By Dr Martin Timchur and Dr Kristin Grace
In the medial right upper abdomen there is an inverted ‘exclamation’ shaped homogenous soft tissue opacity with large central lucency that has calcified margins. An additional large partially calcified concretion is seen proximal to the ‘tail’ of the opaque mass with suggestion of obstruction and dilatation of the gall bladder.
Milk of Calcium gall bladder (AKA limy bile) is a rare finding (prevalence less than 1%) in patients that have undergone biliary lithiasis surgery. There is a minor predilection toward females and occurs in any age, although patients over 40 are most common. The appearance is due to the presence of a viscous substance composed of calcium carbonate and has a high association with cholelithiasis and chronic cholecystitis.
Patients may be asymptomatic and the condition is identified incidentally on x-ray (as in this case) or they may present with symptoms including RUQ tenderness or jaundice. Patient’s with associated cholelithiasis may present with symptoms related to obstruction including right shoulder pain and mid-back pain.
The pathophysiological mechanism is unknown, however it is suggested to develop from stasis of bile content in the gallbladder such as a Phrygian cap or porcelain gallbladder, or due to bile duct (CBD) obstruction or pancreatic tumour. This leads to inflammation of the gallbladder and eventually hydrops (dilatation of the gallbladder) often due to obstruction. This can then present as acute cholecystitis.
On x-ray, milk of calcium gallbladder will appear as highly radiodense and may demonstrate a calcium-fluid level on standing x-rays. Obstruction may be visualised by non-calcified, or calcified gall stones (cholelithiasis) and dilatation, as in this case.
Ultrasound is not particularly useful for diagnosis, as it does not differentiate gallbladder sludge from limy bile.
CT is probably the best modality to full evaluate the disorder as it allows for assessment of the limy bile, lithiasis (stones), obstruction, hydrops, cholecystitis and surrounding anatomical structures.
MRI is no more valuable than CT for assessing milk of calcium gallbladder, however Magnetic Resonance Cholangiopancreatography (MRCP) is a special type of MR protocol that produces detailed images of the hepatobiliary and pancreatic systems and is most accurate in both sensitivity and specificity for detecting obstruction.
Spontaneous resolution has been reported, however surgery is the mainstay for treatment, especially when associated with obstruction and cholecystitis. If left untreated, the condition may progress to emphysematous cholecystitis or pancreatitis.
- There are many abdominal soft tissue caclifications (previously covered in another PRO CPD Article), though milk of calcium gallbladder has a characteristic appearance and is usually diagnostic on conventional x-ray.
- It is a rare condition which may be asymptomatic or present with RUQ tenderness or typical cholecystitis symptoms.
- Any associated causes, including gall stones should be explored through CT to evaluate for inflammation, obstruction, hydrops and pancreatitis.
- Management is usually directed to a hepatobiliary surgeon, though spontaneous resolution may occur.
I hope you have enjoyed PRO’s case of the month, proudly provided by Total Lifestyle Chiropractic Airlie Beach. If you have any interesting cases that you would like interpreted by our team of chiropractic radiologists, or if you would like to share your case as a PRO case of the month, please contact Martin at Martin@ProXrayManagement.com
To download a free PDF version of this case study please click here: PRO Case Study – MOC_Gallbladder