S3474 Symptomatic Cholelithiasis in the Setting of Porcelain Gallbladder and SARS-CoV-2 (COVID-19) Infection

Abstract

Introduction: Porcelain gallbladder, a rare entity with female preponderance, is a manifestation of chronic inflammation of the gallbladder. It is an incidental finding characterized by calcification of the gallbladder wall on imaging studies. The affinity of SARS-CoV-2 for angiotensin converting enzyme 2 (ACE2) which is widely expressed in the lungs, heart, intestines, gallbladder, kidneys, and adipose tissue may account for its ability to accentuate indolent inflammation in the gastrointestinal tract. Case Description/Methods: 56 year old African American female with medical history of gastroesophageal reflux disease, obesity and hypertension presented with a 3 day history of fever, shortness of breath, cough and sudden onset intermittent, burning epigastric and right upper quadrant (RUQ) pain with no aggravating or relieving factors. Vital signs at presentation; Temperature 100.8 F, Respiratory rate 20 breaths/ minute, pulse of 89beats/min, oxygen saturation 97% on room air and blood pressure 147/105mmHg. Physical examination findings were reduced air entry at the lower lung zones bilaterally and moderate epigastric and RUQ tenderness. She was positive for SARS-CoV-2 RNA. Chest X-ray showed large bilateral lower lobe atelectasis and increased interstitial process in the lower lung fields. She was admitted for COVID pneumonia. On admission day 1 patient continued to complain of RUQ pain, warranting RUQ ultrasound scan which showed prominent gallbladder calculus with posterior shadowing, likely porcelain gallbladder in the setting of existing gallstones. Patient was managed with vitamins, ceftriaxone, azithromycin, remdesivir, famotidine and tylenol for pain. Abdominal pain improved and she was discharged home on day 3 of hospitalization for outpatient follow up. Discussion: Our patient presented with symptomatic cholelithiasis, in the setting of COVID infection and porcelain gallbladder. We believe this finding bolsters the assertion that COVID infection accentuates gallbladder inflammation which consequently leads to precipitation/ worsening of symptoms of underlying chronic gall bladder disease. In light of the aforementioned, we believe the diagnostic challenge is the ability to make a clear distinction between de novo inflammation of the gallbladder and accentuation of an ongoing chronic inflammatory process. Given that there is a risk of porcelain gallbladder progressing to gallbladder cancer, should routine surveillance be performed in this population of patients?