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Korean J Gastroenterol Vol. 65 No. 6, 370-374http://dx.doi.org/10.4166/kjg.2015.65.6.370pISSN 1598-9992 eISSN 2233-6869
CASE REPORT
Korean J Gastroenterol, Vol. 65 No. 6, June 2015www.kjg.or.kr
수술 위험도가 높은 다장기 부전을 동반한 급성담낭염 환자에서 병상에서의 초음파유도하 경위 담낭 흡인 및 세척
윤소희, 박문식, 이재운, 양민아, 한상훈, 이영재, 정금모, 조용근, 김지웅, 조진웅
서남대학교 의과대학 예수병원 소화기내과
Bedside Endoscopic Ultrasound-guided Transgastric Gallbladder Aspiration and Lavage in a High-risk Surgical Case Due to Acute Cholecystitis Accompanied by Multiorgan Failure
So Hee Yun, Moon Shik Park, Jae Un Lee, Min A Yang, Sang Hoon Han, Young Jae Lee, Geum Mo Jeong, Yong Keun Cho, Ji Woong Kim, and Jin-Woong Cho
Department of Gastroenterology, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
Cholangitis and cholecystitis are intra-abdominal infections that show poor prognosis upon progression to sepsis and multiorgan failure. Administration of antibiotics with high antimicrobial susceptibility and removal of infected bile at the initial treatment are important. After undergoing ERCP for diagnostic purposes, a 58-year-old man developed acute cholangitis and cholecystitis accompanied by rhabdomyolysis, multi-organ failure, and severe sepsis. Broad-spectrum antibiotics with bedside endoscopic nasobiliary drainage were administered, but clinical symptoms did not improve. Therefore, bedside EUS-guided transgastric gallbladder aspiration and lavage was performed, resulting in successful treatment of the patient. We report the above described case along with a discussion of relevant literature. (Korean J Gastroenterol 2015;65:370-374)
Key Words: Sepsis; Rhabdomyolysis; Cholangitis; Cholecystitis; Endosonography
Received October 10, 2014. Revised December 14, 2014. Accepted December 18, 2014.CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Copyright © 2015. Korean Society of Gastroenterology.
교신저자: 조진웅, 560-750, 전주시 완산구 서원로 365, 예수병원 소화기내과Correspondence to: Jin-Woong Cho, Department of Gastroenterology, Presbyterian Medical Center, 365 Seowon-ro, Wansan-gu, Jeonju 560-750, Korea. Tel: +82-63- 230-1310, Fax: +82-63-230-1309, E-mail: [email protected]
Financial support: None. Conflict of interest: None.
INTRODUCTION
Bacteremia has been reported in 15% and 27% of diag-
nostic and therapeutic cases of ERCP, respectively. Most cas-
es of post-ERCP bacteremia are temporary phenomena
which rarely cause problems from a clinical perspective.1
Cholangitis occurs in only 0.57% to 0.87% of cases, whereas
cholecystitis occurs in 0.2%;2,3 however, because they can
progress to sepsis, multiorgan failure, and eventually death,
implementation of an aggressive treatment protocol from the
initial treatment is necessary.
We experienced a patient with post-ERCP acute chol-
angitis and cholecystitis accompanied by rhabdomyolysis,
multi-organ failure, and severe sepsis who was treated suc-
cessfully with endoscopic nasobiliary drainage (ENBD) and
bedside EUS-guided transgastric gallbladder aspiration and
lavage. The authors report the current case to demonstrate
usefulness of bedside EUS-guided transgastric gallbladder
aspiration and lavage as an alternative method in the
high-risk group of cholecytectomy.
CASE REPORT
A 58-year old man was admitted to the current hospital be-
Yun SH, et al. EUS-guided Gallbladder Aspiration and Lavage in Acute Cholecystitis 371
Vol. 65 No. 6, June 2015
Fig. 1. (A) MRCP; normal bile duct andpancreatic duct. (B) Duodenoscopic finding (TJF 260V; Olympus, Tokyo, Japan); a bulging ampulla of vater. (C) ERCP; no definitive distal common bile duct filling defect by balloon catheter with iopamidol enhance-ment. (D) Plain abdominal radio-graphy; complete contrast enhance-ment in the gallbladder and bile ducttwo days after ERCP.
