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Multiple Minute Gallbladder Muscle Calcifications

The Surgery Journal

July 2021
07(03):e172-e173

DOI:10.1055/s-0041-1731449

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CC BY 4.0

Authors:

Adriana Handra-Luca

Hôpital Avicenne – Hôpitaux Universitaires Paris-Seine-Saint-Denis

The calcifications were located at direct contact to the gallbladder muscle (A–F). Some of them were also at contact to the inter-muscle cell connective tissue. Calcifications were also observed at contact to capillary vessel wall (in the muscle layer). To note would be the presence of granular dystrophia of muscle cells (G). Original magnification ×40 (A–I).

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Multiple Minute Gallbladder Muscle Calciﬁcations

Adriana Handra-Luca, MD, PhD1,2

1Serviced'AnatomiePathologique,APHPGHUAvicenne,Bobigny,

France

2University Sorbonne Paris Nord, UFR SMBH, Bobigny France

Surg J (NY) 2021;7:e172–e173.

Address for correspondence Adriana Handra-Luca, MD, PhD, Service

d'Anatomie Pathologique, APHP GHU Avicenne, Universite Paris Nord

Sorbonne Cite; 125 rue Stalingrad, 93009 Bobigny, France

(e-mail: adriana.handra-luca@aphp.fr).

We have read with great interest the article of Iqbal et al

reporting cases of porcelain gallbladder.1Most reported

cases show calciﬁcations when at an extensive stage or of

bone metaplasia type.2,3 However, other types of calciﬁca-

tions can be detected in the gallbladder wall, for example,

intracellular epithelial mucosal calciﬁcations in chronic

Fig. 1 The calciﬁcations were located at direct contact to the gallbladder muscle (A–F). Some of them were also at contact to the inter-muscle

cell connective tissue. Calciﬁcations were also observed at contact to capillary vessel wall (in the muscle layer). Tonote would be the presence of

granular dystrophia of muscle cells (G). Original magniﬁcation ×40 (A–I).

received

May 11, 2019

accepted after revision

May 7, 2021

DOI https://doi.org/

10.1055/s-0041-1731449.

ISSN 2378-5128.

This is an open access article published by Thieme under the terms of the

Creative Commons Attribution License, permitting unrestricted use,

distribution, and reproduction so long as the original work is properly cited.

(https://creativecommons.org/licenses/by/4.0/)

Thieme Medical Publishers, Inc., 333 Seventh Avenue, 18th Floor,

New York, NY 10001, USA

Perspective

THIEME

e172

Article published online: 2021-07-22

cholecystitis.4We would like to draw attention on another type

of gallbladder calciﬁcations that of multiple, minute, muscle

layer calciﬁcations (►Fig. 1). Most calciﬁcations were situated

between the muscle cells or between muscle cells and the

connective tissue (ﬁbrotic or not) of the muscle layer. Some

calciﬁcationsweresituatedinzoneofmusclegranular

degeneration/dystrophia and at contact to capillary walls (with-

out calciﬁcations in arteries or veins). The number of reactive

lymphocytes was not increased at contact. The gallbladder wall

showed mild subacute and chronic cholecystitis.

The histogenesis of this type of extraskeletal calciﬁcation

is difﬁcult to precise. Renal failure might be incriminated

since the medical history revealed increased serum creati-

nine, cortical right renal cyst in the context of type-2 diabe-

tes diagnosed 5 years previously. Calciﬁcations were

detected in the aortic valves, abdominal aorta, iliac and

femoral and popliteal arteries, and microcalciﬁcations in

the liver (segments 5, 7, and 8), while bone demineralization

was diagnosed on computed tomography (CT)-scan. An

additive/favoring effect of drugs taken cannot be ruled out,

ramipril/hydrochlorothiazide being known to raise serum

creatinine, uric acid, as well as calcium and levetiracetam/

parahydroxybenzoate/maltitol, renal failure.5,6 Moreover,

muscle degeneration was detected at contact of some of

the calciﬁcations, possibly result of is chemia as related to the

cirrhosis-related vascular changes and to atorvastatine-re-

lated muscle abnormalities.7

In conclusion, we report multiple, minute gallbladder

calciﬁcation located in the muscle layer, perivasculary or

not. Such lesions of complexetiology and possibly correspond-

ing to an incipient stage of porcelain gallbladder might be of

potential clinical relevance for imaging diagnosis.

Conﬂict of Interest

None declared.

