Clinical Presentation, Imaging, and Management of Acute Cholecystitis PDF

Clinical Presentation, Imaging, and Management of Acute Cholecystitis Venkata S. Katabathina, MD, Abdul M. Zafar, MD, and Rajeev Suri, MD Acute cholecystitis (AC) is a life-threatening emergency that commonly occurs as a complication of gallstones. Severe r...

Clinical Presentation, Imaging, and Management of Acute Cholecystitis Venkata S. Katabathina, MD, Abdul M. Zafar, MD, and Rajeev Suri, MD Acute cholecystitis (AC) is a life-threatening emergency that commonly occurs as a complication of gallstones. Severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphyʼs sign with an elevated white blood cell count are the classical clinical manifestations of AC. Although ultrasonography is typically the initial diagnostic examination in patients with suspected AC, computed tomography and magnetic resonance imaging are commonly performed to identify complications; cholescintigraphy is recommended in patients with equivocal findings on the other imaging modalities, as this technique has the highest diagnostic accuracy in the diagnosis of AC. Imaging studies are also helpful in the timely detection of complications associated with AC. Although laparoscopic cholecystectomy is considered the gold-standard treatment for AC, percutaneous gallbladder drainage with or without cholecystostomy tube placement is a safe, effective management technique for surgically high-risk patients with multiple medical conditions. This treatment can be used as either a bridging therapy, with elective cholecystectomy performed at a later time after improvement of the patientʼs condition, or as definitive treatment in surgically unfit patients. Radiologists play a pivotal role in the initial diagnosis and management of patients with AC. Tech Vasc Interventional Rad 18:256-265 C 2015 Elsevier Inc. All rights reserved. KEYWORDS Cholecystitis, Drainage, Aspiration Introduction tomography (CT), magnetic resonance (MR) imaging, and cholescintigraphy, play an important role in the Acute inflammation of the gallbladder secondary to cystic confirmation of the diagnosis and detection of associated duct obstruction in patients with gallstones is known as complications.6 Each imaging technique has varied sensi- acute cholecystitis (AC). AC is a common clinical problem tivity and specificity values in the diagnosis of AC and has accounting for up to 5% of emergency room visits and 9% a different role to play in management; for example, of hospital admissions.1 Up to 10% of patients with AC, whereas US is widely used for an initial examination in especially those in critical care units, do not have stones or all patients suspected to have AC, MR imaging is reserved sludge in the gallbladder; inflammation of the gallbladder for patients who may have biliary obstruction.6 Although in this group of patients without any cystic duct obstruc- laparoscopic cholecystectomy is the treatment of choice for tion is known as acute acalculous cholecystitis (AAC).2 patients with AC, image-guided percutaneous gallbladder AAC is typically associated with high morbidity and drainage (PT-GBD) with or without cholecystostomy tube mortality if it is not managed in a timely manner.3-5 placement is an effective therapy for select patients with Severe right upper quadrant pain, fever, and positive multiple medical comorbidities precluding them from Murphyʼs sign with an elevated white blood cell count on undergoing surgery. In addition, the interventional radi- laboratory examination are diagnostic of AC; however, ologist plays a pivotal role in the treatment of complica- imaging studies, including ultrasound (US), computed tions from cholecystectomy and cholecystostomy. In this article, we will review the pathophysiology, clinical features, complications, and imaging findings of AC with Department of Radiology, University of Texas Health Science Center at special emphasis on the role of each imaging technique in the San Antonio, San Antonio, TX. Address correspondence to: Rajeev Suri, MD, Department of Radiology, management of patients with AC. Then, we will present the University of Texas Health Science Center at San Antonio, 7703 Floyd “ins” and “outs” of cholecystostomy tube placement, including Curl Dr, San Antonio, TX 78229. E-mail: [email protected] anticipated complications and how to tackle them. 256 1089-2516/15/$ - see front matter & 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.tvir.2015.07.009 Acute cholecystitis 