Eric vanSonnenberg, MD â€¢¿ Horacio B. D'Agostino, Alan Lurie, MD2 â€¢¿ Robert R. Varney, MD
MD â€¢¿ Giovanna Casola, MD â€¢¿ David B. Hoyt, MD â€¢¿
Gallbladder Perforation and Bile Leakage: Percutaneous [email protected]
Three patients with spontaneous gallbladder perforation and one with an iatrogenic bile leak causing bile peritonitis were treated success fully by means of percutaneous catheter drainage. Three patients had cholelithiasis as the cause of perforation; the fourth patient had previously undergone gallstone dis solution with methyl terf-butyl ether lavage and developed bile peritonitis a few hours after remov al of the catheter. In three patients, a percutaneous cholecystostomy catheter provided successful decom pression; in the fourth patient, drainage was performed with a per cutaneous sump catheter in the sub hepatic space adjacent to the gall bladder. No specific complications occurred. Follow-up was performed at 1, 12, 22, and 59 months, respec tively. To date, one of the four pa tients has undergone elective chole cystectomy (1 month after drain age). The remainder of the patients are asymptomatic. This preliminary experience suggests that the severe complication of gallbladder perfora tion and bile leakage may be treat ed, at least temporarily, by means of percutaneous drainage. Index terms: Cholecystitis, 762.285 â€¢¿ Callblad der, calculi, 762.289 â€¢¿ Gallbladder, interven tional procedure, 762.129 â€¢¿ Gallbladder, perfo ration, 762.285 Radiology
OMPLICATED medical illnesses and increasing age are factors that increase the frequency of mortal ity when cholecystectomy is per
formed for acute gallbladder disease. Several recent articles document treatment of acute calculous chole cystitis in high-risk patients by means of percutaneous cholecystos tomy (PC) (1â€”5).In this article, we
describe an expanded use of PCâ€”for treatment of frank perforation of the gallbladder or leakage of infected bile. PC or catheter
acute setting. PATIENTS
Four patients (two men and two wom Three
had an acute epi
sode of cholecystitis with septicemia due to gallstones. Each of these patients was considered high risk for surgery. Two pa tients were over 70 years old and had multiple
myocardia! infarction, renal failure, neu rovascular disorder); the third patient was dependent on a ventilator due to adult
respiratory distress syndome and pulmo nary emboli and had been in the inten sive care unit for over 1 month with multisystem organ failure. The fourth pa tient was 36 years old and had bile penito nitis, but was otherwise healthy. She had
accordance with U.S. Food and Drug Ad
Surgery (D.B.H.), University of California, San Diego, Medical Center, 225 Dickinson St. San Diego, CA 92103. Received June 25, 1990; revi sion requested August 14; revision received Oc tober 15; accepted November 12. Address re
print requests to E.V. 2 Current
Diego, Calif. c RSNA,
catheter (Medi-tech/Boston Scientific, Watertown, Mass), a 12-F sump catheter (Medi-tech), and one 8-F and one 10-F pigtail nephrostomy catheter (Cook, Bloo mington, md). Broad spectrum antibiotics
to each patient.
RESULTS Catheter drainage
acute perforation and leakage in each patient. The patients were treated with a combination of catheter drain age, antibiotics, and supportive mea sures until sepsis cleared tients were symptom-free. tient defervesced within
and the pa Each pa 48 hours,
resolved within 4
days in all patients.
vived the acute episode, and all are alive at follow-up. Catheters me mained in the patients for 14, 19, 30, and 36 days, respectively.
tens were removed when each patient was clinically well with respect to gallbladder infection and leakage (ie, sepsis resolved, condition at physical
examination improved, and bile drainage was clear). Cholecystogmams were obtained of two patients and me vealed patent cystic and bile ducts. Patients were followed-up at 1, 12,
22, and 59 months, respectively. Bile cultures were positive in all patients. Three patients had Escheri chia coli, one had entemococcus, one the hole in the gallbladder. All patients had Enterobactemiaceae, and one had werefebnile (101Â°â€”104.2Â°F [38Â°â€”39.7Â°C]), yeast (two patients had more than and had leukocytosis (white blood cell one organism). After the successful ministration-approved
US-guided drainage was performed and supplemented with use of fluorosco py in three patients. CT was used for guidance in one patient. Drainage cathe ters included a 7-F locking gallbladder
en) aged 36â€”83 years are included in the study.
