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i Oi 3

Case

Report

1

..

Percutaneous Cholecystostomy Drainage of Acute Emphysematous Cholecystitis Harlan

L. Vingan,1

Stephen

D. Wohlgemuth,2

and J. Sumner

Recent reports document the usefulness of percutaneous cholecystostomy drainage in the therapy of acute inflammatory diseases such as cholecystitis or empyema of the gallbladder [1 2]. It also has been shown that the gallbladder

for the Treatment

Bell lIla

obstruction

with

a guidewire,

an indwelling

endoprosthesis

fever,

chills,

and pain

in the right

upper

,

reserved for patients in whom a transhepatic approach is either unsuccessful or contraindicated. We recently used the gallbladder as an approach for definitive therapy of a patient with complete distal common bile

duct obstruction

who secondarily

developed

emphysematous

cholecystitis. The percutaneous cholecystostomy tube used to treat the acute infection was directly converted, via the

cystic duct, into a permanent

internal/external

drain.

WBC

count

The

(Fig.

is an

diabetes

urinary

bladder.

81 -year-old mellitus

woman

and

She presented

with

transitional

a history cell

for evaluation

of

insulin-

carcinoma

of rapidly

of

the

progressive

jaundice.

On admission i2.i

mg/dl

617

lU/I.

(207

Sonography

bile duct dilatation showed duct biliary

and

CT showed

with

proximal

stricture

dilatation

(Fig.

tree was attempted,

Received

intrahepatic

and extrahepatic

due to a mass in the head of the pancreas.

a malignant-appearing

1 A).

but despite

of the distal Endoscopic

ERCP

common

drainage

bile of the

being able to cross

the

bilirubin

quadrant

developed.

22.9 mg/dl (392

was

The

level was 1 001 lU/I. The patient care unit with a diagnosis of Gram-

of the entire

biliary

system

via percutaneous

cho-

lecystostomy was attempted. This decision was made, in part, because the plain film of the abdomen showed contrast material in the gallbladder after the ERCP, suggesting cystic duct patency. A 12French vanSonnenberg sump catheter (Medi-tech, Inc., Watertown, MA) was placed in the gallbladder by trocar technique. This was done a lateral tolerated

transhepatic the

reaction.

approach

catheter

Three

placement

hundred

under well,

milliliters

CT guidance. without

The

evidence

of thick,

of

foul-smelling

withdrawn, which subsequently grew K!ebsie!/a pneumoniae and Psoudomonas aeruginosa. Bile cytology results were negative. External biliary drainage was continued, and the patient’s condition bile was

improved following

rapidly. Within 24 hr, she was afebrile and alert. During the week, the WBC count returned to normal, the bilirubin level

was i i .4 mg/dl (1 95 Mmol/l), and the alkaline phosphatase level was 268 lU/I. The patient underwent cholangiography via the external drainage catheter distal

after common

exchanged

1 week.

This

bile

stricture.

duct

for an internal/external

showed One

a patent week

cystic later,

drain via the cystic

after revision May 29, 1990. Norfolk, VA 23507. Address Inc., 61 61 Kempsville Circle, Norfolk, VA 23502. Sentara Norfolk General Hospital and Eastern Virginia Medical School, Norfolk, VA 23507. of Gastroenterology, Sentara Norfolk General Hospital and Eastern Virginia Medical School, Norfolk, VA 23507.

duct

this

and

catheter

the was

duct. Side holes

April 5, 1 990; accepted

I Department Medical Center 2 Department 3

the patient was afebrile with a total bilirubin level of Mmol/l); SGOT, 74 lU/i ; and alkaline phosphatase,

x 10/l,

1B).

Decompression

vasovagal

patient

dependent

to 29.4

negative sepsis. At this time, an abdominal radiograph and a CT scan showed air in the gallbladder wall and in the intrahepatic bile ducts

patient

Report

rose

Mmol/l), and alkaline phosphatase was transferred to the intensive

by using Case

not

level

,

can be used as a site for draining the biliary system obstructed distal to the cystic duct [1 3]. This approach is usually

could

be advanced across the stricture. No further drainage was attempted, and the patient was started on antibiotics. Within the next 48 hr.

of Radiology, Sentara Norfolk General Hospital and Eastern Virginia Medical School,

Radiologists, of Surgery,

Department

AJR 155:1013-1014,

November

1990 0361 -803x/90/1555-1013

© American

Roentgen

Ray Society

reprint

requests

to H. L. Vingan,

VINGAN

1014

El

AL.

AJR:155,

Fig. 1.-A,

ERCP

Iignant-appeanng

shows

stricture

November

irregular,

abrupt,

ma-

of distal common

bile

duct with proximal dilatation. B, CT scan shows air in gallbladder

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acteristic

were left in the gallbladder, drainage. line

The

patient

phosphatase

was

bile duct, and bowel, establishing discharged

with

normal

bilirubin

internal and

alka-

levels.

When she returned for a tube change 3 months later, she was free of pain, anicteric,

and had gained

25 pounds.

Discussion

Emphysematous cholecystitis is a particularly virulent infection most often seen in diabetic patients. Emphysematous cholecystitis related to ERCP has been described [4]. A characteristic feature is the presence of air in the gallbladder wall or lumen. The morbidity and mortality rates are higher than those associated with other forms of acute cholecystitis, and prompt surgery (cholecystectomy or cholecystostomy) is warranted [5-7]. Our patient was unusual in that her acute cholecystitis was superimposed on a malignant-appearing stricture of the distal common bile duct, presumably due to carcinoma of the pancreas. The exact cause of the obstruction was never actually determined, as multiple bile cytology specimens were negative. The patient was thought to be too ill for open or imagingguided biopsy. After she recovered from the acute infection, a conservative, palliative management approach was decided on by the referring physicians, and no biopsy was performed.

of emphysematous

1990

wall char-

cholecystitis.

The placement of the cholecystostomy catheter via a transhepatic approach healed the acute cholecystitis and provided an access to the biliary system for permanent internal/external biliary drainage. Sideholes in this catheter were placed in the gallbladder, bile duct, and bowel to ensure adequate drainage of the entire biliary system. This case illustrates the successful percutaneous treatment of emphysematous cholecystitis. Percutaneous cholecystostomy should be considered as a temporizing procedure in critically ill patients with emphysematous cholecystitis in whom surgical intervention is contraindicated.

REFERENCES

1 . Pearse DM, Hawkins IF, Shaver R, Vogel tomy in acute cholecystitis and common

S. Percutaneous duct obstruction.

cholecystosRadiology

1984;1 52:365-367 2. Lindemann SR, Tung G, Silverman 5, Mueller P. Percutaneous

tostomy:

3. Vogelzang therapeutic

a review.

Semin

Intervent

Radiol

R, Nemcek A. Percutaneous efficacy.

Radiology

i988;5:1

cholecys-

79-185

cholecystostomy:

diagnostic

4. Baker JP, Haber GB, Gray RR, Handy S. Emphysematous

cholecystitis

complicating endoscopic retrograde cholangiography. Gastrointest 1982;28:184-186 5. Glenn F. Cholecystostomy in the high risk patient with biliary tract Ann Surg 1977;185:185-191

6. Gingrich

and

1988;5:179-185

R, Awe W, Boyden A, Peterson

cholecystitis: factors influencing morbidity 1968;1 16:31 0-314 7. Sharp K. Acute cholecystitis. Surg C/in North

C. Cholecystostomy and

mortality.

Endosc disease.

in acute Am

Am 1988;68:269-279

J Surg