257 Pathophysiology, Clinical Patients with AC or AAC can develop complications if the Features, and Complications condition is not treated in a timely manner; however, complications are more commonly seen in patients with Cystic duct obstruction secondary to an impacted gall- AAC and in patients of advanced age, those with multiple stone with associated bile stasis is the initial event in the comorbidities, and those with a delayed presentation.1 development of AC; this leads to sustained high pressure Gangrenous cholecystitis (gallbladder empyema) with sub- within the gallbladder lumen that impairs normal mucosal sequent perforation is the most common complication. blood flow and subsequent ischemia. Chemical mediators Other common complications include gallbladder mucocele such as lysolecithin are released within the stagnant bile, formation, emphysematous cholecystitis, hemorrhagic chol- damaging ischemic mucosa, and leading to chemical ecystitis, pericholecystic abscess, cholecystoenteric fistula, cholecystitis with accumulation of inflammatory infiltrate gallstone ileus, Mirizzi syndrome, and peritonitis.10,11 and gallbladder wall edema.2 Although bacterial infection is uncommon within the first 48 hours, the risk of infection may increase to 70% by the end of the first week if treatment is not initiated. Escherichia coli, Enterobacter Role of Imaging organisms, Klebsiella organisms, and Enterococcus organ- The role of diagnostic imaging in the management of isms are the most commonly identified organisms in patients with AC and AAC is 2-fold: establish the diagnosis patients with AC.7 Depending on the type and severity in suspected individuals on the basis of clinical and of infection, there may be significant necrosis of the laboratory findings and detect complications.6 Although gallbladder wall with subsequent perforation and pericho- multiple imaging modalities are available for the diagnosis lecystic abscess formation.7 Again, the combination of bile of AC, their sensitivity, specificity, and diagnostic accuracy stasis plus ischemia is responsible for AAC development. values differ considerably, and each has a unique role to Patients receiving total parenteral nutrition and those with play in the management of the condition. Both clinicians recent trauma, surgery, shock of any kind, burns, sepsis, or and radiologists should be aware of the advantages and critical illness are at an increased risk of developing bile drawbacks of each imaging technique so that they can stasis and inspissation, which can cause toxic destruction select the appropriate study that is tailored to the needs of of the gallbladder epithelium.8 This results in the activa- the particular patient in question.6 tion of similar pathophysiologic events as in patients with US is the most commonly used initial imaging techni- AC. Low-volume states such as congestive cardiac failure, que in cases of suspected AC based on clinical features. fever, and dehydration may also directly cause gallbladder US has sensitivity and specificity values of 82% and 81%, wall ischemia and play a central role in AAC pathogenesis.9 respectively, for the diagnosis of AC.6 US is a fast, readily Severe, steady, and prolonged right upper quadrant and available technique that is often diagnostic for AC; addi- epigastric pain with associated fever, nausea, vomiting, tionally, this imaging modality may exclude some non- and anorexia is the most common clinical presentation of biliary causes for right upper quadrant pain. US findings AC. On physical examination, patients typically appear ill, of AC include cholelithiasis, gallbladder sludge, and tachycardic, and febrile with voluntary and involuntary distended gallbladder with wall thickening (more than abdominal guarding and may have a positive Murphyʼs 3-5 mm), wall edema, pericholecystic fluid, and presence sign.2 A meta-analysis concluded that none of the various of a positive sonographic Murphyʼs sign (Fig. 1).12 The studied clinical signs and symptoms of AC had a statisti- gallbladder may be decompressed in cases of perforated cally significant positive or negative likelihood ratio; AC and there will be associated pericholecystic or among all, a positive Murphyʼs sign had the highest perihepatic fluid collections; intraluminal gas bubbles likelihood ratio of 2.8 with 65% sensitivity and 87% may be seen with emphysematous cholecystitis.11 Among specificity.1 Leukocytosis with an increased number of all findings, gallbladder wall thickening