cause of an abdominal CT finding of a 3.55 mm lesion in the
distal common bile duct at a local clinic. The patient was re-
cently diagnosed with hypertension and had a 20-year his-
tory of alcohol consumption of 80 g a day. The complete blood
counts were as follows; hemoglobin 12.0 g/dL, white blood
cells 5,700/mm3 (with a neutrophil count of 37%) and plate-
lets 252,000/mm3. The blood chemistry was as follows; se-
rum glutamic oxaloacetic transaminase (SGOT) 20 U/L, se-
rum glutamic pyruvic transaminase (SGPT) 29 U/L, ALP 375
IU/L, GGT 148 U/L, albumin 4.5 g/dL, total bilirubin 0.4
mg/dL, amylase 57 U/L, lipase 66 U/L, BUN 25 mg/dL, crea-
tinine 0.9 mg/dL, HBsAg negative, hepatitis B surface anti-
body negative, HCV antibody negative, and CA 19-9 3.0
U/mL. MRCP performed to examine the lesion on the distal
common bile duct minutely found no evidence of bile duct di-
lation or a mass (Fig. 1A). On ERCP for a definitive diagnosis
of a distal biliary lesion, a bulging papilla was detected (Fig.
1B), and following injection of the bile duct with 20 mL of 30%
iopamidol diluted with saline as contrast medium using a bal-
loon catheter a normal biliarygram was observed with no par-
ticular findings of interest (Fig. 1C).
Two days after ERCP, the patient complained of high fever
and shortness of breath. His urine output decreased to 30 mL
per hour. The complete blood counts were as follows; hemo-
globin 13.3 g/dL, white blood cells 11,200/mm3 (with a neu-
trophil count of 80%), and platelets 250,000/mm3. The
blood chemistry was as follows; SGOT 946 U/L, SGPT 581
U/L, ALP, 715 IU/L, GGT 1,021 U/L, total bilirubin 1.4 mg/dL,
myoglobin 15,593 ng/mL, creatine phosphokinase 3,480
U/L, lactate dehydrogenase 2,470 IU/L, BUN 40 mg/dL, cre-
atinine 3.8 mg/dL, amylase 41 U/L, and lipase 40 U/L. The
results of arterial blood gas analysis showed metabolic
acidosis of the following values: pH 7.045, oxygen partial
pressure 68.3 mmHg, carbon dioxide partial pressure 36
mmHg, bicarbonate 9.6 mmol/L, and base excess minus
19.8 mmol/L. Therefore, we diagnosed the patient with a
post-ERCP acute cholangitis and cholecystitis accompanied
by rhabdomyolysis, multiorgan failure, and severe sepsis. On
plain abdominal radiography, the gallbladder and bile duct
were completely filled with contrast medium (Fig. 1D). A sim-
ple chest radiograph also showed diffusely increased density
in both lung fields. The patient was transferred to the in-
tensive care unit (ICU) to begin application of mechanical
ventilation and continuous renal replacement therapy.
Extended-spectrum -lactamase-positive Escherichia coli was detected in the blood cultures, thus broad-spectrum an-
372 윤소희 등. 급성담낭염에서 초음파유도하 담낭 흡인 및 세척
The Korean Journal of Gastroenterology
Fig. 2. (A) The gallbladder and common bile duct showing complete enhancement with surrounding fluid collection on the hepato-biliary CT scan 3 days after ERCP. (B) Adherenceof an inflamed gallbladder wall to adjacent stomach on the CT scan 3 days after ERCP. (C) EUS; the gall-bladder and stomach walls attached because of the inflammation and internal heterogenous echogenicity with irregular thickened gallbladder wall. (D) EUS-guided trans-gastric gall-bladder aspiration and lavage using a19-gauge needle (G52012, ECHO- HD-19-A; Cook Medical, Limerick, Ireland).
tibiotics were administered. However, the patient’s clinical
symptoms and blood test results worsened. Therefore, a hep-
ato-biliary CT scan was taken 3 days after ERCP. The gall-
bladder and bile duct were still filled with contrast medium
despite 3 days after ERCP (Fig. 2A) and gallbladder wall thick-
ness measuring 4.8 mm, gallbladder distension, peri-chol-
ecystic fluid collection, and adherence of an inflamed gall-
bladder wall to the adjacent stomach were observed on the
CT scan (Fig. 2B). Biliary drainage for removal of infected bile
was required at 6 days after ERCP. We used duodenoscopy
(TJF 260V; Olympus, Tokyo, Japan) and then performed bed-
side ENBD in ICU after confirming location of the drainage
catheter by aspirating the bile within the bile duct without flu-
oroscopic guidance, and maintained frequent irrigation.
