Question

A 49-year-old Caucasian woman presents with a 2-month history of worsening abdominal pain. The patient describes the pain as crampy, unrelenting abdominal pain that begins in the right upper and middle quadrant of the abdomen; very occasionally, it will go into right shoulder area. The pain usually occurs shortly after especially heavy meals, usually within 30 minutes; it then eventually subsides, although this takes anywhere from 60 - 120 minutes. Physical examination reveals significant right upper quadrant tenderness and rigidity with a palpable, firm mass. Ultrasound performed in the office reveals complete calcification of the gallbladder wall; there is a hyperechoic semilunar appearance with posterior acoustic shadowing.

A symptomatic patient as described above with such severe calcification as seen on ultrasound would most likely be treated via what method?

1 Reassurance only
2 Periodic ultrasound imaging study
3 Open cholecystectomy
4 Laparoscopic cholecystectomy
5 Percutaneous biliary stent placement

Answer 1

The best treatment for the presented case of severe calcification of the gallbladder wall, known as porcelain gallbladder, along with symptomatic presentation is surgical intervention, specifically laparoscopic cholecystectomy. This minimally invasive surgery is the preferred method for treating symptomatic gallbladder disease.

Step-by-step explanation:

The clinical presentation of the 49-year-old patient, including the crampy, unrelenting abdominal pain particularly after heavy meals, along with the physical examination revealing significant right upper quadrant tenderness and rigidity, and the ultrasound findings suggesting a completely calcified gallbladder wall (often referred to as "porcelain gallbladder") indicate a classic case of symptomatic gallbladder disease. In such cases, the treatment is typically surgical.

The presence of symptoms and the ultrasound findings guide the therapeutic approach. For this patient, a laparoscopic cholecystectomy (option 4) would be the treatment of choice. This minimally invasive surgical procedure involves removing the gallbladder using a laparoscope and has become the standard treatment for symptomatic gallstones and complications of gallstone disease, such as significant calcification of the gallbladder wall.

Reassurance only (option 1), periodic ultrasound imaging (option 2), and percutaneous biliary stent placement (option 5) would not address the underlying problem in this case and could lead to severe complications if the condition is left untreated. Although an open cholecystectomy (option 3) could also be considered, it is often reserved for cases where laparoscopic cholecystectomy is contraindicated or cannot be safely performed.