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: jeja-1004@daum.net

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

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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-

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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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