Transgastric endoscopic ultrasound (EUS)-guided gallbladder drainage for acute cholecystitis

 

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Acute cholecystitis occurs in 4 % – 7 % of patients with a covered metallic stent (CMS) placed in the bile duct [1] [2]. Percutaneous transhepatic gallbladder drainage, which involves an external drainage tube, decreases the ability of the patient to carry out their normal daily activities. Recently, endoscopic ultrasound (EUS)-guided drainage has been employed successfully for hepatogastrostomy, bilioduodenostomy, and pancreatogastrostomy [3] [4] [5]. We report here a patient who underwent EUS-guided gallbladder drainage for acute cholecystitis caused by CMS placement.

A 71-year-old man with unresectable pancreatic cancer underwent deployment of a CMS for obstructive jaundice. On the eighth post-procedure day, he complained of abdominal pain and developed fever, associated with an increase in white blood cell counts and raised serum level of C-reactive protein. Computed tomography revealed an enlarged gallbladder, suggesting acute cholecystitis and requiring continuous drainage of the gallbladder. Therefore, after obtaining informed consent, we carried out EUS-guided gallbladder drainage. An echoendoscope (GF-UCT240-AL5; Olympus, Tokyo, Japan) was introduced into the stomach, and a 19-gauge needle (Echo-Tip; Wilson-Cook, Winston-Salem, North Carolina, USA) was used to puncture the gallbladder ([Fig. 1]) and create a gastro-gallbladder fistula. The infected bile was immediately aspirated via the needle and the gallbladder was irrigated with a contrast medium containing an antibiotic. A 0.035-inch guide wire (Revowave, Olympus, Tokyo, Japan) was passed through the needle under fluoroscopic guidance until it reached the gallbladder; the guide wire was coiled within the gallbladder ([Fig. 2]). Three biliary dilation catheters (6 Fr, 7 Fr, and 9 Fr; Soehendra Biliary Dilation Catheters, Wilson-Cook, Winston-Salem, North Carolina, USA) were serially advanced over the guide wire to dilate the diameter of the tract. A pigtail stent (diameter 7 Fr; length 4 cm) was placed over the guide wire to bridge the gallbladder and the antrum of the stomach ([Fig. 3], [4]). There were no procedure-related complications. The patient’s fever and abdominal pain resolved rapidly and laboratory data showed improvement 5 days later. Although the stent was kept in place for 6 months without any additional intervention, such as removal or exchange of the stent, there were no recurrent symptoms.

Fig. 1 Gallbladder punctured under endoscopic ultrasound guidance before placement of the guide wire.

Fig. 2 Fluoroscopic image showing the coiled guide wire in the gallbladder.

Fig. 3 Fluoroscopic image showing the placement of the stent through the gastro-gallbladder fistula. The tip of the stent was positioned in the gallbladder.

Fig. 4 Endoscopic view of the stent inserted into the gallbladder from the antrum of the stomach.

Endoscopy_UCTN_Code_TTT_1AS_2AD

References

• 1 Maria S, Plinio R, Renon U. et al . Malignant biliary obstruction: Treatment with ePTFE-FEP-covered endoprostheses-initial technical and clinical experiences in a multicenter trial.  Radiology. 2002;  225 35-42
  CrossrefPubMedGoogle Scholar
• 2 Isayama H, Komatsu Y, Tsujino T. et al . A prospective randomised study of covered versus uncovered diamond stents for the management of distal malignant biliary obstruction.  Gut. 2004;  53 729-734
  CrossrefPubMedGoogle Scholar
• 3 Burmester E, Niehaus J, Leineweber T. et al . EUS-cholangio-drainage of the bile duct: report of 4 cases.  Gastrointest Endosc. 2003;  57 246-251
  Google Scholar
• 4 Giovannini M, Moutardier V, Pesenti C. et al . Endoscopic ultrasound-guided bilioduodenal anastomosis: a new technique for biliary drainage.  Endoscopy. 2001;  33 898-900
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Francois E, Kahaleh M, Giovannini M. et al . EUS-guided pancreaticogastrostomy.  Gastrointest Endosc. 2002;  56 128-133
  CrossrefPubMedGoogle Scholar

M. KitanoMD, PhD 

Division of Gastroenterology and Hepatology
Kinki University School of Medicine

Ohno-higashi 377-2
Osaka-sayama 589-8511
Japan

Fax: +81-72-3660221

Email: m-kitano@med.kindai.ac.jp