References

1Iqbal S, Ahmad S, Saeed U, Al-Dabbagh M. Porcelain gallbladder:

often an overlooked entity. Surg J (NY) 2017;3(04):e145–e147

2Schnelldorfer T. Porcelain gallbladder: a benign process or con-

cern for malignancy? J Gastrointest Surg 2013;17 (06):1161–1168

3Porcelain gallbladder. Accessed April 20, 2019 at: http://knowl-

edge.statpearls.com/chapter/0/27436

4Albores-Saavedra J, Henson DE, Klimstra D. AFIP atlas of tumor

pathology. In: American Registry of Pathology. Tumors of the Gall-

bladder,Extrahepatic BileDucts andVaterianSystem Series 4.Vol. 23.

Washington, DC: Armed Forces Institute of Pathology; 2015:234

5https://eurekasante.vidal.fr/medicaments/vidal-famille/medica-

ment-gp2002-COTRIATEC.html August 30th 2018; https://www.

vidal.fr/medicaments/cotriatec-5-mg-12-5-mg-cp-151373.html

6https://eurekasante.vidal.fr/medicaments/vidal-famille/medica-

ment-gp802-KEPPRA .html August 30th 2018; https://www.vidal.

fr/medicaments/keppra-1000-mg-cp-pellic-18342.html

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ment-gf340007-TAHOR.html August 30th 2018; https://www.

vidal.fr/medicaments/tahor-10-mg-cp-pellic-15953.html

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Porcelain Gallbladder: Often an Overlooked Entity

Article

Full-text available

Oct 2017

Background Porcelain gallbladder (GB) is a rare but potentially premalignant condition with minimal symptoms. Accident and Emergency (A&E) departments often tend to investigate abdominal pain through plain radiographs, which are occasionally reported by radiologists, thereby leaving behind few uncommon conditions, such as porcelain gallbladder unreported. Objectives We present three cases of porcelain GB in which initial diagnosis was not considered due to the presence of various other calcifications in the upper abdomen. Methods In A&E, plain abdominal X-rays were routinely performed in all three patients to investigate nonspecific postprandial abdominal pain. Although GB calcification was easy to diagnose on plain films, it was initially overlooked to be a cause of the symptoms and later was diagnosed on abdominal CT scans, performed for further evaluation. Results Abdominal X-rays revealed thin curvilinear calcification in the GB wall, partially calcified neck and body, and gall stones. CT scan confirmed porcelain GB in all three patients. Conclusion Gallbladder mural calcification is a rare cause of nonspecific abdominal pain, which is often overlooked on plain abdominal X-rays causing missed diagnosis. The association of porcelain GB with adenocarcinoma entails special emphasis on timely diagnosis and prompt management.

Tumors of the Gallbladder, Extrahepatic Bile Ducts, and Vaterian System

Book

Oct 2017

Porcelain Gallbladder: A Benign Process or Concern for Malignancy?

Article

Feb 2013
J GASTROINTEST SURG

Thomas Schnelldorfer

Background: Gallbladder wall calcifications, otherwise known as porcelain gallbladder, have received considerable attention due to its perceived association with gallbladder carcinoma. While the perception of a strong correlation persists, more recent reports raise conceivable doubts. Study design: A systematic literature search was conducted of human studies describing gallbladder wall calcification and its association with gallbladder malignancy. Results: The 111 articles which met inclusion criteria identified 340 patients with gallbladder wall calcification. Of the 340 patients, 72 (21 %) were diagnosed with malignancy of the gallbladder. When examining a subgroup of 13 studies (n = 124) without obvious selection bias, the rate of gallbladder malignancy was only 6 % (0-33 %) compared to 1 % (0-4 %) in a matched cohort of patients without gallbladder wall calcification (p = 0.036, relative risk 8.0 (95%CI 1.0-63.0)). Multivariate analysis identified the presence of symptoms typical for gallbladder cancer (odds ratio 83.6, 95%CI 2.3-2979.1, p = 0.015) and the presence of a gallbladder mass (odds ratio 3226.6, 95%CI 17.2-603884.8, p = 0.003) as the only independent prognostic factors for harboring gallbladder malignancy. Conclusions: The risk of harboring gallbladder cancer in patients with gallbladder wall calcifications is lower than recently anticipated. The risk factors identified have only limited clinical value, since they are stigmatic for advanced gallbladder cancer. In the absence of better risk stratification and in the presence of a relative low rate of associated malignancy, prophylactic cholecystectomy appears appropriate for otherwise healthy patients; whereas a non-operative approach should be considered in patients with significant co-morbidity.

AFIP atlas of tumor pathology

J Albores-Saavedra
D E Henson
D Klimstra

Albores-Saavedra J, Henson DE, Klimstra D. AFIP atlas of tumor pathology. In: American Registry of Pathology. Tumors of the Gallbladder, Extrahepatic Bile Ducts and Vaterian System Series 4. Vol. 23. Washington, DC: Armed Forces Institute of Pathology; 2015:234