Ahmed M. Elmeligui, MBBCh, MD1, Ameya A. Deshmukh, BA2, Javier Tejedor-Tejada, MD3, Enad Dawod, MD4, Jose Nieto, DO, FACG5; 1Kasr Alainy Hospital / Cairo University, Cairo, Al Jizah, Egypt; 2Midwestern University - CCOM, Downers Grove, IL; 3Hospital Universitario Rio Hortega, Valladolid, Castilla y Leon, Spain; 4New York-Presbyterian/Weill Cornell Medical Center, New York City, NY; 5Borland Groover Clinic, Jacksonville, FL
Introduction: Acute cholecystitis is an inflammation of the gallbladder and is a life-threatening condition that usually presents with nausea, vomiting, fever and right upper quadrant abdominal pain. Mortality due to acute cholecystitis ranges from 1% to 10%. Non-surgical interventions like percutaneous cholecystostomy and ERCP are well established therapeutic alternatives in elderly patients with significant comorbidities, who are poor candidates for surgery.
Methods: A 71-year-old male with existing abdominal carcinomatosis due to metastatic appendiceal cancer presented with severe right upper quadrant abdominal pain and tenderness to palpation with positive murphy’s sign. Patient was febrile (101°F). Lab result were significant for moderate leukocytosis 14.2x103 c/mm3. Abdominal ultrasound revealed thick walled gallbladder with sludge inside. He underwent hepatobiliary scintigraphy and the results noted poor gallbladder uptake. Diagnosis was confirmed for acute cholecystitis. A linear array echoendoscope was passed into the duodenum where the markedly distended gallbladder filled with echogenic content was visualized. A 10 mm x10 mm lumen apposing metal stent (LAMS) was inserted using an electric enhanced catheter and subsequently passed into gallbladder. The inner flange of the lumen apposing metal stent was deployed into the gallbladder lumen guided by echoendoscope. The outer flange was deployed in the duodenal bulb under endoscopic guidance and cholecystoduodenostomy was established CRETM balloon dilation device (Boston Scientific) was used to dilate the stent in order to allow proper drainage of the gallbladder content. The pyogenic content was discharged into the duodenal bulb and full gallbladder drainage was achieved. A pediatric upper endoscope was passed through cholecystoduodenostomy opening into the gallbladder lumen and endoscopic view confirmed drainage of all pyogenic contents. Discussion: The patient was kept on antibiotics and a low residue diet. One week after, the patient’s condition was improved as his temperature decreased to 97°F. The total leukocytic count completely normalized. Over last decade, EUS-guided gallbladder drainage has proven itself significantly superior with a clinical success rate comparable to that of percutaneous cholecystostomy or trans-papillary drainage. It has lower adverse events, hospital stay and requires fewer repeat procedures.
Endosonographic view showing distended gallbladder with echogenic content inside.
Endoscopic view showing deployed LAMS exiting out of the gallbladder and into the lumen of the duodenal bulb.
Endoscopic view showing cystic duct with discharge of pyogenic content.
Disclosures: Ahmed Elmeligui indicated no relevant financial relationships. Ameya Deshmukh indicated no relevant financial relationships. Javier Tejedor-Tejada indicated no relevant financial relationships. Enad Dawod indicated no relevant financial relationships. Jose Nieto: Boston Scientific – Consultant. ERBE – Consultant.