A 80-years-old man was referred to the emergency department with fever and diffuse abdominal pain over 2 days associated with vomiting. The patient had significant complex co-morbidities, like uncontrolled hypertension, cardiovascular disease and asthmatic bronchitis. On physical examination, his temperature is 39ºC, the vital signs are within normal limits and the abdomen is tender on palpation in the right hypochondrium. Laboratory tests revealed leukocytosis (19,32 10³/µL), elevation of transaminases (AST 150 U/L e ALT 83 U/L ) and a serum PCR of 2,6 ng/ml (normal, 3,5–5 g/dL). Abdominal ultrasonography showed peri-vesicular vesicular abscess, with 10 cm, filled by heterogeneous, gallbladder little filled, with irregular and thickened wall. It was also observed one subphrenic collection communicating with gallbladder (Figure 1). These aspects are consistent with acute cholecystitis complicated by perforation and peri-vesicular abscess, confirmed by abdominal tomography.
Figure 1: a. Gallbladder little filled, with irregular and thickened wall;
Figure 1: b. Peri-vesicular abscess, with 5 cm;
Due to the urgency of treatment in this type of pathology and the high surgical risk, we opted for percutaneous cholecystostomy. Under ultrasound guidance, we punctered gallbladder through a transhepatic route and proceeded to the placement of pigtail drain/draining catheter (16 Fr) and drained purulent material contaminated with bile (Figure 2). Bacteriological analysis revealed the presence of klebsiella pneumoniae. Appropriate antibiotic therapy was instituted. The duration of the percutaneous drainage was approximately eight days. There was clear improvement of the clinical situation. Before leaving the drain, abdominal ultrasound was performed and showed gallbladder well filled, with normal size and regular wall.
Figure 2: Percutaneous cholecystostomy under sonographic guide, through a transhepatic route;
A locking pigtail drain (16 Fr) was used.
Acute cholecystitis is a major cause of emergency surgical admission. However, surgical options are often unfavourable in patients who are very unwell, or have numerous medical co-morbidities, in which the mortality rates are significant (1). Percutaneous cholecystostomy has been shown to be beneficial in high-risk patient groups, predominantly as a bridging therapy; allowing safer elective cholecystectomy once the patient has recovered from the acute illness; or, in the minority, as a definitive treatment in patients deemed unfit for surgery (2).
(1) Atar E. et al. Percutaneous cholecystostomy in critically ill patients with acute cholecystitis: complications and late outcome. Clinical Radiology 2014; 69: 247-252.
(2) Little M. W. et al. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clinical Radiology 2013; 68: 654-660.
Cátia Leitão, Helena Ribeiro, João Pinto, Ana Caldeira, Eduardo Pereira
Serviço de Gastrenterologia, Hospital Amato Lusitano, Castelo Branco, Portugal.