Clinical Radiology(1992)
45, 273-275
Technical Report: Percutaneous Cholecystostomy in Acute Acalculous Cholecystitis S. T A Y L O R ,
J. R A W L I N S O N *
and D. E. MALONE
Department of Radiology, McMaster University Medical Centre, Hamilton, Ontario, Canada, and *Department of Radiology, Queen Elizabeth Hospital, Gateshead, UK Acute. acalculous cholecystitis is a significant cause of morbidity and mortaliy in patients with other serious illnesses (Howard, 1981) and the mortality rate after surgical cholecystostomy may reach 15% (McGahan and Lindfors, 1989). Radiologically controlled percutaneous cholecystostomy is a safe, minimally invasive, procedure which may be curative (McGahan and Lindfors, 1989; Berger et aL, 1989). Both cases described here were successfully treated by percutaneous cholecystostomy. A modified Seldinger technique was used in one and a direct 'trocar' puncture in the other. Percutaneous cholecystostomy, which is technically relatively straightforward, is now the treatment of choice for acute acalculous cholecystitis. Taylor, S., R a w l i n s o n , J. & M a l o n e , D . E . ( 1 9 9 2 ) . Clinical Radiology 4 5 , 2 7 3 - 2 7 5 . T e c h n i c a l R e p o r t : Percutaneous
CASE
Cholecystostomy
in Acute Acalculous
REPORTS
Case 1. A 57-year-old male underwent a total gastrectomy for gastric carcinoma. A post-operative gastrografin study showed no anastomotic leak. On day 12 after the operation he became pyrexial (39°C) with a leucocytosis (30000 WBC/cm3). Ultrasound (US) showed a 3 cm subhepatic collection posterior to a sludge-containing but otherwise normal gall-bladder (Fig. 1). Percutaneous abscess drainage was performed under computed tomography (CT) guidance. Twenty millilitres of pus was aspirated. Sinography showed communication between the abscess cavity and the duodenal stump. At first he improved clinically but 2 days later fever recurred and he developed right upper quadrant (RUQ) pain and tenderness. US and CT showed satisfactory abscess drainage and a gall-bladder wall 'halo' due to oedema (Fig. 2a a n d b). A diagnosis of acute acalculous cholecystitis (AAC) was made. Percutaneous cholecystostomy (PC) was performed under combined US and fluoroscopic control following premedication with intramuscular atropine (0.6 mg). A 'Mitty-Pollack' co-axial needle system (a 22 cm long 22 G needle inside a 14 cm long 18 G co-axial metal sheath) (Baltaxe et al., 1984~ Cook, Bloomington, Indiana) was used. The tip of the 22 G needle was placed, transhepatically, in the gall-bladder under
Fig. 1 - Transverse US image (Case 1). The gall-bladder (closed arrow) is thin-walled and contains some sludge. The sonolucent abscess (open arrow, cursors) lies posteromedial to it. A, Aorta; I, IVC. Correspondence to: Dr D. E. Malone, Department of Radiology, McMaster U'nivers~ty Medical Centre, 1200 Main Street West, Hamilton, Ontario LSN 3Z5, Canada.