is the most band forms is the most common laboratory abnormality, reliable diagnostic feature for AC: a cutoff of 3.5 mm seen in up to 60% of patients, and a positive bacterial yields 80% sensitivity and 99% specificity, whereas a culture has been reported in one-half to two-thirds of cutoff of 3 mm affords 100% sensitivity with a trade-off patients with AC.5,7 Elevated total bilirubin and alkaline of 90% specificity.9 However, clinical decisions should phosphatase levels are not common in a patient with not be based solely on US findings, as the diagnostic uncomplicated AC and should raise concern for biliary accuracy of US leaves substantial room for error. In obstruction.1 The combination of history, clinical signs, patients with clinically equivocal findings, cholescintig- laboratory values, and imaging findings should be used in raphy should be considered.6 Patients with AAC show US diagnosing AC and excluding other etiologies of right findings similar to those seen with AC with the exception upper quadrant pain. On the other hand, patients with of an absence of gallstones and sludge within the AAC demonstrate a variable clinical presentation that gallbladder.9 depends on the underlying predisposing conditions. Cholescintigraphy using 99mTc-hepatic iminodiacetic Vague abdominal pain, leukocytosis, and unexplained acid (HIDA) is a useful imaging technique to establish the fever with associated jaundice in a critically ill patient in diagnosis of AC and has the highest diagnostic accuracy of the intensive care unit should raise suspicion for AAC, and all imaging techniques, with a sensitivity of 96% and a US should be performed immediately.9 specificity of 90% for the diagnosis of AC.6,13 Intravenous 258 V.S. Katabathina, A.M. Zafar, and R. Suri Figure 2 A 44-year-old man with acute cholecystitis. Cholescinti- graphy image obtained 60 minutes after administration of 99mTc-HIDA shows nonvisualization of gallbladder, consistent with acute cholecystitis. CT is estimated to be 73%-99% sensitive and 42%-74% specific for AC.6 CT is particularly useful in the detection of complications of AC such as perforation, hemorrhage, emphysema, and abscess formation.6,15 Figure 1 US images demonstrate distended gallbladder with intraluminal stones and diffuse wall thickening, consistent with acute calculous cholecystitis. The patient had positive Murphy’s sign and elevated white counts of 14,000. (IV) 99mTc-HIDA is taken up selectively by hepatocytes and excreted into bile. Nonvisualization of the gallbladder within 60 minutes is suggestive of cystic duct obstruction and AC (Fig. 2).13 The main limitations of cholescintig- raphy are longer scan times, logistical problems regarding after-hours availability, and use of ionizing radiation. Severe liver disease, critical illness, and prolonged fasting can also lead to false negative results on HIDA, especially in patients with AAC. Morphine-augmented cholescintig- raphy may be helpful in select cases; a positive result is defined as nonvisualization of the gallbladder at 30 minutes after morphine administration. Despite a reported sensitivity of 100%, a false positive rate of 83% precludes the routine use of morphine-augmented cholescintigraphy in patients with AC.14 CT is less preferable than US in suspected cases of AC but is often the first test used to evaluate acute abdominal pain given its ability to assess for alternative abdominopelvic diagnoses. CT findings of AC include cholelithiasis, abnor- mal gallbladder distention, mural or mucosal hyperenhance- ment, wall thickening and edema, pericholecystic fluid, and adjacent soft tissue stranding (Fig. 3).10,12 Reactive hyper- Figure 3 Contrast-enhanced axial CT images depict distended emia of the hepatic parenchyma adjacent to the gallbladder, gallbladder with pericholecystic fat stranding and few foci of described as the “CT rim sign,” may also be seen in select intraluminal air (arrow), consistent with acute emphysematous cases.10 Evidence on the diagnostic accuracy of CT is scarce. cholecystitis. Acute cholecystitis 259 MR imaging can also be used for the diagnosis of AC. This imaging technique has diagnostic accuracy values comparable to those of US.6 Despite this good diagnostic performance, the cost, scan times, and availability of MR imaging limit its use for this purpose. However, MR imaging is definitely indicated in patients with suspected biliary obstruction secondary to choledocholithiasis or Mirizzi syndrome.6,16 MR imaging shows findings similar