Endoscopic management of a perforated gallbladder

An 88-year-old woman with obesity (body mass index 40 kg/m²), diabetes, and heart failure presented with acute cholecystitis. Computed tomography (CT) showed a distended gallbladder with a large stone ([Fig. 1]). She was started on intravenous fluids and antibiotics. After 5 hours into her admission, she began to become lethargic and had increasing tachycardia. The patient was deemed a nonsurgical candidate owing to her comorbidities and age. Given the recent evidence [1], the patient was referred for endoscopic ultrasound (EUS)-guided drainage after multidisciplinary discussion.

Fig. 1 Computed tomography showed a distended gallbladder with a large stone.

On EUS, free fluid was noted around the gallbladder, which was consistent with a perforated gallbladder ([Fig. 2], [Video 1]) and explained the clinical deterioration. The decision was made to drain the gallbladder where the gallbladder wall was intact. A 10 × 10 mm lumen-apposing metal stent (LAMS) was placed into the gallbladder through a site of intact wall in a transduodenal approach ([Fig. 3]). Repeat CT scan was performed after the procedure given the suspicion of a perforated gallbladder, and confirmed the diagnosis ([Fig. 4]). The LAMS was positioned away from the perforation on CT and was in place in the gallbladder. The patient was discharged 7 days later with resolution of symptoms and normalization of laboratory values.

Fig. 2 Endoscopic ultrasound showed free fluid around the gallbladder, consistent with a perforated gallbladder.

Video 1 Endoscopic management of a perforated gallbladder.

Fig. 3 Endoscopic image showing a lumen-apposing metal stent, which was placed in a transduodenal approach into the gallbladder at a site of intact wall.

Fig. 4 Computed tomography scan after the procedure confirmed a perforated gallbladder.

CT scan at 8 weeks showed resolution of the gallbladder perforation, with the LAMS in place ([Fig. 5]). Endoscopy was performed, and the stent and gallstone were removed. Contrast was injected into the gallbladder and showed no further filling defects in the entire biliary system. On 4-week follow-up the patient was doing well without any symptoms.

Fig. 5 Computed tomography scan 8 weeks after the procedure showing resolution of a perforated gallbladder.

This case demonstrates that EUS-guided drainage can be effective in patients with acute cholecystitis who are unsuitable for surgery, even when a perforated gallbladder is suspected. It is important to place the LAMS at a site of intact gallbladder wall.

Endoscopy_UCTN_Code_CCL_1AF_2AF_3AB

Publikationsverlauf

Artikel online veröffentlicht:
27. August 2021

• Reference

• 1 Teoh AYB, Kitano M, Itoi T. et al. Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: an international randomised multicentre controlled superiority trial (DRAC 1). Gut 2020; 69: 1085-1091