A case of intramural pure pigment gallstones, which were fortuitously found in post-mortem examination, is presented. The incidence, mechanism of formation of the stones and roentgenological diagnosis of the intramural gallstones, porcelain gall bladder, are mentioned.</p

Kawanishi, Koichi

Nishimura, Fumio

English

Okayama University Scientific Achievement Repository

Acta Medica OkayamaVolume 17, Issue 4 1963 Article 4AUGUST 1963Intramural pure pigment gall-stones, a casereportKoichi Kawanishi∗ Fumio Nishimura†∗Okayama University,†Okayama University,Copyright c©1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.Intramural pure pigment gall-stones, a casereport∗Koichi Kawanishi and Fumio NishimuraAbstractA case of intramural pure pigment gallstones, which were fortuitously found in post-mortemexamination, is presented. The incidence, mechanism of formation of the stones and roentgeno-logical diagnosis of the intramural gallstones, porcelain gall bladder, are mentioned.∗PMID: 14123341 [PubMed - indexed for MEDLINE] Copyright c©OKAYAMA UNIVERSITYMEDICAL SCHOOLActa Med. Okayama 17, 203-208 (1963)INTRAMURAL PURE PIGMENT GALLSTONESA CASE REPORTKoichi KAWANISHI and Fumio NISHIMURADepartment of Internal Medicine, Okayama University Medical School(Director: Prof. K. Hiraki)Received for publication, Nov. 25, 1963Gallstones usually form in the gall blander and occasionally in the biliaryducts. Recently we experienced intramural pure pigment gallstones which werefound fortuitously in an autopsy case. One of the forms of the intramural gall-stones; "porcelain gall bladder", in which the wall of the gall bladder becomesimpregnated with calcium, has been described in the European and Americanlituratures but only a few cases are reported in Japan. The following case illus-trated here is not a typical porcelain gall bladder, but a gall bladder with purepigment stones which are found scattered disseminatedly almost in the entirewall of the gall bladder throughout. A search of the literature fails to report ofa similar case and brief report seems warranted.CASE REPORTClinical Summary. The patient, 52-year-old male, whose pulmonarytuberculosis was first noticed in August 1939, had bedrest or hospitalizationuntil April 1943. In October 1956 his pulmonary tuberculosis reactivated andhe was given SM and PAS. In May 1958 he developed right exudative pleurisy:received SM, PAS and INH, and in April 1960 he was admitted to KokuritsuOkayama Ryoyosho (Okayama National Sanatorium) under the diagnosis ofpulmonary tuberculosis, far advanced, active, with right old pleurisy.Physical examination on admission revealed a slightly reduced male in nodistress. The heart was normal in size with reguiar rhythm without any mur-mur. The right chest showed a dullness and diminished breath sounds associatedwith moist rales. The abdomen revealed no pathological findings. Otherwisenegative. Chest X-ray revealed two giant cavities with many other small cavitiesin the right upper lung area and right old pleurisy. Laboratory studies such asc. B. C., urinalysis were within normal limits. Red cell sedimentation rate 65mm per hour. Vital capacity was 1450 ml. Per cent vital capacity was 61 %.Sputum examination showed many acid fast bacilli on smear.Hospital Course: In June and July 1960 he had right thoracoplasty,resected portion of I to VII ribs, followed by antituberculous chemotherapy. In2031Kawanishi and Nishimura: Intramural pure pigment gall-stones, a case reportProduced by The Berkeley Electronic Press, 1963204 K. KAWANISHI and F. NISHIMURAJanuary 1962 he had a curetting of the remaining right VI rib and the anteriorarea of the right thoracic wall on the suspicion of the tuberculous caries associa-ted with a cold abcess. In April 1962 his general and cardio-pulmonary condi-tions became poorer without any improvement of the pulmonary tuberculouslesion; the heart with grade III systolic murmur at the apex, P2 stronger thanA2, vital capacity 1100 ml., per cent vital capacity 31 %, antecubital venouspressure 17 cm H 20. He complained of shortness of breath, loss of appetite,belching distress, nausea, discomfort or pain in the epigastric region. Electro-cardiograms from April 1962 to October 1962 revealed typical pulmonary P andtwo to one right bundle branch block which was followed by intermittent rightbundle branch block that later changed to persistent complete right bundle branchblock. Several liver function tests and other routine