to those seen with US and CT in patients with AC or AAC. Additionally, a focal absence of mucosal enhancement on contrast-enhanced MR images (the “interrupted rim sign”) suggests the possibility of gallbladder gangrene and per- foration.16 MR cholangiopancreaticography is extremely helpful in the detection of bile duct stones and in the exclusion of extrinsic compression on the common bile duct (CBD) or the common hepatic duct by the impacted cystic duct stone (Mirizzi syndrome), which has significant management implications (Fig. 4).16 Management Management of AC has evolved over time, from the treat- ment of inflammation with antibiotics and elective open cholecystectomy after 4-6 weeks, to earlier open cholecys- tectomy, to laparoscopic cholecystectomy (initially elective and recently with a trend toward earlier laparoscopic cholecystectomy). Currently, the management of AC con- sists of supportive care for treating inflammation (IV fluid resuscitation, analgesia, and anti-inflammatory medica- tions), gallbladder decompression to remove irritants (cholecystostomy), and gallbladder removal (cholecystec- tomy). AC is primarily an inflammatory process. Nonsteroidal Figure 4 Axial T2-weighted MR image and MRCP image demonstrate acute calculous cholecystitis and a stone in the anti-inflammatory drugs are first-line drugs for AC; opiates distal CBD (arrow). such as morphine, meperidine, and hydromorphone are acceptable alternatives for acute pain management. Given the development of secondary infection in up to one-half acute inflammation has resolved. Any emergent situations to two-thirds of AC cases, antibiotics covering gram- such as gangrene, emphysematous cholecystitis, necrosis, negative bacteria and anaerobes are routinely administered perforation, abscess, or worsening clinical status despite to all patients diagnosed with AC and continued until supportive therapy (sepsis, hemodynamic instability, and clinical resolution or cholecystectomy.5,7 intractable pain) also warrant emergent surgery (Fig. 5). Cholecystectomy has traditionally been the definitive A longitudinal analysis of discharge data from 43,341 therapy for AC. Initially, open cholecystectomy (first patients with AAC found that among patients with severe described in 1882) was used; now laparoscopic cholecys- shock and sepsis, cholecystectomy afforded a significant tectomy (first described in 1987) is most common. In a survival benefit compared with no intervention (hazard cohort of 10,304 patients who did not undergo cholecys- ratio ¼ 0.56; P o 0.001), whereas percutaneous cholecys- tectomy during admission for the first episode of uncom- tostomy (PC) did not (hazard ratio ¼ 1.13; P ¼ 0.256).4 plicated AC, approximately 25% of patients experienced Cases with high surgical risk but without emergent recurrent events related to cholelithiasis over a median surgical indications are routinely managed with PC follow-up of 3.4 years.17 This high recurrence rate justifies (Fig. 5). PC is a therapeutic procedure that involves sterile the use of cholecystectomy after an episode of AC. Early placement of a needle (or more commonly a drainage cholecystectomy within 3 to 7 days of presentation is catheter) into the gallbladder to drain bile. PT-GBD with a preferred to late cholecystectomy because of lower morbid- catheter placement is the most common cholecystostomy ity, shorter hospital stay, and lower cumulative costs.17,18 procedure; two less common alternatives include percuta- The limiting factor for cholecystectomy is the balance neous gallbladder aspiration (PGBA) and endoscopic between the surgical risk of cholecystectomy and the US-guided gallbladder aspiration. Traditionally, gallblad- ongoing morbidity of AC. Low-risk patients generally der drainage is intended to be a bridge to cholecystectomy undergo cholecystectomy during the same admission once on improvement of the patientʼs surgical risk. 260 V.S. Katabathina, A.M. Zafar, and R. Suri Figure 5 Flowchart describing the management of acute cholecystitis, including supportive care, cholecystostomy, and cholecystectomy. Percutaneous Cholecystostomy procedures, especially in an intensive care unit setting. CT should be used for patients in whom gallbladder visual- Indications ization by US is limited secondary to the disease process PC is indicated for gallbladder drainage in high surgical (ruptured nondistended gallbladder or gallbladder filled risk patients with moderate to severe cholecystitis (calcu- with gallstones), body