Until nine days after ERCP, the volume of pus and bile drain-
age was reduced at 100 mL per day, and the clinical symp-
toms did not show improvement. Thus, bedside EUS-guided
transgastric gallbladder aspiration and lavage were per-
formed for treatment of the cholecystitis. On EUS (UCT 240;
Olympus), the gallbladder wall was severely swollen and the
gallbladder was filled with inhomogenous low-echogenic
materials. The gallbladder and stomach walls became at-
tached because of inflammation (Fig. 2C). Accordingly, a
19-gauge needle (G52012, ECHO-HD-19-A; Cook Medical,
Limerick, Ireland) was used to perform EUS-guided trans-
gastric gallbladder aspiration on the distal antrum for drain-
age of pus and lavage with normal saline (Fig. 2D). After
EUS-guided aspiration and lavage, approximately 1,000 mL
of pus and bile were drained per day through the existing
ENBD. Body temperature was normalized, and the results of
blood test showed gradual improvement. The patient’s urine
volume showed a gradual increase, which warranted dis-
continuation of dialysis and he was discharged after 57 days
with procedure of EUS-guided aspiration and lavage.
DISCUSSION
Post-ERCP sepsis is a rare complication reported in 3.4%
and 0.16% of therapeutic and diagnostic ERCP cases,
respectively.4 Risk factors for developing cholangitis, chol-
ecystitis, and sepsis include biliary dilatation, biliary stent in-
sertion, prolonged total procedure time, hilar cholangio-
carcinoma, overzealous injection of contrast medium, and in-
adequate disinfection of endoscopic equipment. Most of the
aforementioned risk factors are associated with incomplete
drainage of the bile duct,4,5 in which case the mechanism that
Yun SH, et al. EUS-guided Gallbladder Aspiration and Lavage in Acute Cholecystitis 373
Vol. 65 No. 6, June 2015
causes sepsis can be explained by biliary-venous reflux.
According to a study on the relationship between biliary-ve-
nous reflux and biliary pressure, biliary-venous reflux begins
to occur at a biliary pressure of 22 cmH2O. When the biliary
pressure exceeds 30 cmH2O, bacteria within the bile duct
can cause bacteremia through systemic circulation.6 Even in
the current case, the contrast medium was not drained well
after the ERCP, which is believed to be the result of the ERCP
procedure followed by edema of the ampulla of Vater, gall-
bladder dysfunction, and dysfunction of the ampulla of Vater.
Enteric bacteria are a common pathogen of infection that
occurs after ERCP. Investigation of microflora in bile aspi-
rates of patients with acute cholecystitis found that E. coli (29.7%) and Klebsiella pnemoniae (27%) were the most
common.7 Rhabdomyolysis can be accompanied by chole-
cystitis. According to Kim et al.,8 4% of rhabdomyolysis cases
in South Korea are caused by infection; and associated with
bacteria, including Legionella, Francisella tularensis,
Meningococcus, Hemophilus influenza, Streptococcus,
Salmonella, E. coli, Leptospirosis, Coxiella burnetii, Staphy-lococcus, Pseudmonas, Klebsiella, Enterococcus faecalis,
and Bacteroide.9 Even in the current patient, E. coli was found
in the blood culture and was therefore suspected to be the
causal organism of the sepsis and rhabdomyolysis.
Acute cholecystitis results in closure of the cystic duct and
induces inflammation from stimulation of the concentrated
bile within the gallbladder. As a result, chemical cholecystitis
occurs and the bacterial infection is exacerbated. The result-
ing increase in the gallbladder wall tension causes a gradual
decrease in the vascular supply, which progresses to tension
gangrene and perforation.10 Consequently, gallbladder de-
compression, which decreases the gallbladder wall tension
and drains the concentrated and infected bile within the gall-
bladder, is a very important treatment.
Although cholecystectomy is the definitive treatment of
gallbladder decompression in acute cholecystitis, various other
conservative methods such as bridging or definitive therapy are
applied for treatment of the elderly and high-surgical risk group.