percutaneous treatment of gallbladder perforation and peritonitis from bile leakage.
ted healing of four patients with a perforated gallbladder, obviating
gallstones and had undergone successful dissolution of multiple gallbladder calculi with methyl tert-butyl ether (MTBE) in
sent our entire
turned to the hospital 4 hours after ne moval of the PC catheter with symptoms and signs of acute bile peritonitis from
18.4 X 109/LJ) with a left shift. Perfora tion was documented sound (US), computed
by means of ultra tomography (CT),
These patients repre
MTBE methyl tert-butyl
ether, PC = percutaneous
gallbladder drainage, treatment for the gallstones was as follows: obser vation in two patients, contact disso lution by means of MTBE in one pa tient (Fig 1), and cholecystectomy in
one patient (Fig 2). In the latter pa tient, cholecystectomy was per formed 1 month after catheter drain
age, and the gallbladder be partially gangrenous
was found to with granu
lomatous reaction microscopically; at the time of the elective surgery, the
patient was not acutely ill, and he was ambulatory and pain-free. The patient with the bile leak after MTBE dissolution had the second PC cathe tem removed without problem 19 days
after the acute bile leak. The patient
has remained asymptomatic. Chole cystectomy was discussed with and
to all four patients;
of the four refused.
DISCUSSION The salient feature of these cases is that percutaneous drainage effective ly enabled the treatment of gallblad
der perforation and bile leakage with infection and allowed healing of the gallbladder. This method of therapy avoided cholecystectomy in the acute setting, and, to date, has obviated surgery in three of the four patients.
may have been lifesav
ing in the two high-risk patients with multiple medical problems
em than in healthier
great who un
dergo elective cholecystectomy. While
safe, morbidity rise markedly
and mortality in the elderly
with severe respiratory
with many controvem
Images of a 52-year-old
tostomy vary from 3.5% to over 20% (9,10), depending on the patient's physiologic state at the time of sum
with fever and sep
sis. (a) Transverse sonogram shows the lateral penicho!ecysticsubhepatic fluid collection (ar rows) due to gallbladder perforation. (b) Cholecystogram demonstrates the large, partially obstructing stone in the neck of the gallbladder (arrows); the gallbladder wall perforation exits laterally into the infected collection. (c) Cholecystogram obtained 12 days after PC shows that the perforation has healed. Obstruction from the stone is still present (arrows). Another stone is visualized in the midportion of the gallbladder (arrowheads). (d) Cholecys togram obtained 3 hours after administration of MTBE shows that the stones are dissolved and the cystic duct is patent.
with acute cholecystitis
life-threatening arrhythmia; howev em,catheter injection of contrast ma
healing of the gallbladder
were effective in our patients. We
curred with catheter decompression and antibiotics, despite proved perfo ration and bile leakage. Surgical principles suggest that perforation is
of necrosis, and necrosis
has been considered an indication for emergency surgery. In one study, the authors suspected gallbladder perfo ration and used PC to cure an elderly
have been reported
tenial did not confirm perforation (11). The most interesting pathophysio logic finding in our patients was that
requires emergent removal and de bnidement of tissue. The one patient who underwent cholecystectomy, 4
due to gallstones
14). As in the these clinical life-threatening percutaneous last resort. A
gery. Hydrops, empyema of the gall bladder, and calculous and acalculous cholecystitis of the gallbladder with out perforation have been drained ef fectively by means of percutaneous cholecystostomy (1â€”5).Perforated in
siesâ€”mncluding indications for use, frequency of use, and advisability in relation to cholecystectomy. In addi tion,
myocamdial disease, sepsis, and frank gallbladder perforation (6â€”8).Even cholecystostomy was considered to be a high risk in these patients; it is
weeks after PC, had a partially gan gmenous gallbladder at surgery with a granulomatous reaction microscopi cally,
was asymptomatic. Successful percu taneous catheter drainage of con tained abscesses in the pancreas and gastrointestinal tract that were com
patients in this series, situations are usually emergencies, and treatment is used as a variety of catheters
catheter. This catheter is easy to in sent and may be used for drainage or dissolution therapy (15). Follow-up has been expectant for two patients in our series. Neither has had recurrence of symptoms at 12 and 59 months. One of these patients continues to have gallstones; the oth em had
the bile leak. A third patient under went gallstone dissolution with MTBE 3 weeks after PC. Follow-up cholecystograms of that patient docu mented closure of the perforation prior to solvent infusion. The patient
has been asymptomatic
with no stone March 1991
â€œ¿necessitatesâ€• as perforation
into the peritoneum
soft tissues. (a) CT scan shows the gall
stones (arrowheads). (b) Percutaneous catheter placed through the overlying purulent collection into the gallbladder by using CT guidance. This route was chosen rather than the conventional transhepatic approach to enable the additional drainage of the soft-tissue abscess. (c) Af ter removal
of 75 cm3 of pus, the gallbladder
soft tissues are decompressed.