laboratory studies showedwithin normal limits in February 1963. On March 11, 1963 he suffered upperrespiratory infection followed by severe generalized malaise and developed acuteexacerbation of the chronic cor pulmonale. He was given cardiac drugs, bron-chodilators and antibiotics. Because of persistent complaining of the loss ofappetite and epigastric pain, upper G.1. series was done on March 20, 1963and revealed a niche in the first portion of the duodenum. He was put on anta-cids, anticholinergic-antispasmodic drugs and ulcer diet. Laboratory studies onMarch 29, 1963 showed R. B. C. 3.500,000, Hb 12.5 gm dl. and positive occultblood of the stool. His general and cardio-pulmonary conditions grew still worse.On April 4, 1963 large amounts of soft tarry stool were noted and epigastricpain became more severe. He had a downhill course with continuous defecationof tarry or reddish stool and expired on April 12. 1963.Autopsy: The body is that of an emaciated, elderly male, 164 cm talland weighing approximately 38 kg. The principal gross anatomical findings areillustrated. The right thorax shows status, postthoracoplasty. The heart weightis 420 gm. Right heart is enlarged. The wall of the right ventricle measures0.8 cm in thickness. The right upper lobe of the lung contains nodulartuberculous lesions and some small cavities including yellowish-whitish tenaciouspurulent material. A cavity measuring 10 X 9 X 8 cm and containing moderateamounts of yellowish·white tenacious purulent material is present in the anteriorand lateral portion of the right supradiaphragmatic area. The peripheral areaof the left upper lobe contains bullous changes of the pulmonary tissue measuringup to 3 cm in diameter. The stomach is filled with large amounts of blood. Thegastric mucosa shows no pathological findings. The duodenum has a roundmucosal defect measuring 1. 5 X 1. 0 cm in diameter, in the center of which ablood vessel measuring O. 7 mm in diameter is explored, in the upper wall1.5 cm from the pylorus ring. The liver weighs 1000 gm and is pale in color.The gall bladder measures 7 cm in length and adheres in the midportion of the2Acta Medica Okayama, Vol. 17 [1963], Iss. 4, Art. 4http://escholarship.lib.okayama-u.ac.jp/amo/vol17/iss4/4Intramural Pure Pigment Gallstones a Case Report 20Sbody to the liver. It contains yellow and slightly turbid bile. The wall containsblack and exactly fragil solid materials measuring up to 3 mm in diameter,about thirty in number. They scatter disseminately almost in the entire wallthroughout. The mucosa has a velvety lining and the bile tree is patent through-out.Microscopically (Figs. 1 and 2), almost all of the epithelium of the gall blad-der is lost. The mucosa is mounted on coarse folds. Gland-like spaces (the Ro-kitansky-Aschoff sinuses) extend from the lining to the moderately hypertrophiedmuscular coat. There is an increase of connective tissue in the lamina propriaand between the muscle bundles. All the connective tissue is infiltrated withlymphocytes, plasma cells, fibrocytes and mononuclear cells. Some of the Ra-kitansky-Aschoff sinuses contain darkish-brown homogenous material.Fig.l Wall of the gall bladder. Proli-ferated lamina propria and muscle layer. TheRokitansky-Aschoff sinus extends to the peri-muscular layer and contains pure pigmentstone.Fig. 2 Photomicrograph of a part of theRokitansky-Aschoff sinus and pure pigmentstone. There are a tall columnar epitheriallining and many infiltrated cells in the laminapropria.COMMENTEuropean and American lituratures describe that gallstones usually form inthe gall bladder and only occasionally in the biliary ducts, while many observa-3Kawanishi and Nishimura: Intramural pure pigment gall-stones, a case reportProduced by The Berkeley Electronic Press, 1963206 K. KAWANISHI and F. NISHIMURAtion.s1 in Japan reveal that gallstones are found in frequency of 50 to 80 per centin the gall bladder, 20 to 50 per cent in the biliary ducts and 1 to 5 per cent inthe liver. But intramural gallstones are very rare. In 1929 FLOERCHEN2 firstdescribed porcelain gall bladder, in which the wall of the gall bladder becomesimpregnated with calcium so that a cracking sound may be elicited on touch.CAPUA3, TAscHENDORF4 and ScHIN~ described it in the roentgenological studies.In Japan, YAMAMOTO et a/.6 reported two cases suggestive of porbelain gall blad-der in the roentgenological study in 1958. Recently FUJII et ae experienced asurgical removal of a gall