Acute cholecystitis is a clinical diagnosis based on history, physical exam, laboratory values and imaging. The most common cause of acute cholecystitis is cystic duct obstruction from biliary stones (calculous cholecystitis) . Once the diagnosis of acute calculous cholecystitis is made, a surgical evaluation is warranted. The majority of patient will go on to surgical resection of the gallbladder. For patients with acute cholecystitis who are not surgical candidates, percutaneous cholecystostomy is indicated. The majority of PC’s placed are done in the IR suite or Radiology procedure room with CT or US and Fluoroscopy image guidance . Bedside cholecystostomy is indicated in patients who are too unstable to travel to IR suite for tube placement [7, 19].
There are no absolute contraindications to emergent PC placement if the procedure is life-saving. Relative contraindications include uncorrectable coagulopathy. In some cases it may not be possible to access the gallbladder percutaneously due to intervening bowel or because of gallbladder rupture and decompression.
In addition to calculous cholecystitis, percutaneous cholecystostomy is also indicated for acalculous cholecystitis, seen often in patients in intensive care, and pregnant women where medical treatment alone is unsuccessful . Acute acalculous cholecystitis is associated with a high morbidity and mortality and is thought to be a manifestation of systemic disease rather than a process confined to the gallbladder alone . Because it can be difficult to recognize clinical signs of acute acalculous cholecystitis and intensive care patients are often on antibiotics and pain medication as well as parenteral nutrition (increasing their risk), percutaneous cholecystostomy can be used as diagnostic and therapeutic procedure in patients with unexplained sepsis . For some, PC may be a definitive treatment for acalculous cholecystitis [1, 10].
In elderly patients with multiple comorbidities or poor general condition, percutaneous cholecystostomy can be performed safely and after removal a cholecystectomy can be performed with acceptable conversion rate .
In pregnant patients, acute cholecystitis is seen with lower frequency, 0.1%. The traditional management during pregnancy is conservative treatment; however, this may lead to prolonged treatment and more complications. Laparoscopic cholecystectomy is also available, though risks with anesthesia and surgery still provide significant drawbacks. For those patients with failure to respond to conservative management, percutaneous cholecystostomy is used as a temporizing measure, until the patient is able to have abdominal surgery post partum