A 68-year-old woman comes to the office for a preventive visit. The patient feels well, and recently lost 4 kg (8.8 lb) on a new diet and exercise regimen. She has no recent history of abdominal pain, jaundice, or changes in her stools. Past medical history is notable for hypertension and hypercholesterolemia, for which the patient takes appropriate medications. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. On examination, the abdomen is soft and nontender, and no hepatosplenomegaly is noted. However, a firm mass is palpated in the right upper quadrant. CT scan of the abdomen is ordered and is given in the exhibit. This patient is at elevated risk for which of the following conditions?
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This patient, with a firm, palpable gallbladder and extensive calcification throughout the gallbladder wall, has typical findings of porcelain gallbladder. Patients with this condition may present with right upper quadrant abdominal pain but many are asymptomatic, with findings detected incidentally on imaging done for other reasons. Radiographic features may include a thickened gallbladder wall with a rim of patchy or uniform calcification.
Porcelain gallbladder is a potential manifestation of chronic cholecystitis and is often found in association with multiple gallstones. The pathogenesis is due to dystrophic intramural deposition of calcium salts in the setting of chronic inflammation. Gross findings include a bluish, brittle, thickened gallbladder wall with a "crunchy" texture. Microscopic findings can include calcified plaques within the muscularis or spotty calcification in the mucosa. Porcelain gallbladder is associated with an increased risk of adenocarcinoma of the gallbladder.
(Choice A) Acute ascending cholangitis is typically due to gram-negative infection of the intrahepatic biliary tree. It is a consequence of biliary obstruction (eg, choledocholithiasis) and presents with fever, right upper quadrant abdominal pain, and jaundice.
(Choice B) The risk of cholangiocarcinoma is increased in fibrotic diseases of the bile ducts, such as primary sclerosing cholangitis, congenital fibropolycystic diseases, and chronic infection with Clonorchis sinensis (liver fluke).
(Choices D and E) The risk of hepatocellular carcinoma is increased in many chronic inflammatory diseases of the liver, especially those progressing to cirrhosis. Common conditions include chronic viral hepatitis and alcohol-associated liver disease.
Educational objective:
Porcelain gallbladder is a potential manifestation of chronic cholecystitis and is often found in association with multiple gallstones. It is due to dystrophic intramural deposition of calcium salts in the setting of chronic inflammation. Porcelain gallbladder is associated with an increased risk of adenocarcinoma of the gallbladder.