What Is Your Diagnosis?

Marion Grapperon-Mathis Stockholms Regiondjursjukhus, 128 48 Bagarmossen, Sweden.

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 DVM
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Kerstin Hansson Department of Clinical Sciences, Faculty of Veterinary Medicine and Animal Science, Swedish University of Agricultural Sciences, 750 07 Uppsala, Sweden.

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History

An 11-year-old neutered male Border Terrier was evaluated because of vomiting, polyuria, polydipsia, decreased appetite, and weight loss of 2 weeks’ duration. On admission, the dog was lethargic, dehydrated, and slightly dyspneic. Respiratory rate was high (100 breaths/min) with an abdominal component, and thoracic auscultation revealed mild wheezing bilaterally. Abdominal palpation caused signs of discomfort, and an enlarged liver was suspected. Thoracic radiographs were obtained (Figure 1).

Figure 1—
Figure 1—

Right lateral (A) and ventrodorsal (B) radiographic views of the thorax of an 11-year-old neutered male Border Terrier evaluated because of slight dyspnea. Additional clinical signs included vomiting, polyuria, polydipsia, decreased appetite, and weight loss of 2 weeks’ duration.

Citation: Journal of the American Veterinary Medical Association 245, 3; 10.2460/javma.245.3.273

Determine whether additional imaging studies are required, or make your diagnosis from Figure 1—then turn the page →

Diagnostic Imaging Findings and Interpretation

A mild generalized unstructured interstitial lung pattern is evident and is likely an age-related change coupled with inadequate inspiration. Radiographic findings did not suggest the cause of dyspnea.

On both projections, a thin and continuous semicircular rim of mineralization was seen in the right cranioventral quadrant of the abdomen, in the location of the gallbladder (Figure 2). Differential diagnoses for the gallbladder changes were dystrophic calcification of the gallbladder wall, neoplastic mass with calcification, or large intraluminal content with a calcified outer layer.

Figure 2—
Figure 2—

Same radiographic images as in Figure 1. The gallbladder is outlined by a thin curvilinear and continuous rim of mineralization (arrows). The mild interstitial pulmonary pattern is attributed to poor lung inflation and age-related changes.

Citation: Journal of the American Veterinary Medical Association 245, 3; 10.2460/javma.245.3.273

Abdominal ultrasonography was performed. The gallbladder was moderately filled with heterogeneous echoic content but without calcified choleliths or luminal content. The wall of the gallbladder appeared as a thin hyperechoic rim casting a distinct distal acoustic shadow (Figure 3). The acoustic shadow was seen in the far field of the gallbladder where normally acoustic enhancement is observed. The common bile duct was not seen. The liver was enlarged and hyperechoic. The intrahepatic bile ducts were not dilated. The pancreas was mildly thickened and diffusely hypoechoic and had an irregular contour. Hyperechoic fat and small amounts of anechoic peritoneal fluid were also observed in the cranial portion of the abdomen.

Figure 3—
Figure 3—

Abdominal ultrasonographic image of the dog in Figure 1 showing the gallbladder lumen circumscribed by a relatively even hyperechoic wall causing distinct distal acoustic shadowing (arrows). The thickness of the wall is within reference limits. The content of the gallbladder is heterogeneous, but no choleliths are identified.

Citation: Journal of the American Veterinary Medical Association 245, 3; 10.2460/javma.245.3.273

Tentative diagnoses of pancreatitis, regional peritonitis, and calcification of the gallbladder wall (ie, porcelain gallbladder) were made. Ultrasonographic features of the liver were nonspecific for a disease process.

Treatment and Outcome

Laboratory findings revealed that the dog had diabetes mellitus with ketoacidosis and pancreatitis and peritonitis. Hematologic evaluation revealed polycythemia, thrombocytosis, and a stress leukogram, with severe lymphopenia, mild neutrophilia, and marked monocytosis. Serum biochemical abnormalities included increased C-reactive protein concentration, increased alkaline phosphatase and alanine transaminase activities, hyperglycemia, and increased urea concentration. Urinalysis revealed proteinuria, glucosuria, hemoglobinuria, and ketonuria. The clinical status of the dog worsened rapidly in the next 24 hours, and euthanasia of the patient was elected by the owner and a necropsy was performed.

On gross examination, the pancreas was edematous, the liver was enlarged, and the gallbladder was hard. Histopathologic findings included hepatic steatosis, vacuolization and fibrosis of the islets of Langerhans, and renal glomerulosclerosis with tubuloepithelial fatty infiltration. The gallbladder submucosa and muscular layers were calcified and the serosa layer was fibrotic. No signs of an inflammatory process involving the hepatobiliary system were found. Calcification of the gallbladder wall (ie, porcelain gallbladder) was considered an incidental finding. No abnormalities were identified in the pulmonary parenchyma.

