- Email: [email protected]
Endoscopic Ultrasound–Guided Cholecystoduodenostomy for Acute Cholecystitis in a Patient With Thrombocytopenia and End-Stage Liver Disease Awaiting Transplantation
ELECTRONIC IMAGE OF THE MONTH Endoscopic Ultrasound–Guided Cholecystoduodenostomy for Acute Cholecystitis in a Patient With Thrombocytopenia and End-Stage Liver Disease Awaiting Transplantation Todd H. Baron, Steven Zacks, and Ian S. Grimm Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
42-year-old woman with autoimmune hepatitis–induced cirrhosis maintained on azathioprine and prednisone, medically controlled ascites, and a Model for End-Stage Liver Disease score of 18 was transferred for management of acute cholecystitis. Intermittent, progressive, right, upper abdominal pain developed over a 2-week period, which became continuous and progressively severe. Abdominal computed tomography from the referring hospital showed gallbladder distension with a thick wall, surrounding inflammatory changes, and a 2-cm stone in the neck. Transabdominal ultrasound showed a hydropic gallbladder with a thickened wall. Cholescintigraphy failed to show gallbladder uptake despite morphine administration. Laboratory examination showed a platelet count of 38,000/mm3 and a white blood count of 2.9/mm3. Physical examination showed a positive Murphy’s sign. The patient was deemed a prohibitive
A
risk for cholecystectomy. Ascites and thrombocytopenia precluded percutaneous drainage. The morning of the procedure her platelet count was 33,000/mm3. Two units of pooled platelets were given; a repeat platelet count was not obtained and no platelets were administered after the procedure. Endoscopic therapy was performed under general endotracheal anesthesia. A forward-viewing curvilinear therapeutic channel echoendoscope (TGF-UC180J; Olympus, Center Valley, PA) was used for the entire procedure. The endoscope was passed transorally to the duodenal bulb. Endoscopic ultrasound showed a thick-walled gallbladder with internal debris; gallbladder puncture was performed using a 19-G needle (Figure A) using color Doppler. Brown purulent fluid was aspirated. A 0.035-inch guidewire was coiled in the gallbladder lumen (Figure B, note large calcified gallstone). A cholecystoduodenostomy was
Clinical Gastroenterology and Hepatology 2015;13:e13–e14
ELECTRONIC IMAGE OF THE MONTH, continued created using a 10F electrocautery device (Cystotome; Cook Endoscopy, Winston-Salem, NC) (Figure C). The cystotome was chosen to provide an adequate diameter to allow passage of the 10F stent delivery system. It also coagulated any nonvisible small vessels to potentially reduce bleeding and obviated the need for balloon dilation of the tract. A 10-mm diameter, 10-mm long, biflanged, fully covered, self-expandable metal stent was deployed across the tract (Axios; Xlumena, Mountain View, CA) (Figure D), which drained copious amounts of pus (Figure E). A 7F, 4-cm long, double-pigtail, plastic stent was placed through the lumen. No adverse events occurred and the patient was discharged home the following day and remains well 1 month later. Nonsurgical gallbladder drainage usually is achieved percutaneously.1 Outcomes in high-risk patients are good, although with potential complications and a possible need for permanent external drainage. It can be performed transhepatically or transperitoneally.2 Transhepatic drainage is difficult in patients with cirrhosis and thrombocytopenia. Transperitoneal drainage is difficult in patients with ascites, and leakage can result in peritonitis. Endoscopic transduodenal cholecystostomy is an emerging nonsurgical approach for high-risk patients,3,4 particularly with the availability of newer covered selfexpandable metal stents that provide luminal apposition and prevent intraperitoneal leakage. Endoscopic transpapillary drainage is another option and can be performed without sphincterotomy,5 but carries a risk of pancreatitis. Guidewire passage through an obstructed cystic duct is technically challenging and only small-bore stents can be placed, which
e14
are prone to occlusion and might provide inadequate drainage. We believe transmural drainage is less likely to result in bleeding than percutaneous transhepatic drainage because the needle does not pass through the vascular liver and the use of Doppler allows avoidance of vessels during needle passage. Further data are needed to define the role of transmural (transduodenal, transgastric) drainage in cirrhotic patients as a bridge to liver transplantation and as destination therapy.
References 1.
Chang YR, Ahn YJ, Jang JY, et al. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery 2014; 155:615–622.
2.
Loberant N, Notes Y, Eitan A, et al. Comparison of early outcome from transperitoneal versus transhepatic percutaneous cholecystostomy. Hepatogastroenterology 2010;57:12–17.
3.
Choi JH, Lee SS, Choi JH, et al. Long-term outcomes after endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis. Endoscopy 2014;46:656–661.
4.
Baron TH, Topazian MD. Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc 2007;65:735–737.
5.
Itoi T, Coelho-Prabhu N, Baron TH. Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 2010;71:1038–1045.