The acute episode
and the patient
derwent elective cholecystectomy 1 month later.
recurrence for almost 2 years. The fourth patient underwent an elective
Acknowledgments: Our appreciation to Mi chae! Bauman, RT, and Peggy Chambers.
In this small series, percutaneous treatment was a potentially lifesav ing option for patients with gallblad der perforation. In cases of perfoma tion, PC allows decompression of bile and prevents continued leakage, while allowing the perforation to seal. This suggests that catheter drainage can be used to treat bile peritonitis from gallbladder leakage in the acute setting. Failure of symp toms and signs of sepsis and pemitoni tis to resolve
broad the applicability of this treat ment is, whether the benefits are temporary, and if PC may be used as a definitive front-line therapy in se lected patients. U
Volume 178 â€¢¿ Number 3
McGahan P, Lindfors KK. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology 1989; 172:481-486. Lohela P, Soiva M, Suramo I, Taavitsainen
M, Holopainen 0. Ultrasonic guidance
taneous therapy and indicates the need for emergency surgery. Further studies
for percutaneous puncture and drainage in acute cho!ecystitis. Acta Radio! [Diagn] 1986; 27:543â€”546. Shaver RW, Hawkins IF Jr. Soong J. Per cutaneous cholecystostomy. AJR 1982; 138:1133â€”1136. vanSonnenberg E, Wittich CR, Casola C, et a!. Diagnostic and therapeutic percuta neous gallbladder procedures. Radiology 1986; 160:23-26. Vogelzang RL, Nemcek AA Jr. Percuta neous cholecystostomy: diagnostic and therapeutic efficacy. Radiology 1988; 168:29-34. Alexander 5, McA!pine FS. Cholecystec tomy in the cardiac patient. Med Clin North Am 1966; 50:495-500. Glenn F, Wantz C. Acute cholecystitis following the surgical treatment of unre lated disease. Surg Gynecol Obstet 1956; 102:145-153. !bach JR. Hume HA, Erb WH. Cholecys tectomy in the aged. Surg Gynecol Obstet 1968; 126:523-528.
Welch JP, Malt RA. Outcome of cholecys tostomy. Surg Gynecol Obstet 1972; 135:717-720. 10. Glenn F. Cholecystostomy in the high risk patient with biliary tract disease. Ann Surg 1977;185:185â€”191. 11. Longmaid HE III, Bassett JC, Cottlieb H. Management of gallbladder perforation by percutaneous cholecystostomy. Crit Care Med 1985; 13:686-687. 12. Steiner E, Mueller PR, Hahn PF, et a!. Complicated pancreatic abscesses: prob lems in interventiona! management. Radi ology 1988; 167:443-445. 13. vanSonnenberg E, Wittich CR, Casola C, et a!. Complicated pancreatic inflamma tory disease: diagnostic and therapeutic role of interventiona! radiology. Radiolo gy 1985; 155:335â€”340. 14. Neff CC, Lawson DW. Boerhaave syn drome: interventional radiologic manage ment. AJR 1985; 145:819â€”821. 15. vanSonnenberg E, D'Agostino, HB, Casola
C, Varney RR, Ainge GD. Interventiona! radiology in the gallbladder: diagnosis, drainage, dissolution, and management stones. Radiology 1990; 174:1-6.
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