Cholecystitis
US control (Fig. 3) and the 18 G sheath component pushed over this until their tips coincided. The 22 G needle was removed and a 0.38 in exchange guide-wire was passed through the 18 G sheath and coiled in the gall-bladder. A n 8.3 F nephrostomy catheter (Cope, 1980; Cook) was placed over the guide-wire. This catheter was used because it has a retention loop (to prevent inadvertent dislodgement) and an internal metal cannula (to prevent the catheter from buckling during insertion). Black viscid bile, which was sterile on culture, was aspirated. He made a good recovery. A cholecystogram 7 days later showed a patent cystic duct and no stones (Fig. 4). The cholecystostomy tube was removed a week later. The duodenal fistula closed, the abscess drainage tube was removed and the patient went home 3 weeks after PC. A year later, he has had no symptoms attributable to his gall-bladder. Case 2. A 52-year-old male was transferred to the Intensive Care Unit from another hospital because of respiratory failure secondary to pneumonia complicated by bronchiolitis obliterans. Past medical history included myocardial infarction, cigarette smoking and alcoholism. He required mechanical ventilation. He developed anaemia and thrombocytopenia, left ventricular failure and adult respiratory distress syndrome. Alter 3 weeks on a ventilator right upper quadrant pain and tenderness were noted. US, performed in the intensive care unit, showed a dilatated sludge-filled gall-bladder with a thickened wall (Fig. 5). A diagnosis of acute acalculous cholecystitis was made and PC was planned. His platelet count was 50 000 (normal range 150 000--400 000). Six units of platelets were given intravenously in the 30 min before PC and a further six units over the next 2 h. A trocar kit specially designed for one-stage PC was used (McGahan, 1988; Cook). It consists of a central stylet, a stiffening cannula and a 6.7 F retention loop catheter. These fit together co-axially and form the trocar which is inserted under sonographic guidance. A skin incision was made at the point (identified by US) where the trocar was to be inserted. The angle at which the trocar was to be introduced was estimated with US and the distance from the skin to the middle of the gall-bladder lumen in this direction was measured. A forceps was clamped onto the trocar at this distance from the tip to prevent inadvertent puncture of the free gall-bladder wall (Fache, 1990). The trocar was introduced under US monitoring but its trocar tip was not clearly seen in the gall-bladder lumen. When the forceps touched the skin the central styler was withdrawn, a syringe was attached and aspiration was attempted. Bile was returned, the catheter was fed off the cannula and 200 ml o f bile were aspirated before the catheter was secured. There was no bleeding. The right upper quadrant symptoms and signs resolved. Three days later, a cholecystogram showed the cystic duct was still blocked; 10 days later a repeat study showed it was patent and there were no gall-stones. The catheter was left bzsitu. It remained patent and drained bile until his death 33 days later from intractable respiratory failure.
DISCUSSION A c u t e a c a l c u l o u s c h o l e c y s t i t i s a c c o u n t s f o r 5 - 1 0 % o f all
274
CLINICAL RADIOLOGY
Fig. 3-US-guided PC (sagittal image, right upper quadrant). The needle (arrowheads) has been introduced transhepatically, aiming to puncture the gall-bladderin the region of its extraperitonealattachment and provide a stable path for guide-wireand catheter insertion, g, Gallbladder; L, liver. (a)
(h) Fig. 2 (a) US and (b) CT images (Case 1). The wall of the gall-bladder is thick. It is centrally hypoechoic on US and low in attenuation on C T (the 'halo' sign of acute cholecystitis; arrows). The CT image (b) also shows pericholecystic fluid (open arrow) and the abscess drainage catheter (arrowhead).
cases of cholecystitis and typically occurs in patients with acute multisystem pathology (e.g. trauma, severe burns, major surgery, parenteral nutrition) (Orlando et al., 1983; Frazee et al., 1989)_ Many etiological factors have been proposed (Howard, 1981; Orlando et al., 1983; Kaminski et al., 1987). Untreated, short-term mortality may reach 35"/0 (Beckman et al., 1985). Gall-bladder decompression is usually curative (Eggermont et al., 1985; Berger et al., 1989). Long-term mortality rates up to 59%, due to severe multisystem disease, have been reported despite cure of the cholecystitis (McGahan and Lindfors, 1989). Diagnosis may be difficult. The patients may not, because of complex clinical problems/mechanical ventilation, be able to communicate. Unexplained fever, right upper quadrant tenderness and a high white cell count are the classical signs (Orlando et al., 1983). Biochemistry is often non-specifically abnormal. US shows a dilatated, often thick walled ( > 5 ram), gall-bladder containing
Fig. 4 - Contrast study via the cholecystostomy catheter (arrowheads on day 7 post-PC (Case l). There are no calculi; the cystic duct is patent. The abscess drainage catheter is indicated by curved arrows.
