Milk of calcium bile

Case contributed by Bernard Pilet

Presentation

Patient was admitted at our Emergency Department for headaches and a brief episode of unconscienceness after fall at home. She was brought in by ambulance. Her medical history includes cirrhosis, Paget disease, calcifying pancreatitis, renal insufficiency, and insulin dependent diabetes. Brain scan and lung X-ray proved to be normal for her age. Lab revealed cholestasis.

Patient Data

Age: 94
Gender: Female
Modality: Ultrasound

Gallbladder hydrops with non-specific substance in its dependent portion.

The gallbladder has a normal, thin wall, despite the presence of ascites (not shown).

No gallstones or bile duct dilatation are seen.

Modality: CT

Two weeks after previously shown ultrasound.

Hydrops of the gallbladder but no wall thickening. Very dense substance in the gallbladder's dependent part, without any radio-opaque stones identifiable. No dilatation of intrahepatic or extrahepatic bile ducts.

Known liver cirrhosis with ascites.

Known renal insufficiency. No ERCP or intravenous contrast administration over the last 12 months.

Case Discussion

The very high density of the gallbladder contents indicates the presence of either calcium or iodine.

In patients with renal insufficiency, intravenously administered contrast media are often excreted through the biliary system and may get stuck in the gallbladder for a while.

In this case, no contrast media had been given recently. As such, calcium milk is the most probable diagnosis.

Although the ultrasound was negative on that part, the presence of one or more small obstructive non-radio-opaque gallstones in the cystic or choledochus ducts can't be formally excluded, yet could account for the gallbladder hydrops.

On the other hand, the hydrops may be reflecting a long-standing dysfunctional gallbladder due to chronic cholecystitis, even in the absence of biliary stones.

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Case Information

rID: 37749
Case created: 21st Jun 2015
Last edited: 29th Sep 2015
Inclusion in quiz mode: Included

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