The porcelain gallbladder is a rare cholecystopathy, characterized by the calcification of

the gallbladder wall . Inflammatory scarring of the wall, combined with dystrophic
calcification within the wall transforms the gallbladder into a porcelain-like vessel.
Abdominal ultrasound : dense shadowing and calcified walls , 10 mm calculus in the
distal bile duct;
X-ray : A plain abdominal radiograph that shows a right upper quadrant pyriform opaque
mass with curvilinear calcification; this finding suggests porcelain gallbladder.
In the majority of cases it is asymptomatic and it may not be discovered until the patient
undergoes medical tests , most commonly an X-Ray .
The benefits of a laparoscopic cholecystectomy are a shorter recovery time and a
decreased risk of bleeding and infection.
Case report :
Chief Complaint : the pacient is a 68 years old female presenting with : abdominal pain in
the right upper quadrant , Bilious vomiting , nausea, loss of appetite, fatigue.
Family history : noncontributory
History of present illness : The patient is presenting with a 12 years history of digestive
symptoms and difuse abdominal pain, treated with herbal remedies . A week before the
hospital admission the symptoms have worsened and the patient came for a consult at the
First Surgical Clinic.
Physical examination : - pale and dry skin , abdominal pain intensified by right upper
quadrant palpation, a positive Murphys sign;
Laboratory tests :
- Hgb = 11,2 g%; Hct = 36%
- TBIL= 1,30 mg/dL,
- DBIL=0, 60 mg/dL,
- ALP=160 U/L,
- ALT=46 UI, AST=36 UI,
- WBC=11.000/mmc
Abdominal ultrasound : Granular pattern in the liver, thickened gall bladder with
posterior shadowing
ERCP (Endoscopic retrograde cholangiopancreatography) : sphincterotomy to remove
the duct obstruction
The true incidence of porcelain gallbladder is unknown, but it is reported to be 0.6-0.8%,
with a male-to-female ratio of 1:5.

In 90% of cases it is associated with gallbladder stones.

Patients with porcelain gallbladder are usually asymptomatic, and the condition is usually
found incidentally on plain abdominal radiographs, sonograms, or computed tomography
(CT) images
Although the exact cause is not clear, it is believed that there are three possible
mechanisms that lead to porcelain gallbladder :
1. Gallbladder inflammation and calcification of the wall; The radiopaque material
consists of calcium carbonate or, less commonly, calcium phosphate or calcium
bilirubinate;
2. Cystic duct obstruction with distended gallbladder and wall inflammation;
3. Arterial stenosis of the cystic artery with gallbladder wall necrosis;
There are 2 types of calcified gallbladders :
1. complete and diffuse intramural calcification;
2. incomplete and selective mucosal calcification;
Although it has been strongly associated with gall bladder cancer, recent studies suggest
that the association between these two entities is less than previously thought. Still the
relationship between these two entities is controversial, and given the poor prognosis of
gall bladder cancer, most of the surgeons would prefer prophylactic cholecystectomy.
Recently, it has been suggested that the risk of gall bladder cancer in porcelain gall
bladder depends upon the pattern of calcification and it has been shown that patients with
selective mucosal calcification have a higher risk of malignancy as compared to diffuse
intramural calcification. In these situations, the surgeon must avoid malignant peritoneal
dissemination by taking special precautions :
- the gallbladder must not be perforated during the cholecystectomy
- it must be used a endobag technique for retrieval of gallbladder
- the evacuation of retained pneumoperitoneum has to be done with the trocars in
place;
- extemporaneous histopathological examination;
Differential diagnosis :
-

large gallbladder opaque calculi

calcified hidatyd cysts, primary and metastatic liver tumors
calcification in old adrenal hemorrhage and adrenal masses
calcified renal cysts, right renal calculi

The porcelain gallbladder is a rare disorder in which chronic cholecystitis produces mural
calcification.
Patients with porcelain gallbladder are usually asymptomatic, and the condition is usually
found incidentally.

The particularity of the case emphasizes the advantages of minimally invasive approach
on an elderly patient with multiple comorbidities and gallbladder stones.