Comments

Several organ changes have been described in conjunction with diabetes mellitus, including pathological changes to the gallbladder such as emphysematous cholecystitis.1 Porcelain gallbladder is defined as calcification of the gallbladder wall. The condition is rare in companion animals. To the authors’ knowledge, only one case of porcelain gallbladder has been reported in a dog; that dog had biliary adenocarcinoma of the gallbladder neck, cholelithiasis, and biliary obstruction.2

In humans, porcelain gallbladder is a rare manifestation of chronic gallbladder disease.3 Chronic cholecystitis, intramural hemorrhage with subsequent calcification, imbalances in calcium metabolism, and giardiasis are predisposing conditions, but the etiology remains unclear.3 For several decades, porcelain gallbladder was reported to be associated with increased risk of biliary neoplasia, but this now appears more controversial.3,4

Various imaging techniques have been used in humans with porcelain gallbladder. Findings on survey radiographs are usually straightforward, but the thickness of the calcified gallbladder wall is variable; it may be thin and faintly visible or amorphous, patchy, and thick. If doubt exists, cross-sectional imaging such as ultrasonography or CT can more accurately depict calcification.5 Confusion may arise in cases with emphysematous cholecystitis and a stone-filled gallbladder when only ultrasonographic criteria are used.4 Intramural gas is characterized by hyperechoic foci within the gallbladder wall, with or without reverberation artifacts, which may migrate with alteration of patient position or appear like a hyperechoic ring emanating from the entire circumference of the gallbladder.6 A stone-filled gallbladder results in the wall-echo-shadow sign: 2 curvilinear, parallel echogenic lines (gallbladder wall and stone surface) separated by a hypoechoic space (interpositioned bile) with distal shadowing (sound attenuation by the stone).7 In the dog of the present report, the radiographic and ultrasonographic findings excluded the presence of biliary gas and lithiasis.

Contrarily to the only previously reported case,2 the porcelain gallbladder in this dog was not associated with any neoplasia. This mirrors what is currently seen in humans in whom porcelain gallbladder is either an incidental finding or associated with biliary neoplasia.

  • 1. Armstrong JA, Taylor SM, Tryon KA, et al. Emphysematous cholecystitis in a Siberian Husky. Can Vet J 2000; 41: 6062.

  • 2. Brömel C, Smeak DD, Léveillé R. Porcelain gallbladder associated with primary biliary adenocarcinoma in a dog. J Am Vet Med Assoc 1998; 213: 11371139.

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  • 3. Palermo M, Núñez M, Duza GE, et al. Porcelain gallbladder: a clinical case and a review of the literature [in Spanish]. Cir Esp 2011; 89: 213217.

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  • 4. Khan ZS, Livingston EH, Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder. Arch Surg 2011; 146: 11431147.

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  • 5. Kane RA, Jacobs R, Katz J, et al. Porcelain gallbladder: ultrasound and CT appearance. Radiology 1984; 152: 137141.

  • 6. Bloom RA, Libson E, Lebensart PD, et al. The ultrasound spectrum of emphysematous cholecystitis. J Clin Ultrasound 1989; 17: 251256.

  • 7. Rybicki FJ. The WES sign. Radiology 2000; 214: 881882.

  • Figure 1—

    Right lateral (A) and ventrodorsal (B) radiographic views of the thorax of an 11-year-old neutered male Border Terrier evaluated because of slight dyspnea. Additional clinical signs included vomiting, polyuria, polydipsia, decreased appetite, and weight loss of 2 weeks’ duration.

  • Figure 2—

    Same radiographic images as in Figure 1. The gallbladder is outlined by a thin curvilinear and continuous rim of mineralization (arrows). The mild interstitial pulmonary pattern is attributed to poor lung inflation and age-related changes.

  • Figure 3—

    Abdominal ultrasonographic image of the dog in Figure 1 showing the gallbladder lumen circumscribed by a relatively even hyperechoic wall causing distinct distal acoustic shadowing (arrows). The thickness of the wall is within reference limits. The content of the gallbladder is heterogeneous, but no choleliths are identified.

  • 1. Armstrong JA, Taylor SM, Tryon KA, et al. Emphysematous cholecystitis in a Siberian Husky. Can Vet J 2000; 41: 6062.

  • 2. Brömel C, Smeak DD, Léveillé R. Porcelain gallbladder associated with primary biliary adenocarcinoma in a dog. J Am Vet Med Assoc 1998; 213: 11371139.

    • Search Google Scholar
    • Export Citation
  • 3. Palermo M, Núñez M, Duza GE, et al. Porcelain gallbladder: a clinical case and a review of the literature [in Spanish]. Cir Esp 2011; 89: 213217.

    • Search Google Scholar
    • Export Citation
  • 4. Khan ZS, Livingston EH, Huerta S. Reassessing the need for prophylactic surgery in patients with porcelain gallbladder. Arch Surg 2011; 146: 11431147.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5. Kane RA, Jacobs R, Katz J, et al. Porcelain gallbladder: ultrasound and CT appearance. Radiology 1984; 152: 137141.

  • 6. Bloom RA, Libson E, Lebensart PD, et al. The ultrasound spectrum of emphysematous cholecystitis. J Clin Ultrasound 1989; 17: 251256.

  • 7. Rybicki FJ. The WES sign. Radiology 2000; 214: 881882.

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