IS Case 355: Percutaneous cholecystostomy for acute emphysematous cholecystitis

Richard Gong, MD

2009 URMC Imaging Sciences
Publication Date: 2010-03-01

History

Patient is an 86-year-old female with history of dementia presenting to the Emergency Department with mental status changes after waking up. She had a low grade fever.

Findings

Contrast enhanced CT shows distended gallbladder with multiple stones. There is gas within the gallbladder. Ultrasound obtained during cholecystostomy shows sludge within the gallbladder with pericholecystic fluid. Fluoroscopic images confirmed initial placement of a Hawkins needle in the gallbladder and subsequent drainage tube in the gallbladder. CT obtained at a later date shows continued distension of the gallbladder due to presumed obstructed drainage catheter.

Discussion

Cholecystectomy is the standard treatment for acute cholecystitis. However, some patients have significant comorbidities and are deemed at high risk for emergent surgery. The mortality rate for emergent cholecystectomy in low-risk elderly patients is around 10% and as high as 46% in high-risk elderly patients. Younger patients with significant comorbidities may also be at high risk for cholecystectomy. For these patient, percutaneous cholecystostomy may be the procedure of choice.

Percutaneous cholecystostomy is a less invasive radiologic procedure that may be performed with only conscious sedation and local anesthesia. In some case, it can be performed at the bedside in the intensive care unit for critically ill patients. The procedure involves placement of a drainage catheter in the gallbladder with image guidance using a combination of ultrasound and fluoroscopy. The cholecystostomy tube can be placed utilizing a transhepatic or transperitoneal approach. There is some debate regarding which approach is preferred. Cholecystostomy allows for immediate decompression of the gallbladder and can serve as a temporizing measure until the patient is clinically fit for surgery or as a definitive treatment, especially in acalculous cholecystitis.

References

  1. Byrne MF, Suhocki P, Mitchell RM, et al. Percutaneous cholecystostomy in patients with acute cholecystitis: experience of 45 patients at a US referral center. J Am Coll Surg. 2003 Aug;197(2):206-11. PMID: 12892798

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