habitus, or overlying bowel loops.21 lous or acalculous) who are not improving with conserva- tive management (generally within 72 hours) (Fig. 5).19 This procedure is also indicated to create a portal of access Selection of Approach for future therapeutic procedures in the gallbladder. PC can be performed through a transhepatic (TH) or trans- peritoneal (TP) approach (Fig. 6). The TH approach is preferred because of the greater stability of the catheter, more Contraindications rapid tract maturation, lower theoretical risk of bile peritoni- PC is contraindicated in any emergent situations such as tis, and lesser risk of bowel injury. Ideally, the catheter should gangrene, emphysematous cholecystitis, necrosis, perfora- enter the gallbladder through its bare area. The TP approach tion, abscess, or worsening clinical status despite supportive may be used when extensive liver disease precludes the TH therapy (sepsis, hemodynamic instability, and intractable approach. The TP approach is preferably performed in a pain). This procedure should not be performed in cases of plane along the long axis of the gallbladder to allow for linear technical nonfeasibility (lack of access and gallbladder filled access for future gallbladder interventions (Fig. 6). Tradition- with gallstones limiting tube placement). PC is also contra- ally, the TP approach has been used for coagulopathic indicated in cases of gallbladder malignancy because of the patients given the theoretical risk of hepatic bleeding, but a risk of tumor seeding. Finally, caution must be exercised in recent retrospective study did not support this practice.20 An coagulopathic patients, although a recent study of 242 anchoring device may be used to tack the gallbladder to the patients undergoing US-guided PC found no significant abdominal wall, narrowing the gap between the wall and difference in bleeding among noncoagulopathic and coagu- gallbladder and thus decreasing bile leaks. lopathic patients (International Normalized Ratio Z1.5 and platelet count r50  109/L or history of anticoagulant medication use in the preceding 5 days).20 Preprocedure Checklist Clinicians should obtain informed consent from the patient, perform presedation assessment, obtain IV access, Imaging Modality for Guidance provide broad-spectrum antibiotic coverage, ensure the Available imaging should be reviewed to determine gallblad- presence of equipment and personnel to monitor vital der anatomy and its relationship to the liver and the bowel signs, administer analgesia, and moderate sedation accord- loops. US is the modality of choice for image-guided PC as it ing to institutional guidelines (the authors usually use IV allows for real-time visualization and the option of bedside fentanyl 50-100 mcg and midazolam 1-2 mg). Acute cholecystitis 261 Figure 6 TH and TP approaches to percutaneous cholecystostomy. Schematic diagram, CT imaging helping to plan TH or TP access, and US-guided needle access for TH and TP access. Arrows in CT images are pointing to TH and TP approaches, respectively. (Color version of figure is available online.) Procedure visualization of the trajectory. Approximately 10-15 cc of local The patient is placed supine and the access site over the right anesthetic (1% lidocaine) is administered along the intended flank (mid-axillary to mid-clavicular) is sterilely prepared and access path (via the anterior or anterolateral approach), with draped. A limited sonogram with a transducer of 2-5 MHz is special attention to the hepatic capsule. Access to the gallblad- performed to confirm adequacy and depth of the access path. A der (TH or TP) can be obtained with either the Seldinger or the biopsy guide mounted on the US transducer may be helpful for trocar technique depending on operator preference. 262 V.S. Katabathina, A.M. Zafar, and R. Suri Figure 7 Seldinger approach to percutaneous cholecystostomy. Schematic diagram delineating TH needle access, guidewire placement, serial dilatation of the tract, and locking pigtail catheter placement. (Color version of figure is available online.) Seldinger Technique based on US imaging and aspiration by bile or pus, the After a skin incision is made at the selected access site in the trocar is removed and the catheter is advanced into the intercostal or subcostal region, the gallbladder is accessed gallbladder and locked and secured in position. (under US guidance) with an 18-gauge needle. A 21-gauge The catheter may be upsized to 10-12 F based on the needle with