sludge but no stones (Eggermont et al., 1985). A hypoechoic gall-bladder wall 'halo' (Fig. 2a and b) is virtually diagnostic (Beckman et al., 1985). Pericholecystic fluid may be seen (Fig_ 5). PC may be performed in the intensive care unit under US guidance. An anterior transhepatic approach to the gall-bladder, aiming to puncture it proximally through the extraperitoneal attachment to the liver (Fig. 3) may reduce the risk of bile leakage. Passing the guide-wire and catheter through the liver helps stabilize them (McGahan and Lindfors, 1989). The fundus of the gall-bladder can
PC IN ACALCULOUS CHOLECYSTITIS
275
tic cholecystography is deferred for at least 36 h b u t is i m p o r t a n t as small stones m a y be missed o n US (Ekberg a n d Weiber, 1991). The tube is n o t removed until the cystic duct is k n o w n to be p a t e n t (Fig. 4) a n d a tube tract has had time to form (7 10 days) ( M c G a h a n , 1988). In seriously ill patients, whose ability to form a fibrous tract m a y be questionable, the P C tube c a n be left on free drainage. Late complications include bile peritonitis or recurrent acute cholecystitis following i n a d v e r t e n t / p r e m a t u r e catheter removal.
Acknowledgements. We thank Janet Kuc for her assistance with the manuscript.
REFERENCES
Fig. 5 - Sagittal US image of gall-bladder (Case 2). The gall-bladder is large and contains sludge.There is pericholecysticfluid (arrow). The free wall of the gall-bladder (+) does not appear thickened; there is oedema of the pericholecysticconnective tissue (arrowheads). be p u n c t u r e d directly if necessary (Fache, 1990). Technical options for PC are the modified Seldinger (Case 1) and trocar techniques (Case 2). The modified Seldinger technique m a y use either a co-axial needle (Case 1) or a coaxial dilatator set (Cope, 1984; Cook). A retention loop catheter should be used (Cope, 1980; Hawkins, 1985; M c G a h a n , 1988). I n Case 2 the trocar was n o t clearly seen on US a n d bile aspiration was used to confirm the correct position. H a d bile n o t been o b t a i n e d the trocar would have been slowly w i t h d r a w n while aspirating t h r o u g h the syringe. If bile were returned before complete withdrawal, the catheter would have been fed offthe cannula. If not, a second a t t e m p t would have been m a d e with the reassembled trocar (Fache, 1990). If the trocar tip is clearly seen in the gall-bladder l u m e n with US the catheter is simply fed off it and secured. I m m e d i a t e complications include sepsis and vagal reactions. B r o a d - s p e c t r u m antibiotics should be given before PC. Vagal reactions m a y lead to h y p o t e n s i o n or cardiac arrest (van S o n n e n b e r g et aL, 1984). Cardiovascular m o n i t o r i n g is essential a n d a t r o p i n e can either be given as premedtcation o r d r a w n up before P C for immediate use if needed. It is i m p o r t a n t to minimize guide-wire a n d catheter m a n i p u l a t i o n s . T h u s the 'onestage' trocar technique is the m e t h o d of choice. Coagu l a t i o n should be n o r m a l . Where necessary, t e m p o r a r y correction o f c o a g u l a t i o n defects enables PC to be performed, as in Case 2. T r a n s i e n t bile leakage d u r i n g PC m a y cause severe pain; it is i m p o r t a n t to be aware of this and to realize that it is n o t usually clinically significant (Treplick et al., 1990). The bile is usually sterile (Berger et al., 1989). D i a g n o s -
Baltaxe, HA, Mitty, HA & Pollack, HM (19843. Multipurpose coaxial needle used for percutaneous nephrostomy. Radiology, 153, 259. Beckman, l, Dash, N, Sefczej, R, Lupetin, AR, Anderson, JS, Diamond, DL et al. (1985). Ultrasonographic findings in acute acalculous cholecystitis. Gastrointestinal Radiology, 10, 387 389. Berger, H, Pratschke, E, Arbogast, H & Stabler, A (1989). Pcrcutaneous cholecystostomy in acute acaleulous cholecystitis. Hepato-Gastroenterology, 36, 346 348. Cope, C (1980). Improved anchoring of nephrostomy catheters: loop technique. American Journal of Roentgenology, 135, 402. 403. Cope, C (1984). Single stick percutaneous nephrostomy. Seminars in Interventional Radiology, 1, 1 4.
