Teaching Case

A patient with a history of chronic renal and pulmonary insufficiency, presented with right upper abdominal pain and positive Murphy sign.

The patient had a history of chronic renal and pulmonary insufficiency and presented with right upper abdominal pain, positive Murphy sign and positive biochemical tests, typical for acute cholecystitis and jaundice. Ultrasonography (US) revealed a distented gallbladder of 14x5 cm, partially filled with bile sludge. A round cystic mass of 6 cm diameter was found on the pancreatic head and was considered to be a pseudocyst, due to previous history of pancreatitis. Intra- and extrahepatic bile ducts were dilated causing jaundice. Surgery and endoscopy were excluded because the patient was in high surgical risk, so percutaneous treatment was favored. Percutaneous cholecystostomy (PC) with a 8 Fr locking pigtail catheter (Boston Scientific, Watertown, MA, USA) was performed under US-guidance (Fig.1a). Subsequently computed tomography (CT) after transcatheteral injection of diluted contrast medium confirmed the findings, showing the opacified common bile duct obstructed by external pressure of the pseudocyst (Fig.1b). Under CT-guidance, percutaneous drainage of the pseudocyst was performed. Despite double draining, bilirubin level didn't decrease satisfactorly, and in order to spare a new transhepatic biliary drainage, we transformed the PC- to a biliary catheter by catheterizing the cystic and common bile duct (Fig.2a). Opacification of the pseudocyst revealed a communication with the pancreatic duct (Fig.2b). One month later the pseudocyst was smaller but the communication to the pancreatic duct still patent. We decided to replace the biliary catheter with a plastic endoprosthesis, but the stent migrated immediately into the duodenum where it stayed for one month. So we had to keep the biliary catheter in place and we finally retrieved the plastic stent through the gallbladder with help of a Nitinol Goose Neck Snare (Fig. 3a and b). Six weeks later, the pseudocyst stopped draining and new opacification showed no residual cavity, but the communication was still patent. However the catheter was removed because no stenosis in the distal pancreatic duct was seen (Fig. 4a). At the same time the biliary catheter was replaced by a PC-catheter (Fig. 4b). Two weeks later controll cholangiography opacified a normal biliary tree and US didn't disclose any collection recurrence, so that PC-catheter was also retrieved after a total period of 4 months. The patient is for the last 3 years disease free.

Percutaneous cholecystostomy is a well established method in high surgical risk patients. It can be the definitive treatment in cases of acalculous cholecystitis, while in cases of calculous one, further percutaneous lithotomy can be tried. Some patients with gallbladder lithiasis are of lower surgical risk after the initial drainage, so that they can be operated on. CBD stones can cause cholangitis and obstructive jaundice combined with acute cholecystitis. In such cases, if endoscopy is impossible, lithotomy through the cystic duct is the method of choice. If the CBD obstruction is caused by external pressure, due to lymph nodes enlargement, malignant obstruction of the distal CBD or benign disease such as pancreatic pseudocyst, additional percutaneous techniques can be performed like in our case. In malignant disease a metallic or plastic stent can be inserted through the cystic duct, without need of new transhepatic biliary puncture. Pseudocyst drainages have to be removed after the communicating fistula from the pancreatic duct is closed. In our case the fistula was after 3,5 months still patent but we removed the catheter because no distal stenosis was found. Would the pseudocyst increase in size, long term drainage or embolization of the fistula could be tried.