an Accustik II system (Boston Scientific, Natick, viscosity of the aspirated gallbladder contents. Satisfactory MA) or Neff set (Cook Medical, Bloomington, IN) may also placement of the catheter is confirmed by aspiration of bile be used. Roughening up the distal needle tip or jiggling the or pus and the catheter loop (tram track appearance) seen stylet within the needle can help to improve needle visual- in the gallbladder on US. Injection of 3-5 mL of iodinated ization on US. It is preferable to gain access to the contrast under fluoroscopy may also be used to confirm gallbladder with the single wall puncture technique (ie, placement; a low contrast dose is preferred to avoid sepsis. needle entering the gallbladder lumen after puncturing only The catheter is then locked and secured to the skin with the anterior gallbladder wall and not cross-puncturing the anchoring sutures or with a commercial anchoring device distal wall). Once the needle tip is within the gallbladder, and connected to a drainage bag to drain under gravity. bile and pus are aspirated to confirm adequate positioning and are sent for microbiological studies. A 0.035-in guide- wire is inserted through the 18-gauge needle (or 0.018-in Follow-up and Postprocedure Care wire through the 21-gauge needle), and the needle or access Bed rest is recommended for 2-4 hours after the procedure, set is exchanged over the wire for serial dilators and finally with monitoring of vital signs and adequate pain control. The for an 8-F locking pigtail catheter (Fig. 7). The needle- catheter should be gently flushed with 5-10 mL of sterile water catheter exchange portion of the procedure may also be or normal saline at least once every 24 hours, and antibiotics performed under US or fluoroscopic guidance. should be continued for at least 48 hours. Removal of the PC tube should be guided by clinical parameters, maturation of the tract, and patency of the cystic duct allowing antegrade Trocar Technique biliary drainage (Fig. 8). To check for tract maturation and This technique has fewer steps and is theoretically more antegrade biliary patency before removing the catheter, the efficient. After a skin incision at the selected access site is clinician should exchange the indwelling catheter for a flush made, an 8-F locking pigtail catheter preloaded on a trocar catheter over a guidewire to maintain access. Cholecystogram needle is advanced directly into the gallbladder under US via the flush catheter will confirm cystic duct or CBD guidance. When satisfactory positioning has been achieved patency and tract maturation. If there is peritoneal contrast Acute cholecystitis 263 leakage (because of a nonmature tract, often seen with ascites) Timely clinical recognition of complications (bleeding, or an occluded cystic duct, the pigtail catheter should be pericholecystic fluid collections, bowel injury, liver abscesses, replaced over the guidewire. Usually, the tract takes 3-4 weeks pneumothorax, bile leak, and catheter displacement), early to mature. If PC is used for long periods, the catheter should confirmation with cross-sectional imaging, and appropriate be replaced every 3 months. Patients or their caregivers should image-guided percutaneous or open surgical management be provided with instructions about flushing the catheter and (endovascular embolization of arterial or venous injury, fluid routine wound care. or abscess aspiration or drainage, chest tube placement, and gallbladder catheter upsizing or repositioning) are essential in improving overall outcomes after PC and decreasing mortal- Outcomes ity. Mortality attributable to PC is difficult to delineate as the The technical success of PC is defined as successful placement patients undergoing this procedure are often elderly (average of the cholecystectomy tube. Several recent studies have age, 66-75 years) and critically ill and have multiple reported 98.5%-100% technical success rates for PC.5,20,22-25 comorbidities.3,20,22 Conceivably, mortality after PC may be The clinical success of PC is determined by improvement in mainly the result of underlying risk factors rather than clinical parameters (including fever, leukocytosis, and pain) procedural complications. A study reporting lower mortality within 2-3 days. The reported clinical success rates in the in ambulatory patients than in already hospitalized patients literature range from 68%-97.5%, likely in part because of the (29% vs 44%) treated with PC for AC at the same institute lack of