Eggermont, AM, Lameris, JS & Jeekel, J (1985). Ultrasound-guided percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis. Archives of Surgery, 120, 1354 1356. Ekbcrg, O & Weiber, S (1991). The clinical importance ofa thickwalled, tender, gall-bladder without stones on ultrasonography. Clinical Radiology, 44, 38 41. Fache, JS (1990). Transcholecystic intervention. Radiologic Clinics of North America, 28, 1157 1169. Frazee, RC, Nagornay, DM & Mucha, P (1989). Acute acalculous cholecystitis. Mayo Clinic Proceedings, 64, 163-167. Hawkins, 1F Jr (1985). Percutaneous cholecystostomy. Seminars in Interventional Radiology, 2, 97 103. Howard, RJ (1981). Acute acalculous cholecystitis.American Journal of Surgery, 141, 194-198. Kaminski, DL, Deshpanda, YG & Thomas, LA (1987). The role of prostaglandins E and F in acalculous gallbladder disease. Hepatogastroenterology, 34, 70-73. McGahan, JP (1988). A new catheter design for percutaneous cholccystostomy. Radiology, 166, 149 152. McGahan, JP & Lindfors, KK (19893. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology, 173, 481 485. Orlando, R, Gleason, E & Drezner, AD (1983). Acute acalculous cholecystitisin the criticallyill patient. American Journal of Surgery, 145, 472-476. Teplick, SK, Brandon, JC, Wolferth, CC, Amron, G, Gambescia, R & Zitomer, N (1990). Percutaneous interventional gallbladder procedures: personal experience and literature review. Gastrointestinal Radiology, 15, 133 136. van Sonnenberg, E, Wing, VW, Pollard, JW & Casola, G (19843. Life-threatening vagal reactions associated with percutancous cholecystostonry. Radiology, 151,377 380.
45, 273-275
Technical Report: Percutaneous Cholecystostomy in Acute Acalculous Cholecystitis S. T A Y L O R ,
J. R A W L I N S O N *
and D. E. MALONE
Department of Radiology, McMaster University Medical Centre, Hamilton, Ontario, Canada, and *Department of Radiology, Queen Elizabeth Hospital, Gateshead, UK Acute. acalculous cholecystitis is a significant cause of morbidity and mortaliy in patients with other serious illnesses (Howard, 1981) and the mortality rate after surgical cholecystostomy may reach 15% (McGahan and Lindfors, 1989). Radiologically controlled percutaneous cholecystostomy is a safe, minimally invasive, procedure which may be curative (McGahan and Lindfors, 1989; Berger et aL, 1989). Both cases described here were successfully treated by percutaneous cholecystostomy. A modified Seldinger technique was used in one and a direct 'trocar' puncture in the other. Percutaneous cholecystostomy, which is technically relatively straightforward, is now the treatment of choice for acute acalculous cholecystitis. Taylor, S., R a w l i n s o n , J. & M a l o n e , D . E . ( 1 9 9 2 ) . Clinical Radiology 4 5 , 2 7 3 - 2 7 5 . T e c h n i c a l R e p o r t : Percutaneous
CASE
Cholecystostomy
in Acute Acalculous
REPORTS
Case 1. A 57-year-old male underwent a total gastrectomy for gastric carcinoma. A post-operative gastrografin study showed no anastomotic leak. On day 12 after the operation he became pyrexial (39°C) with a leucocytosis (30000 WBC/cm3). Ultrasound (US) showed a 3 cm subhepatic collection posterior to a sludge-containing but otherwise normal gall-bladder (Fig. 1). Percutaneous abscess drainage was performed under computed tomography (CT) guidance. Twenty millilitres of pus was aspirated. Sinography showed communication between the abscess cavity and the duodenal stump. At first he improved clinically but 2 days later fever recurred and he developed right upper quadrant (RUQ) pain and tenderness. US and CT showed satisfactory abscess drainage and a gall-bladder wall 'halo' due to oedema (Fig. 2a a n d b). A diagnosis of acute acalculous cholecystitis (AAC) was made. Percutaneous cholecystostomy (PC) was performed under combined US and fluoroscopic control following premedication with intramuscular atropine (0.6 mg). A 'Mitty-Pollack' co-axial needle system (a 22 cm long 22 G needle inside a 14 cm long 18 G co-axial metal sheath) (Baltaxe et al., 1984~ Cook, Bloomington, Indiana) was used. The tip of the 22 G needle was placed, transhepatically, in the gall-bladder under
Fig. 1 - Transverse US image (Case 1). The gall-bladder (closed arrow) is thin-walled and contains some sludge. The sonolucent abscess (open arrow, cursors) lies posteromedial to it. A, Aorta; I, IVC. Correspondence to: Dr D. E. Malone, Department of Radiology, McMaster U'nivers~ty Medical Centre, 1200 Main Street West, Hamilton, Ontario LSN 3Z5, Canada.
