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Percutaneous Cholecystostomy in the Management of Acute Cholecystitis

A 59-year-old man with endstage liver disease, portal hypertension, and suspected hepatocellular carcinoma presented with 3 days of anorexia, right upper quadrant abdominal pain, and nausea. Physical examination revealed right upper quadrant tenderness. The patient was afebrile with a white blood cell count of 6000/cubic millimeter. A contrast-enhanced computed tomography (CT) of the abdomen revealed gallbladder distention, pericholecystic inflammatory stranding, and multiple gallstones (Fig. 1). Ultrasound (US) revealed a thickened gallbladder wall and multiple gallstones (Fig. 2). Based on clinical and imaging findings, acute calculous cholecystitis was diagnosed. Given the patient’s significant comorbid conditions and estimated high risk of general anesthesia, a percutaneous cholecystostomy (PC) tube was placed using US and fluoroscopic guidance in the radiology department. An 8-French locking pigtail catheter was inserted into the gallbladder via the transhepatic approach using intravenous sedation and local anesthesia (Fig. 3). Culture of nonpurulent bile yielded Enterococcus and a-hemolytic streptococcus species. Based on culture results, the patient was started on intravenous piperacillin/ tazobactam. The patient’s nausea and abdominal tenderness resolved within 24 hours after PC tube placement. He was discharged on the fourth hospital day with the cholecystostomy tube to bag drainage, a 14-day course of oral amoxicillin/clavulanate, and scheduled for follow-up in surgery clinic to determine optimal timing of cholecystectomy.