a single set of criteria.22,23,25 Cholecystectomy should supports this hypothesis.5 be considered for patients who do not show signs of improve- Traditionally, cholecystectomy has been the end-goal in ment within 48-72 hours of undergoing a cholecystostomy. patients with AC. In actuality, 60%-88% of patients with severe AC undergoing PC do not undergo cholecystectomy in their life.17,26 In this group of patients, PC is considered as Complications definitive treatment rather than as bridging therapy. Although Procedure-related complications may be seen in 2.4%-16% of the underlying reasons for this observation in this population cases within the first few days. Most complications, including have not been delineated, chronic comorbidities causing procedure-related mortality (0%-1.4%), sepsis (0.9%), bleeding continued high surgical risk likely play a role. This brings owing to hepatic arterial or venous injury requiring transfusion forward the role of PC as a potentially definitive treatment for (0.4%-1.9%), bile peritonitis or bile leak (1.9%-2.4%), bowel AC in select patients.22,25 Analysis of a large administrative injury, liver abscesses, pneumothorax, and vasovagal reaction, data set from the University Health System Consortium are relatively rare. Minor complications such as catheter demonstrated that, in comparison with cholecystectomy, displacement (4.5%-13.2%) and minor bleeding (1.2%) com- PC for AC in patients with 3 or more comorbidities affords prise most procedure-related events (Fig. 9).5,20,25 lower morbidity, decreased length of stay, and lower costs.19 Percutaneous Gallbladder Aspiration The indications, technique, and intraprocedural complica- tions for PGBA are similar to those of PC. This minimally invasive procedure can be performed at bedside. No tube is placed and no fistula is created, which may translate into greater patient comfort, earlier recovery, and decreased intensity of follow-up. The procedure can be repeated multiple times and antibiotics may be instilled within the gallbladder. Initial studies of PGBA have reported promising results. In 2 retrospective studies including a total of 192 patients, 65%-71% of patients with AC improved after a single PGBA, whereas a second percutaneous intervention improved clinical symptoms in 24%-29% of patients. Com- plications, including intra-abdominal hemorrhage, bile leak- age, and gallbladder hemorrhage, were seen in up to 3.4% of cases. No procedure-related mortality was noted.27,28 Figure 8 Percutaneous cholecystogram in a 55-year-old Endoscopic Ultrasound-Guided man 3 weeks after PC procedure demonstrates patent cystic Gallbladder Aspiration duct, antegrade flow of contrast into the duodenum, and a mature tract with some contrast leakage to the superficial soft Endoscopic US-guided gallbladder aspiration can be per- tissues. formed through the transpapillary route. Experience with 264 V.S. Katabathina, A.M. Zafar, and R. Suri Figure 9 CT and percutaneous cholecystograms revealing complications after PC tube placement in different patients: (A) catheter dislodgement outside the gallbladder, (B) hemorrhage in the gallbladder, (C) intraperitoneal bile leakage, and (D) pericholecystic bile leakage. this technique is limited. This procedure is performed in References patients with AC for whom percutaneous approaches are contraindicated or infeasible. This approach is reported to 1. Trowbridge RL, Rutkowski NK, Shojania KG: Does this patient have have 84%-98% technical success and 97%-100% clinical acute cholecystitis? J Am Med Assoc 289:80-86, 2003 [erratum in J Am Med Assoc 2009;302:739] success. Complications, including duodenal perforation 2. Knab LM, Boller AM, Mahvi DM: Cholecystitis. Surg Clin North Am and pneumoperitoneum, have been seen in 5%-7% of 94:455-470, 2014 cases.29 3. Anderson JE, Chang DC, Talamini MA: A nationwide examination of outcomes of percutaneous cholecystostomy compared with chol- ecystectomy for acute cholecystitis, 1998-2010. Surg Endosc Conclusion 27:3406-3411, 2013 4. Anderson JE, Inui T, Talamini MA, et al: Cholecystostomy offers no PT-GBD and cholecystostomy tube placement are safe and survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock. J Surg Res 190:517-521, 2014 minimally invasive procedures that can provide an impor- 5. Joseph T, Unver K, Hwang GL, et al: Percutaneous cholecystostomy tant bridge to laparoscopic cholecystectomy in patients for acute cholecystitis: ten-year experience. J Vasc Interv Radiol with AC or can serve as