Acute Cholecystitis and PC Overview

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Questions and Answers

What complication may cause persistent biliary leakage after the removal of a pigtail catheter?

Gallstone ileus

Hepatic abscess

Cholecystocutaneous fistula (correct)

Cholecystitis

Favorable clinical outcomes from PC procedures are reported in less than 90% of patients.

False

What is the recommended procedure for managing abscess formation within the subcutaneous abdominal wall?

Cholecystectomy with drainage of the collection.

A significant bile leak can occur after the removal of a PC catheter, especially in cases involving an iatrogenic rent in the __________.

GB wall Signup and view all the answers

Match the following outcomes or procedures with their appropriate descriptions:

Cholecystectomy = Procedure to remove the gallbladder Biliary peritonitis = Complication from significant bile leaks Trans-peritoneal route = Common route with iatrogenic rent risks Tractogram = Assessment of cystic duct and CBD patency Signup and view all the answers

What is the primary management strategy for mild acute cholecystitis?

Medical therapy and early cholecystectomy Signup and view all the answers

Acalculous cholecystitis is less common than calculous cholecystitis in critical illness settings.

False Signup and view all the answers

What is percutaneous cholecystostomy primarily used for?

To drain the gallbladder in patients with moderate to severe acute cholecystitis. Signup and view all the answers

Acute cholecystitis (AC) can result from _ and _ as common predisposing factors.

gallstones, critical illnesses Signup and view all the answers

Match the following types of cholecystitis with their respective characteristics:

Calculous cholecystitis = Caused by gallstones Acalculous cholecystitis = No gallstones present Moderate acute cholecystitis = Grade II condition Severe acute cholecystitis = Grade III condition Signup and view all the answers

What is one of the primary purposes of percutaneous cholecystostomy?

To drain fluid from the gallbladder Signup and view all the answers

Gallbladder empyema can be treated with ultrasonically guided percutaneous drainage.

True Signup and view all the answers

What is the significance of understanding risk factors for perioperative complications in laparoscopic cholecystectomy?

It helps improve patient outcomes and reduce surgical risks. Signup and view all the answers

The first cholangio________ was Dr. John S. Bobbs.

ecystotomist Signup and view all the answers

Match the following studies with their focus:

Akhan O, Akinci D, Ozmen MN (2002) = Percutaneous cholecystostomy Sparkman RS (1967) = Cholangiography history Giger UF, Michel J-M (2006) = Risk factors for complications Duncan C et al (2016) = Cholecystostomy in the presence of ascites Signup and view all the answers

Which patient demographic is suggested to particularly benefit from percutaneous cholecystostomy (PC)?

Very elderly patients with acute cholecystitis Signup and view all the answers

In which clinical setting is emergency bedside ultrasound-guided PC indicated?

Intensive care unit with acalculous acute cholecystitis Signup and view all the answers

What factor increases the risk of developing acute cholecystitis in patients admitted to the ICU?

Prolonged stay in ICU due to poly-trauma Signup and view all the answers

How might extensive burns affect the incidence of acute cholecystitis?

By causing severe dehydration and prolonged total parenteral nutrition Signup and view all the answers

What is a significant underlying condition that may warrant the performance of percutaneous cholecystostomy?

Neurological diseases in elderly patients Signup and view all the answers

What is the potential mortality rate in critically ill patients due to diagnosis complications?

Up to 50% Signup and view all the answers

Which of the following is considered a common finding on ultrasound for diagnosing acute cholecystitis?

Pericholecystic fluid Signup and view all the answers

What are the newly expanded indications for percutaneous transhepatic gallbladder drainage (PTGBD)?

Cholangitis and biliary obstruction Signup and view all the answers

Which procedure was first performed much later than the initial cholecystostomy?

Image-guided cholecystostomy Signup and view all the answers

What is a critical characteristic of EUS-GBD as a medical procedure?

It is relatively new and technically challenging. Signup and view all the answers

What is the primary reason for keeping patients fasting overnight before a procedure involving the common bile duct?

To ensure adequate distension of the gallbladder Signup and view all the answers

Which imaging technique can confirm the patency of the cystic duct?

Percutaneous cholecystogram Signup and view all the answers

What is a significant technical limitation in performing PC procedures?

Narrow or tortuous cystic duct Signup and view all the answers

Under what circumstances might the trans-peritoneal route be preferred over the transhepatic route for PC?