Percutaneous transhepatic gallbladder drainage (PTGBD)
is a well-established alternative drainage method used in the
high-risk group and the rates of technical success of and clin-
ical response to this procedure were 100% and 90%,
respectively.11 In addition, endoscopic transpapillary gall-
bladder drainage by naso-biliary gallbladder drainage tube or
stent has been used, but technical success rate as low as
64-81% has been reported.12,13 A recent study reported a
100% success rate for EUS-guided transmural gallbladder
drainage using double-pigtail plastic stent.14 In addition, a
covered self-expandable metal stent upgrading the plastic
stent showed a 100% success rate and despite the fact that
2 of the 15 patients who received the covered self-ex-
pandable metal stent developed posttreatment pneumo-
peritoneum, all of the patients achieved complete recovery
through conservative treatments.15
No research has reported on EUS-guided gallbladder aspi-
ration and lavage, and most studies have been related to per-
cutaneous gallbladder aspiration; however, usefulness of as-
piration and lavage itself can be ascertained from these
studies. In a prospective randomized trial comparing a group
treated with antibiotics only and another group treated with
ultrasound-guided percutaneous aspiration and lavage for
acute cholecystitis, Salim16 reported that clinical symptoms
and hematological improvements were significantly higher in
the latter group, thus demonstrating the effectiveness of as-
piration and lavage in treatment of cholecystitis. In a study
comparing PTGBD and aspiration, the success rates were
100% and 82%, respectively. The 18% failure rate of the aspi-
ration group using a 21-gauge needle was attributed to the
high viscosity of bile due to sludge and pus. However, 61% of
the patients who received aspiration showed significant im-
provements in clinical responses.17 Tsutsui et al.18 reported
on the effectiveness of repetitive aspiration; the drainage ef-
fect of the initial aspiration was 71%, and the second aspira-
tion increased the effectiveness of the drainage up to 96%.
As a study comparing EUS-guided gallbladder drainage
(EUS-GBD) and PTGBD, EUS-GBD and PTGBD showed similar
technical (75% vs. 97%) and clinical (100% vs. 96%) success
rates. Similar complication rates were also reported (7% vs. 3%) and adverse events reported in the study were pneumo-
peritoneum in the EUS-GBD group and hemobilia in the
PTGBD group and all patients recovered through con-
servative treatment.19 The reported incidence of bleeding as
the most serious complication of PTGBD is 2.5%20 and the re-
ported complications of EUS-GBD are bile peritonitis, pneu-
moperitoneum, and stent migration. Determining exact in-
cidence of complication is difficult because no large pop-
ulation based studies of EUS-GBD have been reported; how-
ever, all patients recovered through conservative treat-
374 윤소희 등. 급성담낭염에서 초음파유도하 담낭 흡인 및 세척
The Korean Journal of Gastroenterology
ment.14,15,19 In addition, the authors reported that the ad-
vantage of EUS-GBD compared with PTGBD was the sig-
nificantly lower procedure pain score.19
Unfortunately, since no study comparing EUS-guided gall-
bladder aspiration and lavage and PTGBD has been re-
ported, studies related to the effectiveness and safety of
EUS-guide aspiration and lavage are needed in the future.
However, we can predict that their effectiveness and safety
are similar to those of EUS-GBD because there is the process
of bile aspiration during the procedure of EUS-GBD. The ad-
vantages of EUS-guided aspiration and lavage comparable
with EUS-GBD and PTGBD are that the procedure can be per-
formed at beside without fluoroscopy guidance and is useful
in patients with large amounts of perihepatic fluid collection
due to inflammation. The current patient showed a high surgi-
cal risk and restricted mobility due to the ongoing treatments
with mechanical ventilation and hemodialysis in the ICU.
Accordingly, we performed bedside EUS-guided gallbladder
aspiration and lavage, resulting in effective treatment of the
cholecystitis accompanied by multiorgan failure.
Consequently, the authors conclude that gallbladder aspi-
ration and lavage for acute cholecystitis can be a useful alter-
native method for patients with high-surgical risk or difficulty
with gallbladder drainage.
ACKNOWLEDGEMENTS
The authors would like to express our deepest gratitude to
Dr. Kyung Hee No, Department of Radiology, Presbyterian
Medical Center for his sincere comments.
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