potentially definitive therapy in 23:83-88, 2012 [e1] high surgical risk patients who are unresponsive to 6. Kiewiet JJ, Leeuwenburgh MM, Bipat S, et al: A systematic review supportive care. The interventional radiologistʼs knowl- and meta-analysis of diagnostic performance of imaging in acute cholecystitis. Radiology 264:708-720, 2012 edge regarding indications, contraindications, approach 7. Csendes A, Burdiles P, Maluenda F, et al: Simultaneous bacteriologic (TH vs TP), technique, preprocedure and postprocedure assessment of bile from gallbladder and common bile duct in control care, and complications of PC tube placement will help to subjects and patients with gallstones and common duct stones. Arch improve patient care. Surg 131:389-394, 1996 Acute cholecystitis 265 8. Huffman JL, Schenker S: Acute acalculous cholecystitis: a review. acalculous cholecystitis: a large multicenter outcome study. Am J Clin Gastroenterol Hepatol 8:15-22, 2010 Surg 206:935-940, 2013 9. Barie PS, Eachempati SR: Acute acalculous cholecystitis. Gastro- 20. Dewhurst C, Kane RA, Mhuircheartaigh JN, et al: Complication rate enterol Clin North Am 39:343-357, 2010 of ultrasound-guided percutaneous cholecystostomy in patients with 10. Shakespear JS, Shaaban AM, Rezvani M: CT findings of acute chole- coagulopathy. Am J Roentgenol 199:W753-W760, 2012 cystitis and its complications. Am J Roentgenol 194:1523-1529, 21. Ginat D, Saad WE: Cholecystostomy and transcholecystic biliary 2010 access. Tech Vasc Interv Radiol 11:2-13, 2008 11. Charalel RA, Jeffrey RB, Shin LK: Complicated cholecystitis: the 22. Chung YH, Choi ER, Kim KM, et al: Can percutaneous cholecys- complementary roles of sonography and computed tomography. tostomy be a definitive management for acute acalculous cholecys- Ultrasound Q 27:161-170, 2011 titis? J Clin Gastroenterol 46:216-219, 2012 12. Smith EA, Dillman JR, Elsayes KM, et al: Cross-sectional imaging of 23. Cha BH, Song HH, Kim YN, et al: Percutaneous cholecystostomy is acute and chronic gallbladder inflammatory disease. Am J Roent- appropriate as definitive treatment for acute cholecystitis in critically genol 192:188-196, 2009 ill patients: a single center, cross-sectional study. Korean J Gastro- 13. Tulchinsky M, Colletti PM, Allen TW: Hepatobiliary scintigraphy in enterol 63:32-38, 2014 acute cholecystitis. Semin Nucl Med 42:84-100, 2012 24. McKay A, Abulfaraj M, Lipschitz J: Short- and long-term outcomes 14. Hung BT, Traylor KS, Wong CY: Revisiting morphine-augmented following percutaneous cholecystostomy for acute cholecystitis in hepatobiliary imaging for diagnosing acute cholecystitis: the poten- high-risk patients. Surg Endosc 26:1343-1351, 2012 tial pitfall of high false positive rate. Abdom Imaging 39:467-471, 25. Li M, Li N, Ji W, et al: Percutaneous cholecystostomy is a definitive 2014 15. Patel NB, Oto A, Thomas S: Multidetector CTof emergent biliary treatment for acute cholecystitis in elderly high-risk patients. Am pathologic conditions. Radiographics 33:1867-1888, 2013 Surg 79:524-527, 2013 16. Tonolini M, Ravelli A, Villa C, et al: Urgent MRI with MR 26. Chang YR, Ahn YJ, Jang JY, et al: Percutaneous cholecystostomy for cholangiopancreatography (MRCP) of acute cholecystitis and related acute cholecystitis in patients with high comorbidity and re- complications: diagnostic role and spectrum of imaging findings. evaluation of treatment efficacy. Surgery 155:615-622, 2014 Emerg Radiol 19:341-348, 2012 27. Komatsu S, Tsukamoto T, Iwasaki T, et al: Role of percutaneous 17. de Mestral C, Laupacis A, Rotstein OD, et al: Early cholecystectomy transhepatic gallbladder aspiration in the early management of acute for acute cholecystitis: a population-based retrospective cohort study cholecystitis. J. Dig Dis 15:669-675, 2014 of variation in practice. CMAJ Open 1:E62-E67, 2013 28. Tsutsui K, Uchida N, Hirabayashi S, et al: Usefulness of single and 18. Gutt CN, Encke J, Koninger J, et al: Acute cholecystitis: early versus repetitive percutaneous transhepatic gallbladder aspiration for the delayed cholecystectomy, a multicenter randomized trial (ACDC treatment of acute cholecystitis. J Gastroenterol 42:583-588, 2007 study, NCT00447304). Ann Surg 258:385-393, 2013 29. Choi JH, Lee SS: Endoscopic ultrasonography-guided gallbladder 19. Simorov A, Ranade A, Parcells J, et al: Emergent cholecystostomy is drainage for acute cholecystitis: from evidence to practice. Dig superior to open cholecystectomy in extremely ill patients with Endosc 27:1-7, 2015