Cholecystitis
US control (Fig. 3) and the 18 G sheath component pushed over this until their tips coincided. The 22 G needle was removed and a 0.38 in exchange guide-wire was passed through the 18 G sheath and coiled in the gall-bladder. A n 8.3 F nephrostomy catheter (Cope, 1980; Cook) was placed over the guide-wire. This catheter was used because it has a retention loop (to prevent inadvertent dislodgement) and an internal metal cannula (to prevent the catheter from buckling during insertion). Black viscid bile, which was sterile on culture, was aspirated. He made a good recovery. A cholecystogram 7 days later showed a patent cystic duct and no stones (Fig. 4). The cholecystostomy tube was removed a week later. The duodenal fistula closed, the abscess drainage tube was removed and the patient went home 3 weeks after PC. A year later, he has had no symptoms attributable to his gall-bladder. Case 2. A 52-year-old male was transferred to the Intensive Care Unit from another hospital because of respiratory failure secondary to pneumonia complicated by bronchiolitis obliterans. Past medical history included myocardial infarction, cigarette smoking and alcoholism. He required mechanical ventilation. He developed anaemia and thrombocytopenia, left ventricular failure and adult respiratory distress syndrome. Alter 3 weeks on a ventilator right upper quadrant pain and tenderness were noted. US, performed in the intensive care unit, showed a dilatated sludge-filled gall-bladder with a thickened wall (Fig. 5). A diagnosis of acute acalculous cholecystitis was made and PC was planned. His platelet count was 50 000 (normal range 150 000--400 000). Six units of platelets were given intravenously in the 30 min before PC and a further six units over the next 2 h. A trocar kit specially designed for one-stage PC was used (McGahan, 1988; Cook). It consists of a central stylet, a stiffening cannula and a 6.7 F retention loop catheter. These fit together co-axially and form the trocar which is inserted under sonographic guidance. A skin incision was made at the point (identified by US) where the trocar was to be inserted. The angle at which the trocar was to be introduced was estimated with US and the distance from the skin to the middle of the gall-bladder lumen in this direction was measured. A forceps was clamped onto the trocar at this distance from the tip to prevent inadvertent puncture of the free gall-bladder wall (Fache, 1990). The trocar was introduced under US monitoring but its trocar tip was not clearly seen in the gall-bladder lumen. When the forceps touched the skin the central styler was withdrawn, a syringe was attached and aspiration was attempted. Bile was returned, the catheter was fed off the cannula and 200 ml o f bile were aspirated before the catheter was secured. There was no bleeding. The right upper quadrant symptoms and signs resolved. Three days later, a cholecystogram showed the cystic duct was still blocked; 10 days later a repeat study showed it was patent and there were no gall-stones. The catheter was left bzsitu. It remained patent and drained bile until his death 33 days later from intractable respiratory failure.
