Presentation
Right upper quadrant pain and distension.
Patient Data
The supine abdominal radiography shows a gallbladder-like structure projected in the expected location of the gallbladder, which appears filled with dense material containing small filling defects.
The imaging features highly suggest milk of calcium (limy bile), with multiple gall bladder calculi.
Incidental finding: Riedel's lobe variant.
Case Discussion
This case nicely illustrates the appearance of dense milk of calcium on abdominal radiography, which appears to fill and outline the gallbladder. The study also shows multiple lucent filling defects that stand out within the dense milk of calcium, likely representing gallstones. The differential diagnosis in this case is vicarious excretion of intravenous iodinated contrast, however, this patient denied taken any I.V contrast material recently.
Limy bile is a rare condition where the gallbladder is filled with a whitish substance primarily composed of calcium carbonate. It can be associated with gallstones and may cause symptoms such as epigastric and right upper quadrant pain, fever, nausea, and jaundice. Diagnosis is straightforward with radiology, as plain abdominal x-rays and CT scans reveal opacification of the gallbladder and/or bile ducts. Most patients undergo cholecystectomy for treatment.
Case co-author: Dr Abdulmuati Alameri.
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