Porcelain Gallbladder

Porcelain gallbladder is calcification of the gallbladder wall, appearing bluish and brittle, often associated with chronic cholecystitis.

• Prevalence 0.06 to 0.8% of cholecystectomy specimens; women more than men (5:1); average age 50 to 60.
• Pathogenesis: chronic inflammation with intramural calcium deposition from stones, cystic duct obstruction and stasis.
• Cancer association: historically reported at 12 to 61%, but recent series show 2 to 6%, with selective mucosal calcification (stippled) higher risk than complete intramural calcification.
• Gallstones are present in over 90%.
• Complications: gallbladder carcinoma, biliary pain, cholecystitis.

• Many are asymptomatic and found incidentally.
• Biliary colic, dyspepsia, right upper quadrant pain, palpable mass (rare).
• Weight loss, anorexia and jaundice suggest malignancy.
• Normal liver tests unless complications.

• Plain radiograph: curvilinear calcification of the gallbladder wall.
• Ultrasound: highly echogenic curvilinear structure with acoustic shadowing (WES triad: wall, echo, shadow).
• CT: precise pattern of calcification (complete intramural, selective mucosal, partial), wall thickening or mass suggesting carcinoma.
• MRI/MRCP or endoscopic ultrasound for suspicious lesions.
• Tumour markers (CA 19-9, CEA) have low specificity.
• Histology after cholecystectomy to exclude carcinoma.

• Laparoscopic or open cholecystectomy is advised for most patients, especially with symptoms, stones, selective mucosal calcification, wall thickening or mass.
• En bloc approach to avoid bile spillage; use of retrieval bag; intraoperative frozen section if suspicious.
• Observation with ultrasound surveillance is reasonable in asymptomatic elderly or high risk patients with complete intramural calcification and no mass or thickening.
• If carcinoma is found incidentally (T1b or deeper): re-resection with wedge resection of liver segments IVb/V and portal lymphadenectomy; adjuvant capecitabine 1250 mg/m2 twice daily on days 1 to 14 every 21 days for 8 cycles.
• Perioperative cefazolin 2 g IV.
• Counsel patients on symptoms and follow up for 5 years after surgery if malignancy found.