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Recurrent Right Upper Quadrant Abdominal Pain PHOTO ROUNDS Pradeepa Vimalachandran, MD, MPH; Jayashree Recurrent right upper Paknikar, MD Creighton University School of quadrant abdominal pain Medicine, Omaha, Neb PradeepaVimalachandran@ A minimally tender mass was detected during palpation creighton.edu DEPARTMENT EDITOR of the abdomen, but a Murphy’s test was negative. An Richard P. Usatine, MD University of Texas Health abdominal x-ray revealed the cause of the patient’s pain. Science Center at San Antonio The authors reported no potential conflict of interest relevant to this An 88-year-old woman presented to quadrant that was detected during palpa- article. our primary care clinic with recurrent right tion of the abdomen. A Murphy’s test was upper quadrant abdominal pain. Her his- negative. A comprehensive metabolic panel, tory was negative for nausea, fever, vomiting, complete blood count, lipase test, amylase chest pain, heartburn, back pain, or changes test, abdominal ultrasound, and abdominal in bowel movement patterns. There was no x-ray (FIGURE) were ordered. association between the pain and her eat- ing patterns. She described the pain as dull, ● WHAT IS YOUR DIAGNOSIS? and rated it as a 4 to 5 out of 10. A physical examination was unremarkable except for ● HOW WOULD YOU TREAT THIS a minimally tender mass in the right upper PATIENT? FIGURE Abdominal x-ray identified the source of the pain IMAGE COURTESY OF: JAYASHREE PAKNIKAR, MD, CREIGHTON MD, CREIGHTON PAKNIKAR, OF: JAYASHREE IMAGE COURTESY UNIVERSITY MEDICAL CENTER JFPONLINE.COM VOL 65, NO 10 | OCTOBER 2016 | THE JOURNAL OF FAMILY PRACTICE 723 PHOTO ROUNDS Diagnosis: Porcelain gallbladder the abdominal x-ray, which showed a well- We diagnosed this patient with porcelain gall- defined air gas bubble encased in a calcified bladder based on her history, physical exam, pouch. and x-ray, which revealed a well-defined air In addition to an x-ray or an ultrasound, gas bubble encased in a calcified pouch. (The a computed tomography scan can confirm the patient’s lab work was unremarkable and the diagnosis of porcelain gallbladder. ultrasound revealed the same findings as seen on the x-ray.) For most patients, Porcelain gallbladder is a rare condition.1 cholecystectomy is recommended It is characterized by intramural calcifications Treatment and management is based on the of the gallbladder wall, which is rarely seen pattern of calcification and the patient’s cur- with chronic cholecystitis.2 rent health status. If there is incomplete cal- There are a few theories behind the eti- cification, cholecystectomy is warranted. ology of porcelain gallbladder. One theory Cholecystectomy may also be warranted when is that gallstones can irritate the gallbladder a patient is symptomatic and has complete wall, leading to inflammation and then cal- calcification of the gallbladder. Regardless of cification. Others believe that porcelain gall- the pattern of calcification, imaging surveil- bladder is due to the obstruction of cystic lance of the patient is necessary. Moreover, ducts, which leads to bile stasis in the gall- cholecystectomy is preferred regardless of One theory bladder, followed by the accumulation of the status of the calcification if the patient is a suggests that calcium carbonate salts.3 good surgical candidate.7 porcelain Patients may present with biliary It is important to send the gallbladder gallbladder pain or a firm palpable mass in the right for histopathological examination after it is is due to the upper quadrant. However, patients are often removed to determine the likelihood of malig- obstruction asymptomatic.4 nancy.7 If cancer is ruled out, then no further of cystic ❚ Cancer risk. There is about a 2% to 3% work-up is necessary. If cancer is detected, ducts, which risk of gallbladder cancer in patients with then further evaluation, including additional leads to bile porcelain gallbladder.5 The nature of the surgery, may be necessary. stasis in the calcification has been linked to the prob- ❚ Our patient was a good surgical candi- gallbladder, ability that a patient will develop gallbladder date, so we recommended cholecystectomy. followed by cancer. Specifically, there is a higher prob- The patient underwent surgery and the the accumulation ability of gallbladder cancer if discontinuous pathology report was negative for cancer. JFP of calcium calcification is noted, or if only some por- 6 CORRESPONDENCE tion of the gallbladder wall has calcified. carbonate salts. Pradeepa Vimalachandran, MD, MPH, 601 North 30th Street, About 80% of all gallbladder cancers are Suite 6720, Omaha, NE 68131; PradeepaVimalachandran@ adenocarcinomas.6 creighton.edu. Differential diagnosis includes GERD, cholecystitis References Right upper quadrant pain is associated with 1. Kane RA, Jacobs R, Katz J, et al. Porcelain gallbladder: ultra- sound and CT appearance. Radiology. 1984;152:137-141. acute hepatitis, acute cholecystitis, acute 2. Ochsner SF, Carrera GM. Calcification of the gallbladder (“por- pancreatitis, gastroesophageal reflex disease celain gallbladder”). Am J Roentgenol Radium Ther Nucl Med. 1963;89:847-853. (GERD), ulcers, and umbilical hernias. In this 3. Stephen AE, Berger DL. Carcinoma in the porcelain gallbladder: patient’s case, her history and physical exami- a relationship revisited. Surgery. 2001;129:699-703. 4. Geller SA, de Campos FP. Porcelain gallbladder. Autops Case nation made a number of diagnoses less likely, Rep. 2015;5:5-7. including acute cholecystitis, GERD, ulcers, 5. Towfigh S, McFadden DW, Cortina GR, et al. Porcelain gallblad- der is not associated with gallbladder carcinoma. Am Surg. and an umbilical hernia. In addition, normal 2001;67:7-10. values on the patient’s lipase and amylase tests 6. Brown KM, Geller DA. Porcelain gallbladder and risk of gall- bladder cancer. Arch Surg. 2011;146:1148. ruled out pancreatitis. 7. Khan ZS, Livingston EH, Huerta S. Reassessing the need for ❚ Imaging brought things into focus. prophylactic surgery in patients with porcelain gallbladder: case series and systematic review of the literature. Arch Surg. The most significant finding in this case was 2011;146:1143-1147. 724 THE JOURNAL OF FAMILY PRACTICE | OCTOBER 2016 | VOL 65, NO 10.
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