bladder with intramural calcium bilirubinate stones.The failing report of the intramural pure pigment gallstones in clinical experi-ence is presumed responsible for radiolucency of the bilirubinate stone and rarityof this stone in the Western countries.Chronic cholecystitis may be induced by various factors, such as the sequelof an acute inflammation of the gall bladder, the presence in the viscus ofpure gallstones or of the mulberry-shaped mixed gallstones and intermittent orcontinuous abnormal composition of the bile. Attenuated or usually nonpathologicenteric organisms may also produce chronic cholecystitis. The most importantof these various conditions is the almost invariable presence of gallstones in thegall bladder. In some instances the gallstones are the cause of and in others arethe sequel to the chronic inflammatory state of the gall bladder.Grossly, the wall of the gall bladder with chronic cholecystitis is increasedto several times its usual thickness. The folds are coarse and in advanced stagesobliterated or absent with trabeculations of the muscular surface. Occasionallythe wall may become impregnated with calcium so that a cracking sound maybe elicited on touch. In this condition it is called "porcelain gall bladder". Micro-scopically the epithelium dips down to line outpouchings of the mucosa towardthe external layers. These outpouchings, the Rokitansky-Aschoff sinuses, usuallyform along blood vessels and penetrate the thickened muscular coat to varyingdepths. Their fundi frequently reach the perimuscular layer. In the porcelain gallbladder the Rokitansky-Aschoff sinuses contain calcium. It is assumed that thesame phenomena may occur in our case illustrated above, in which the stones con-tained in the sinuses are pure pigment but not calcium.TASCHENDORF4 states the following possibilities of the roentgenological diag-nosis of the porcelain gall bladder: 1) Calcified gall bladder in normal size; 2)Calcified gall bladder with atrophy. In this condition long standing and repeat-ing G. B. trouble persists; 3) Calcified gall bladder with simultanous presenceof gallstones. In this condition troubles are elicited by the stones in the bileducts; 4) Atrophied gall bladder with stones and faint but certain presence ofcalcified wall, which is not completely deformed yet and still noticeable tender-ness; and 5) Partial calification of the wall.4Acta Medica Okayama, Vol. 17 [1963], Iss. 4, Art. 4http://escholarship.lib.okayama-u.ac.jp/amo/vol17/iss4/4Intramural Pure Pigment Gallstones a Case Report 207However, the roentgenological diagnosis of the intramural pure pigmentgallstones is presumed to be very difficult because of radiolucency of these stonesand it is thought that there is only a possibility to be fortuitously found in surgeryunder the diagnosis of chronic cholecystitis. In view of this, in the treatment ofgall bladder disorders one should keep in mind a possible presence of this kindof gallstones.SUMMARYA case of intramural pure pigment gallstones, which were fortuitously foundin post-mortem examination, is presented. The incidence, mechanism of forma-tion of the stones and roentgenological diagnosis of the intramural gallstones,porcelain gall bladder, are mentioned.ACKNOWLEDGEMENTWe are indebted to Prof. K. Hiraki of the Department of Internal Medicine for the gui-dance given in the preparation of this paper.REFERENCES1. M IYAKE, H.: Nihon Geka Zensho 24-1, 163, 1957 (in Japanese)2. FLoERcHEN, H. D.: Zentralblatt fur Chirurgie 20, 1251, 19293. CAPUA, A.: Radiol. med. 27, 288, 19404. TAscHENDoRF, W.: Lehrbuch der Roentgenologischen Differential·diagnostik. Band 11,p.315, 19505. SCHINZ, H. R. : Lehrbuch der Roentgendiagnostik. Band IV, p. 3531, 19526. YAMAMOTO, M. et al.: Rinsho Hoshasen 3, 125, 1958 (in Japanese)7. FUJII, H. and YOSHIDA, H.: Personal Communication.5Kawanishi and Nishimura: Intramural pure pigment gall-stones, a case reportProduced by The Berkeley Electronic Press, 1963

et al.: Rinsho Hoshasen 3, 125,

Lehrbuch der Roentgendiagnostik.

Lehrbuch der Roentgenologischen Differential·diagnostik.

Nihon Geka Zensho 24-1, 163,

Personal Communication. Kawanishi and Nishimura: Intramural pure pigment gall-stones, a case report Produced by The Berkeley Electronic Press,

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Intramural pure pigment gallstones, a case report

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Intramural pure pigment gallstones, a case report