To Cut or Not to Cut? A Case of Porcelain Gallbladder

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Porcelain gallbladder (PG) refers to the bluish discoloration of the gallbladder seen in intramural calcification associated with chronic cholecystitis. Traditionally, patients with PG have been considered at increased risk of gallbladder carcinoma (GBC). A 64 year-old man with type 2 diabetes, hypertension, hyperlipidemia, and stroke underwent CT colonography due to inadequate bowel preparation on colonoscopy. CT colonography revealed extensive calcification of the gallbladder wall throughout its length with wall thickening consistent with PG. No stones or gallbladder masses were seen. Patient denied weight loss, fevers, chills, right upper quadrant and epigastric abdominal pain, nausea, vomiting, or intolerance to fatty foods. Physical exam showed an afebrile anicteric male with a soft, nontender abdomen without palpable masses. Labs included normal WBC, bilirubin, alkaline phosphatase, AST, and ALT. The patient was referred for elective laparoscopic cholecystectomy, which was intraoperatively converted to open radical cholecystectomy given concern for malignancy. Pathology exhibited transmural gallbladder fibrosis/hyalinization with extensive mucosal and intramural calcification. No malignant cells or stones were identified.Figure 1PG is a rare manifestation of chronic cholecystitis that commonly affects females. PG has an incidence of 0.06-0.08% at autopsy and up to 1.1% on surgical specimens. Patients are often asymptomatic and diagnosis is based on incidental imaging findings as in our case. Small case series and retrospective reviews from the 1940-1950s associated PG with increased risk of GBC, 12-62%. Based on the risk of GBC, PG has been considered an indication for cholecystectomy even in asymptomatic patients. Recent studies and a systematic review suggest that the risk of GBC is significantly lower, 0-3%. These have led to controversies regarding surgical management versus observation. Multiple arguments support cholecystectomy as a curative treatment in fit patients. However, independent of laparoscopic or open approach, surgery is associated with increased complications and mortality. Major complications include bleeding, infection, biliary and bowel injury. Further studies are required to elucidate the risk and pathogenesis of GBC in PG. Also, risk stratification models should be developed to guide management given the significant risks and the unclear benefits of surgery. We recommend individualized discussions on a case-by-case basis.