Osler in 1885. Out of all the aortic aneurysms, the mycotic aneurysms account for 2.6%. The earlier the diagnosis is made, the better the prognosis will be. As you will have the opportunity to read below, the lack of treatment can be fatal, with hemorrhaging and sepsis being among the most common consequences.

The diagnosis of the mycotic aneurysm during the early stage is quite difficult, due to the fact that the majority of the symptoms are non-specific. It is also important to mention that the mycotic aneurysm can appear as a complication of other medical problems, such as is the case with the infective endocarditis.

You will often see the mycotic aneurysm presented as a false aneurysm (also known as pseudoaneurysm). The true aneurysm occurs when all of the three layers of the arterial wall are involved. These three layers are the intima, media and adventitia. On the other hand, the false aneurysm refers to a collection of blood that has leaked out of the artery but it is confined by the tissues that surround it.

Pathology

When the bacteria reaches the walls of the arteries, it starts to digest it, leading to the appearance to what clearly is a false aneurysm. It should be mentioned that the mycotic aneurysm is characterized by a high degree of instability, with an increased risk for rupture.

The most common mechanisms of infection include: septicemia, adjacent infection (contiguous spread) and septic emboli. There are also risk factors to be considered for the mycotic aneurysm, such as: state of bacteremia, infectious endocarditis, drug abuse (with intravenous administration), state of reduced immunity, aortic trauma or iatrogenic causes, atherosclerotic plaque (pre-existing), native aneurysm (pre-existing) and prosthetic arterial devices (stents or grafts).

As for the most often identified bacterial agents that lead to the appearance of the mycotic aneurysm, these are salmonella, staphylococcus aureus and Klebsiella pneumonia. The latter is more and more often identified as a pathogen leading to the mycotic aneurysm. This can also lead to other health problems, such as the abscess of the liver, spleen or endophthalmitis. Gram-negative bacilli can also cause such health problems, with a preference for the infrarenal sites (often encountered in elderly patients).

The mycotic aneurysm is identified in areas where one would expect the least, such as: aorta (thoracic or abdominal), visceral arteries of the abdomen, arteries of the lower extremities and intracranial arteries (peripheral location, as opposed to the berry aneurysms).

Diagnosis

These are the methods used for the diagnosis of the mycotic aneurysm:

CT or CT angiography

• The location of the aneurysm is atypical (thus excluding the diagnosis of atheromatous disease)
• The aneurysm can present a multilobulated appearance
• The calcification of the arterial wall is interrupted by the aneurysm
• If aorta – rupture of the wall
• Fluid collection and thrombus formation.

The differential diagnosis can be made with other types of aneurysms, such as the atherosclerotic aneurysm and the inflammatory aortic aneurysm.

Treatment

In the situation that the mycotic aneurysm becomes infected, there is a high risk of morbidity and mortality. The treatment measures taken for such measures include the administration of antibiotics, followed by the aggressive surgical debridement of the tissue that has been infected. The surgical intervention is generally completed by the vascular reconstruction. It is possible that the endovascular approach is chosen as treatment for the mycotic aneurysm – this is recommended in patients for whom the open approach is not suitable and also in case of aneurysm rupture.

The size of the mycotic aneurysm may dictate the need for treatment. It is known that small mycotic aneurysm may resolve spontaneously, thus requiring no treatment or surgical intervention. The mycotic aneurysm that have over 1-2 cm in diameter are required to be surgically removed.

Pictures of Mycotic aneurysm

Picture 1 : Diagram showing the Saccular aneurysm, Atherosclerotic aneurysm, Mycotic aneurysm(bottom left) and Traumatic aneurysm

Prognosis

Due to the high mortality rate, the mycotic aneurysm does not present a very good prognosis. The mycotic aneurysm that present a high risk for morbidity or mortality often affects those whose immune system is compromised; it also appears in those who suffer from pre-existing conditions, such as heart disease or atherosclerosis. The elderly patients present mycotic aneurysms that are located at infrarenal sites, while those who are younger present a high risk for intracranial aneurysms.

Complications

A number of complications can arise in patients who suffer from a mycotic aneurysm, such as: rupture of the aneurysm (high risk, leads to hemorrhage), sepsis (the aneurysm is an ongoing source) and embolic infarction.