eMedicine Specialties > Radiology > Gastrointestinal

Porcelain Gallbladder: Imaging

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, LRCP, Chairman of Medical Imaging, Professor of Radiology, NGHA, King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Coauthor(s): Margaret Aird, MBChB, FRCR, Consulting Staff, Department of Radiology, Wythenshawe Hospital; Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; David Sherlock, MBBS, FRCS, Consulting Staff, Department of Surgery, North Manchester General Hospital, Christie Hospital
Contributor Information and Disclosures

Updated: Feb 12, 2008

Radiography

Findings

Plain abdominal radiographs may demonstrate curvilinear calcification in the right hypochondrium, which corresponds to the location and shape of the gallbladder (see Image 1). The thickness of the calcification is variable; it may be thin and faintly visible or amorphous, patchy, and thick. The gallbladder may be large, but its size can vary considerably.

Oral cholecystography reveals a nonfunctioning gallbladder.

Degree of Confidence

Although plain abdominal radiographs have been a standard technique for demonstrating right upper quadrant calcification, sonograms and CT scans appear to be more sensitive (see Image 3). In some patients, plain abdominal radiographs may show no abnormalities. It is no longer considered adequate to use only plain radiographs when evaluating possible calcifications in the upper abdomen.¹⁰

False Positives/Negatives

Calcification in the right upper quadrant of the abdomen has several causes. Calcification can be categorized by the organ system in which it appears; for example, calcification can affect the liver, gallbladder, right kidney, digestive tract, peritoneal cavity, right adrenal gland, and retroperitoneum. Diseases that are associated with these organs include large gallbladder opaque calculi, milk-of-calcium bile, echinococcal cysts, schistosomiasis and other granulomatous disease, old liver infarcts that have healed, calcified renal cysts, renal calculi, calcified nonparasitic liver cysts, primary and metastatic liver tumors, benign liver tumors, and calcification in old adrenal hemorrhage and adrenal masses.

In porcelain gallbladder, plain radiographic findings are usually straightforward and are not often confused with findings related to other causes of calcification in the right upper quadrant. Calcified gallbladder granulomas in schistosomal infestation that are dense enough to be seen on abdominal radiographs have been described. Serpiginous calcification on plain abdominal radiographs in the region of the neck of the gallbladder appears to indicate gallbladder schistosomiasis in patients from endemic areas.⁷

Computed Tomography

Findings

CT scans of porcelain gallbladder will show a curvilinear or rim calcification, which is usually associated with calculi in the anatomic location of the gallbladder. With gallbladder carcinoma (see Images 5-8), an associated pericholecystic mass may be visualized and intrahepatic metastases and hilar lymphadenopathy may be evident.

Degree of Confidence

Although plain abdominal radiographs have been the standard technique for demonstrating right upper quadrant calcification, CT scans appear to be more sensitive than radiographs. In some patients, plain abdominal radiographs may show no abnormalities. It is no longer considered adequate to use only plain radiographs when evaluating possible calcifications in the upper abdomen.¹⁰

False Positives/Negatives

Calcification in the right upper quadrant of the abdomen has several causes. Calcification can be categorized by the organ system in which it appears; for example, calcification can affect the liver, gallbladder, right kidney, digestive tract, peritoneal cavity, right adrenal gland, and retroperitoneum. Diseases that are associated with these organs include large gallbladder opaque calculi, milk-of-calcium bile, echinococcal cysts, schistosomiasis and other granulomatous disease, old liver infarcts that have healed, calcified renal cysts, renal calculi, calcified nonparasitic liver cysts, primary and metastatic liver tumors, benign liver tumors, and calcification in old adrenal hemorrhage and adrenal masses.

Although calcification seen on plain abdominal images can possibly be confused with porcelain gallbladder, the anatomic location, as viewed on CT scans, depicts calcification in the gallbladder fossa. This finding is less likely to create confusion with other findings of upper abdominal calcification.

Magnetic Resonance Imaging

Findings

To the authors' knowledge, magnetic resonance imaging (MRI) findings in porcelain gallbladder have not been reported.

Ultrasonography

Findings

Four distinct patterns have been identified in ultrasonography of porcelain gallbladder, and they are as follows: (1) a hyperechoic semilunar structure with posterior acoustic shadowing that simulates a stone-filled gallbladder devoid of bile (see Image 2), (2) a biconvex curvilinear echogenic structure with variable acoustic shadowing, (3) an irregular clump of echoes with posterior acoustic shadowing (see Image 4), and (4) an echogenic gallbladder wall without acoustic shadowing.

In addition, a spiral image may show findings similar to those seen in scleroatrophic gallbladder lithiasis.¹¹

Degree of Confidence

Although plain abdominal radiographs have been the standard technique for demonstrating right upper quadrant calcification, sonograms appear to be more sensitive than radiographs.¹⁰

False Positives/Negatives

In porcelain gallbladder, plain radiographic findings are usually straightforward and are not often confused with findings related to other causes of calcification in the right upper quadrant. If doubt exists, cross-sectional imaging with a modality such as ultrasonography or CT can more accurately depict calcification in the appropriate organ.¹⁰ Porcelain gallbladder must be distinguished from large solitary calcified gallstones, which seldom are as large as a porcelain gallbladder; however, exceptions can make a definite diagnosis difficult.

Confusion may also arise with emphysematous cholecystitis and a stone-filled gallbladder when only sonographic criteria are used; however, emphysematous cholecystitis usually causes dirty shadowing, which may be interrupted by ring-down shadows caused by gas within the wall or lumen of the gallbladder. A stone-filled gallbladder results in the wall-echo-shadow sign. The wall-echo-shadow sign consists of 2 parallel echogenic lines separated by a hypoechoic space with distal shadowing. The more superficial echogenic line is a result of the interface of the gallbladder wall and the liver; the hypoechoic area is the gallbladder wall itself. The deep echogenic line is the anterior surface of the gallstone(s).

Nuclear Imaging

Findings

Radionuclide uptake images obtained with technetium-99m hepatoiminodiacetic acid (HIDA) demonstrate a nonfunctioning gallbladder.

Porcelain gallbladder has been detected on bone scans.¹²

Degree of Confidence

Nuclear medicine findings are nonspecific because HIDA uptake shows nonfunction in acute cholecystitis and chronic cholecystitis. HIDA uptake scanning is not a recommended imaging procedure for the assessment of porcelain gallbladder.

Angiography

Findings

Angiography is useful when findings are complicated by carcinoma of the gallbladder. Although carcinoma tends to be avascular, angiography can be used to evaluate the hepatic artery and portal vein for occlusion and/or encasement. This information is useful when surgery is contemplated.

Degree of Confidence

Angiography is used for root mapping of the blood supply of the liver and gallbladder, for which angiography has good accuracy. Portal venous and/or hepatic arterial occlusion or encasement also can be demonstrated fairly well on angiograms.

False Positives/Negatives

Hepatic arterial and/or portal venous occlusion or encasement can occur as a consequence of benign inflammatory diseases such as pancreatitis.

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