INTRODUCTION
Porcelain gallbladder is an extremely rare condition with an incidence of 0.06 to 0.8% and considered as high risk for carcinoma gallbladder.1,2 The risk for malignancy ranges from 5 to 22%.3 It is also known as calcified gallbladder and is considered as end stage of chronic cholecystitis. It is more common among elderly females and due to high risk of malignant transformation it is managed by cholecystectomy.
CASE SUMMARY
A 55-year-old female presented with complaints of intermittent pain in right upper abdomen of 15 days duration. There was no history of any fever, jaundice, and vomiting. Abdominal examination was unremarkable. Ultrasound abdomen revealed a large calcified mass in gallbladder fossa with normal common bile duct and normal liver echotexture. After corroboration with X-ray abdomen (Fig. 1), the provisional diagnosis of porcelain gallbladder was made. Contrast-enhanced computed tomography (CECT) abdomen confirmed the diagnosis of porcelain gallbladder with no evidence of malignant change (Fig. 2). Liver function test was normal. Patient was planned for open cholecystectomy. Intraoperatively, it was a difficult dissection as gallbladder was completely calcified, brittle, and densely adhered to liver bed. After dissecting Calot's triangle and dividing cystic duct and artery, gallbladder was excised and sent for histopathologic examination. Postoperative recovery was uneventful.
Histopathology report revealed rigid, thickened chronically inflamed gallbladder wall with transmural calcification. Gallbladder was packed with multiple stones. Microscopic examination showed hemorrhage and fibrosis with focal muscular hypertrophy and calcification. There was no evidence of malignant change.
DISCUSSION
Porcelain gallbladder or calcified gallbladder or cholecystopathia chronica calcarea is a relatively rare condition with an incidence rate of 0.06 to 0.8%.1,2 It is characterized by bluish discoloration and extremely calcified wall of gallbladder. It is commonly seen among elderly females and is associated with gallstones in about 90% of cases.1-3 It is associated with high risk of malignancy and the rate may vary from 5 to 22%.3,4 Porcelain gallbladders are associated with gallstones in 90% of cases. The pathogenesis of gallbladder calcification is still unclear and it is considered a result of obstruction of cystic duct leading to the precipitation of calcium salts in the mucosa or as a result of chronic inflammation resulting in the hemorrhage, scarring, and hyalinization of the wall causing deposition of lime salts. Histological examination shows that the calcification is diffusely scattered throughout the mucosa, submucosa, glandular spaces, and Rokitansky—Aschoff sinuses.1,2,4 This chronic inflammation or the degeneration and regeneration process within the gallbladder epithelium may act as a carcinogenic stimulus.
Porcelain gallbladder patients are usually asymptomatic and this condition is diagnosed as an incidental finding on plain abdominal radiograph, sonography, and CT.5 There are several conditions like large opaque gallstone, calcified hydatid cyst of liver, metastatic deposits, calcified renal cysts, schistosomiasis, calcified lymph nodes, and other granulomatous diseases, which may closely mimic porcelain gallbladder. However, CT is considered as investigation of choice as it can accurately differentiate it from other causes.5
Porcelain gallbladder is associated with a high risk of malignancy; hence, surgical removal should not be delayed. Prophylactic cholecystectomy should be performed.6-8 Open cholecystectomy is preferred over laparoscopic approach due to suspicion of malignancy as well as brittle consistency of gallbladder; however, few studies have quoted successful laparoscopic cholecystectomy in porcelain gallbladder.6-8