DISCUSSION A c u t e a c a l c u l o u s c h o l e c y s t i t i s a c c o u n t s f o r 5 - 1 0 % o f all
274
CLINICAL RADIOLOGY
Fig. 3-US-guided PC (sagittal image, right upper quadrant). The needle (arrowheads) has been introduced transhepatically, aiming to puncture the gall-bladderin the region of its extraperitonealattachment and provide a stable path for guide-wireand catheter insertion, g, Gallbladder; L, liver. (a)
(h) Fig. 2 (a) US and (b) CT images (Case 1). The wall of the gall-bladder is thick. It is centrally hypoechoic on US and low in attenuation on C T (the 'halo' sign of acute cholecystitis; arrows). The CT image (b) also shows pericholecystic fluid (open arrow) and the abscess drainage catheter (arrowhead).
cases of cholecystitis and typically occurs in patients with acute multisystem pathology (e.g. trauma, severe burns, major surgery, parenteral nutrition) (Orlando et al., 1983; Frazee et al., 1989)_ Many etiological factors have been proposed (Howard, 1981; Orlando et al., 1983; Kaminski et al., 1987). Untreated, short-term mortality may reach 35"/0 (Beckman et al., 1985). Gall-bladder decompression is usually curative (Eggermont et al., 1985; Berger et al., 1989). Long-term mortality rates up to 59%, due to severe multisystem disease, have been reported despite cure of the cholecystitis (McGahan and Lindfors, 1989). Diagnosis may be difficult. The patients may not, because of complex clinical problems/mechanical ventilation, be able to communicate. Unexplained fever, right upper quadrant tenderness and a high white cell count are the classical signs (Orlando et al., 1983). Biochemistry is often non-specifically abnormal. US shows a dilatated, often thick walled ( > 5 ram), gall-bladder containing
Fig. 4 - Contrast study via the cholecystostomy catheter (arrowheads on day 7 post-PC (Case l). There are no calculi; the cystic duct is patent. The abscess drainage catheter is indicated by curved arrows.
sludge but no stones (Eggermont et al., 1985). A hypoechoic gall-bladder wall 'halo' (Fig. 2a and b) is virtually diagnostic (Beckman et al., 1985). Pericholecystic fluid may be seen (Fig_ 5). PC may be performed in the intensive care unit under US guidance. An anterior transhepatic approach to the gall-bladder, aiming to puncture it proximally through the extraperitoneal attachment to the liver (Fig. 3) may reduce the risk of bile leakage. Passing the guide-wire and catheter through the liver helps stabilize them (McGahan and Lindfors, 1989). The fundus of the gall-bladder can
PC IN ACALCULOUS CHOLECYSTITIS
275
tic cholecystography is deferred for at least 36 h b u t is i m p o r t a n t as small stones m a y be missed o n US (Ekberg a n d Weiber, 1991). The tube is n o t removed until the cystic duct is k n o w n to be p a t e n t (Fig. 4) a n d a tube tract has had time to form (7 10 days) ( M c G a h a n , 1988). In seriously ill patients, whose ability to form a fibrous tract m a y be questionable, the P C tube c a n be left on free drainage. Late complications include bile peritonitis or recurrent acute cholecystitis following i n a d v e r t e n t / p r e m a t u r e catheter removal.
Acknowledgements. We thank Janet Kuc for her assistance with the manuscript.