Conflicts of interest Dr Baron is an advisor to Xlumena. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.09.001
42-year-old woman with autoimmune hepatitis–induced cirrhosis maintained on azathioprine and prednisone, medically controlled ascites, and a Model for End-Stage Liver Disease score of 18 was transferred for management of acute cholecystitis. Intermittent, progressive, right, upper abdominal pain developed over a 2-week period, which became continuous and progressively severe. Abdominal computed tomography from the referring hospital showed gallbladder distension with a thick wall, surrounding inflammatory changes, and a 2-cm stone in the neck. Transabdominal ultrasound showed a hydropic gallbladder with a thickened wall. Cholescintigraphy failed to show gallbladder uptake despite morphine administration. Laboratory examination showed a platelet count of 38,000/mm3 and a white blood count of 2.9/mm3. Physical examination showed a positive Murphy’s sign. The patient was deemed a prohibitive
A
risk for cholecystectomy. Ascites and thrombocytopenia precluded percutaneous drainage. The morning of the procedure her platelet count was 33,000/mm3. Two units of pooled platelets were given; a repeat platelet count was not obtained and no platelets were administered after the procedure. Endoscopic therapy was performed under general endotracheal anesthesia. A forward-viewing curvilinear therapeutic channel echoendoscope (TGF-UC180J; Olympus, Center Valley, PA) was used for the entire procedure. The endoscope was passed transorally to the duodenal bulb. Endoscopic ultrasound showed a thick-walled gallbladder with internal debris; gallbladder puncture was performed using a 19-G needle (Figure A) using color Doppler. Brown purulent fluid was aspirated. A 0.035-inch guidewire was coiled in the gallbladder lumen (Figure B, note large calcified gallstone). A cholecystoduodenostomy was
Clinical Gastroenterology and Hepatology 2015;13:e13–e14
ELECTRONIC IMAGE OF THE MONTH, continued created using a 10F electrocautery device (Cystotome; Cook Endoscopy, Winston-Salem, NC) (Figure C). The cystotome was chosen to provide an adequate diameter to allow passage of the 10F stent delivery system. It also coagulated any nonvisible small vessels to potentially reduce bleeding and obviated the need for balloon dilation of the tract. A 10-mm diameter, 10-mm long, biflanged, fully covered, self-expandable metal stent was deployed across the tract (Axios; Xlumena, Mountain View, CA) (Figure D), which drained copious amounts of pus (Figure E). A 7F, 4-cm long, double-pigtail, plastic stent was placed through the lumen. No adverse events occurred and the patient was discharged home the following day and remains well 1 month later. Nonsurgical gallbladder drainage usually is achieved percutaneously.1 Outcomes in high-risk patients are good, although with potential complications and a possible need for permanent external drainage. It can be performed transhepatically or transperitoneally.2 Transhepatic drainage is difficult in patients with cirrhosis and thrombocytopenia. Transperitoneal drainage is difficult in patients with ascites, and leakage can result in peritonitis. Endoscopic transduodenal cholecystostomy is an emerging nonsurgical approach for high-risk patients,3,4 particularly with the availability of newer covered selfexpandable metal stents that provide luminal apposition and prevent intraperitoneal leakage. Endoscopic transpapillary drainage is another option and can be performed without sphincterotomy,5 but carries a risk of pancreatitis. Guidewire passage through an obstructed cystic duct is technically challenging and only small-bore stents can be placed, which
e14
are prone to occlusion and might provide inadequate drainage. We believe transmural drainage is less likely to result in bleeding than percutaneous transhepatic drainage because the needle does not pass through the vascular liver and the use of Doppler allows avoidance of vessels during needle passage. Further data are needed to define the role of transmural (transduodenal, transgastric) drainage in cirrhotic patients as a bridge to liver transplantation and as destination therapy.
References 1.
Chang YR, Ahn YJ, Jang JY, et al. Percutaneous cholecystostomy for acute cholecystitis in patients with high comorbidity and re-evaluation of treatment efficacy. Surgery 2014; 155:615–622.
2.
Loberant N, Notes Y, Eitan A, et al. Comparison of early outcome from transperitoneal versus transhepatic percutaneous cholecystostomy. Hepatogastroenterology 2010;57:12–17.
3.
Choi JH, Lee SS, Choi JH, et al. Long-term outcomes after endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis. Endoscopy 2014;46:656–661.
4.
Baron TH, Topazian MD. Endoscopic transduodenal drainage of the gallbladder: implications for endoluminal treatment of gallbladder disease. Gastrointest Endosc 2007;65:735–737.
5.
Itoi T, Coelho-Prabhu N, Baron TH. Endoscopic gallbladder drainage for management of acute cholecystitis. Gastrointest Endosc 2010;71:1038–1045.
Conflicts of interest Dr Baron is an advisor to Xlumena. © 2015 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2014.09.001