PORCELAIN GALLBLADDER

Abstract

To the Editor: An 80-year-old man came to a family medicine outpatient clinic for his annual health examination. His past history was notable for chronic cholecystitis, chronic hepatitis B carrier status, iron deficiency anemia, and chronic renal insufficiency. His chest radiography revealed a round opacity with rim and internal amorphous hyperdensities in the right upper quadrant of the abdomen (Figure 1). Laboratory values were within reference ranges except for an elevated serum creatinine level (1.6 mg/dL) and a low hemoglobin level (11.1 g/dL). Abdominal radiography 1 week later confirmed a similar finding in addition to degenerative joint disease of the spine. Computerized tomography identified a thick layer of nonuniform calcifications coating the inner wall of the Phrygian cap of the gallbladder as a large porcelain gallbladder (Figure 2). Chest radiography revealed a round opacity (arrow) with rim and internal amorphous hyperdensities in the right upper quadrant of abdomen. Abdominal computerized tomography showed a thick layer of nonuniform calcifications coating the inner wall of the Phrygian cap of the gallbladder as a large porcelain gallbladder. Porcelain gallbladder is an uncommon finding of chronic cholecystitis characterized by extensive calcification of the gallbladder wall.1 The term “porcelain gallbladder” is used to describe the bluish discoloration and brittle consistency of the gallbladder wall.2,3 The prevalence of porcelain gallbladder in cholecystectomy specimens has ranged from 0.06% to 0.8%.2,3 In 95% of porcelain gallbladder specimens, cholelithiasis is the accompany finding.2 Porcelain gallbladders are five times as common in women as in men, usually in the sixth decade.3 Diagnosis is frequently made by the detection of a palpable mass in the right upper quadrant of the abdomen or incidentally in an abdominal roentgenogram.3,4 The significance of porcelain gallbladder has been thought to be strongly associated with gallbladder cancer, which has a grave prognosis. The incidence of gallbladder cancer in porcelain gallbladder was reported to be 12% to 61% in an early 1960s series,3,5–10 but two 2001 studies showed a lower incidence of gallbladder cancer in porcelain gallbladder (0% and 5%).6,7 These results have raised the question as to whether prophylactic cholecystectomy is necessarily indicated for those who are asymptomatic or have multiple comorbidities.6,7,11 Laparoscopic cholecystectomy is even suggested in the complete intramural calcification type of porcelain gallbladder, which carries a lower risk of gallbladder cancer than the incomplete mucosal calcification type.4,8,11 At present, prophylactic cholecystectomy is the treatment of choice for porcelain gallbladder.11,12 The natural history of porcelain gallbladder is unclear, as is the causal relationship between porcelain gallbladder and gallbladder cancer. The last report suggested that the smaller number of porcelain gallbladders and different ethnicities in the two 2001 reviews might have confounded the incidence of gallbladder cancer in porcelain gallbladders significantly.10 The patient was informed of the risk malignant degeneration of the porcelain gallbladder, but he refused surgery. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that none of the authors have any financial or any other kind of personal conflicts with this letter. Author Contributions: Study concept and design: Fang-Yeh Chu. Acquisition of subjects and data: Fu-Hsiung Su. Analysis and interpretation of data: Wing-Keung Cheung. Preparation of manuscript: Hsiao-Ping Liang. Critical review and approval: All authors. Sponsor's Role: None.