REFERENCES
Fig. 5 - Sagittal US image of gall-bladder (Case 2). The gall-bladder is large and contains sludge.There is pericholecysticfluid (arrow). The free wall of the gall-bladder (+) does not appear thickened; there is oedema of the pericholecysticconnective tissue (arrowheads). be p u n c t u r e d directly if necessary (Fache, 1990). Technical options for PC are the modified Seldinger (Case 1) and trocar techniques (Case 2). The modified Seldinger technique m a y use either a co-axial needle (Case 1) or a coaxial dilatator set (Cope, 1984; Cook). A retention loop catheter should be used (Cope, 1980; Hawkins, 1985; M c G a h a n , 1988). I n Case 2 the trocar was n o t clearly seen on US a n d bile aspiration was used to confirm the correct position. H a d bile n o t been o b t a i n e d the trocar would have been slowly w i t h d r a w n while aspirating t h r o u g h the syringe. If bile were returned before complete withdrawal, the catheter would have been fed offthe cannula. If not, a second a t t e m p t would have been m a d e with the reassembled trocar (Fache, 1990). If the trocar tip is clearly seen in the gall-bladder l u m e n with US the catheter is simply fed off it and secured. I m m e d i a t e complications include sepsis and vagal reactions. B r o a d - s p e c t r u m antibiotics should be given before PC. Vagal reactions m a y lead to h y p o t e n s i o n or cardiac arrest (van S o n n e n b e r g et aL, 1984). Cardiovascular m o n i t o r i n g is essential a n d a t r o p i n e can either be given as premedtcation o r d r a w n up before P C for immediate use if needed. It is i m p o r t a n t to minimize guide-wire a n d catheter m a n i p u l a t i o n s . T h u s the 'onestage' trocar technique is the m e t h o d of choice. Coagu l a t i o n should be n o r m a l . Where necessary, t e m p o r a r y correction o f c o a g u l a t i o n defects enables PC to be performed, as in Case 2. T r a n s i e n t bile leakage d u r i n g PC m a y cause severe pain; it is i m p o r t a n t to be aware of this and to realize that it is n o t usually clinically significant (Treplick et al., 1990). The bile is usually sterile (Berger et al., 1989). D i a g n o s -
Baltaxe, HA, Mitty, HA & Pollack, HM (19843. Multipurpose coaxial needle used for percutaneous nephrostomy. Radiology, 153, 259. Beckman, l, Dash, N, Sefczej, R, Lupetin, AR, Anderson, JS, Diamond, DL et al. (1985). Ultrasonographic findings in acute acalculous cholecystitis. Gastrointestinal Radiology, 10, 387 389. Berger, H, Pratschke, E, Arbogast, H & Stabler, A (1989). Pcrcutaneous cholecystostomy in acute acaleulous cholecystitis. Hepato-Gastroenterology, 36, 346 348. Cope, C (1980). Improved anchoring of nephrostomy catheters: loop technique. American Journal of Roentgenology, 135, 402. 403. Cope, C (1984). Single stick percutaneous nephrostomy. Seminars in Interventional Radiology, 1, 1 4.
Eggermont, AM, Lameris, JS & Jeekel, J (1985). Ultrasound-guided percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis. Archives of Surgery, 120, 1354 1356. Ekbcrg, O & Weiber, S (1991). The clinical importance ofa thickwalled, tender, gall-bladder without stones on ultrasonography. Clinical Radiology, 44, 38 41. Fache, JS (1990). Transcholecystic intervention. Radiologic Clinics of North America, 28, 1157 1169. Frazee, RC, Nagornay, DM & Mucha, P (1989). Acute acalculous cholecystitis. Mayo Clinic Proceedings, 64, 163-167. Hawkins, 1F Jr (1985). Percutaneous cholecystostomy. Seminars in Interventional Radiology, 2, 97 103. Howard, RJ (1981). Acute acalculous cholecystitis.American Journal of Surgery, 141, 194-198. Kaminski, DL, Deshpanda, YG & Thomas, LA (1987). The role of prostaglandins E and F in acalculous gallbladder disease. Hepatogastroenterology, 34, 70-73. McGahan, JP (1988). A new catheter design for percutaneous cholccystostomy. Radiology, 166, 149 152. McGahan, JP & Lindfors, KK (19893. Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis? Radiology, 173, 481 485. Orlando, R, Gleason, E & Drezner, AD (1983). Acute acalculous cholecystitisin the criticallyill patient. American Journal of Surgery, 145, 472-476. Teplick, SK, Brandon, JC, Wolferth, CC, Amron, G, Gambescia, R & Zitomer, N (1990). Percutaneous interventional gallbladder procedures: personal experience and literature review. Gastrointestinal Radiology, 15, 133 136. van Sonnenberg, E, Wing, VW, Pollard, JW & Casola, G (19843. Life-threatening vagal reactions associated with percutancous cholecystostonry. Radiology, 151,377 380.