Coagulopathy or diffuse liver diseases Signup and view all the answers

What is a relative contraindication for percutaneous cholecystostomy procedures?

Coagulopathy Signup and view all the answers

What is a potential consequence of a significant pneumothorax following a trans-hepatic procedure?

Immediate chest tube placement Signup and view all the answers

What complication can arise from a significant bile leak after a procedure?

Biliary pleural fistula Signup and view all the answers

In the context of managing abdominal complications, what rare event may occur due to inadvertent perforation?

Fulminant peritonitis Signup and view all the answers

What percentage of mortality is reported in patients due to biliary complications following procedures?

3.6% Signup and view all the answers

What early complication is associated with the immediate post-procedural period following a trans-hepatic route?

Pericatheter skin excoriation Signup and view all the answers

Study Notes

Acute Cholecystitis and Percutaneous Cholecystostomy

Acute cholecystitis (AC) is gallbladder inflammation, ranging from mild to severe.
Gallstones and critical illnesses are common causes.
Mild AC is treated medically, while moderate/severe AC often requires early cholecystectomy.
Cholecystectomy isn't always feasible due to comorbidities.
Percutaneous cholecystostomy (PC) is a minimally invasive procedure to drain the gallbladder.

Indications for PC

Patients at high risk for surgery due to comorbidities (e.g., severe AC, calculous or acalculous, emphysematous, hemorrhagic, pregnancy).
Not responding to conservative treatment (IV antibiotics, analgesics, anti-inflammatory meds) after 3 days.
Severe AC in the elderly or patients with cardiovascular/neurological conditions.
Acalculous AC in ICU patients, polytrauma patients, or burn patients.
Emphysematous cholecystitis (gas-producing organisms) – a risky condition, but PC is an alternative to cholecystectomy.
AC in pregnancy- PC may be performed when conservative treatment isn't enough, followed by cholecystectomy post-partum
Hemorrhagic cholecystitis - a complication where blood vessels in the gallbladder are damaged, and surgery may not be feasible.
Gallbladder perforation—PC is life-saving in these cases.
Iatrogenic gallbladder perforation (after liver biopsy) can be effectively treated with PC.
Biliary decompression in patients with cholangitis or pancreatitis who can't undergo ERCP or PTBD.
Cholangitis, biliary obstruction, or as a potential route for stone extraction or dissolution

Contraindications

No absolute contraindications are documented to date.
Relative contraindications include coagulopathy (low platelet count or high INR), ascites.
Patients with a severely contracted gallbladder with multiple stones may have placement difficulty.

Technique

Complete blood count (including platelets), coagulation studies (INR and PT), and liver function tests are standard pre-procedure.
Antibiotics are administered to cover potential bacterial infections.
Imaging guidance (ultrasound or CT) is used to plan the approach (transhepatic or trans-peritoneal).
A small puncture is made, and a guidewire is inserted into the gallbladder.
Dilatation of the tract is performed until a catheter can be placed.
Contrast cholecystogram is sometimes performed to ensure catheter placement.
Local anesthesia and analgesia are typically used during the procedure.
Intercostal approach is often preferred to the trans-peritoneal route for the transhepatic approach.

Post-procedure Care

Patient vitals monitored for several hours following the procedure.
Adequate hydration and antibiotics are continued.
Regular dressing and catheter care are essential.

Complications

Minor complications include pain, catheter dislodgement, mild hemobilia.
Moderate complications include severe hemorrhage, biliary leakage, pleural/pulmonary issues, bowel perforation, and vasovagal syncope.
Delayed complications can include cystic duct/common bile duct stones, subhepatic, gallbladder bed, and subphrenic abscesses, or cholecystocutaneous/cholecystohepatic fistula.
Recurrence of cholecystitis can occur after 7- 1085 days.

Newer Alternatives

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is being increasingly used, offering advantages.
Lumen-apposing metallic stents (LAMS) or internalization of PC (using cholecystoenterostomy stent, EUS guided) could be alternatives.

Outcomes

Generally, PC is a safe and effective procedure with relatively high success and favorable outcomes.
However, recurrence of AC and biliary issues are possible, especially if cholecystectomy isn't performed in all high-risk patients.

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Description

This quiz covers the essentials of acute cholecystitis (AC) and the role of percutaneous cholecystostomy (PC) in its management. Learn about the indications for PC, patient risk factors, and treatment alternatives in cases of severe AC. Ideal for medical students and healthcare professionals seeking insights into gallbladder diseases.