Rare presentation of porcelain gall bladder: carcinoma gall bladder with a large intra-abdominal cystic swelling.

DESCRIPTION A 50-year-old woman was admitted with complaints of pain in the abdomen, a slowly growing painless lump in the central abdomen, anorexia and significant weight loss for the last 3 months. No history of jaundice, itching or fever. Physical examination revealed ovoid 15×15 cm nontender cystic lump (figure 1) with restricted mobility in the mid-abdomen. CECT abdomen revealed malignant gallbladder mass with dense intramural calcification and multiple metastatic SOLs (space occupying lesions) in the liver (figure 2) with large cystic mass in the abdomen (figure 3). Fine-needle aspiration cytology (FNAC) from liver metastasis was positive for adenocarcinoma. Liver enzymes and α-fetoprotein (AFP) levels were normal. Echinococcal antigen was negative. Pig-tail catheter drainage of cystic mass drained ∼1000 ml clear cystic fluid following which pain and swelling subsided. Fluid cytology was negative for malignant cells. She was proposed to be started on palliative chemotherapy but her relatives refused further treatment. Porcelain gall bladder is characterised by extensive calcification of the gall bladder wall with prevalence in cholecystectomy specimens between 0.06% and 0.8% and female predominance (5 : 1). It is associated with cholelithiasis in 95% cases. Risk of malignancy within porcelain gall bladder is <10%. Stephen and Berger reported two patterns of gall bladder wall calcification: complete intramural calcification and selective mucosal calcification. Incidence of cancer arising in the former was negligible compared to risk of 7% in the former.