Porcelain Gallbladder

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.