P0882 - Endoscopic Ultrasound Gallbladder Drainage to Treat...Hypoxia?

Mitchelle Zolotarevsky, MD¹, David Weinstein, MD², Susan Taylor, APN², Melissa Mullens, PA-C², Simon Che, MD², Kevin Ricci, MD², Jacqueline Kalmoe, MD², Edward C. Villa, MD^3
1University of Chicago, NorthShore Internal Medicine, Evanston, IL; ²NorthShore University Health System, Evanston, IL; ³University of Chicago, NorthShore Health Systems, Evanston, IL

Introduction: Endoscopic Ultrasound Gallbladder Drainage (EUS-GBD), is an effective therapy for patients with acute cholecystitis, particularly in patients who are not surgical candidates. We present a unique case of acute cholecystitis treated with EUS-GBD in a patient who had right lung compression from a markedly distended gallbladder with resulting hypoxia that precluded him from surgical intervention.

Case Description/Methods: An 82 year-old male presented to our institution with 4 days of acute onset right upper abdominal pain and right pleuritic chest pain with dyspnea experienced while traveling in East Asia. At presentation, he was found to be tachycardic and hypertensive and was in acute distress secondary to his pain. On exam, his abdomen was non-distended, but he did have diffuse abdominal tenderness to palpation without peritonitic findings on exam. Laboratory analysis revealed a mild leukocytosis of 10.9; total bilirubin of 2.0 mg/dL (direct bilirubin of 0.6 mg/dL) with normal alkaline phosphatase, aspartate aminotransferase (AST), and alanine transaminase (ALT). Computed tomography (Figure A) revealed no pulmonary embolism but demonstrated a markedly distended gallbladder with pericholecystic fat stranding and evidence of right hemidiaphragmatic and hepatic displacement and resulting right lower and right middle lung collapse.

Due to sudden hypoxia with tidal volumes on incentive spirometer of 130 ml, planned cholecystectomy was canceled. Interventional Radiology was consulted, but did not perform percutaneous cholecystostomy tube placement due to transthoracic approach to gallbladder drainage required. Our service was consulted for EUS-GBD.

EUS was performed under monitored anesthesia care (MAC) with endosonography demonstrating a distended gallbladder with large amount of sludge (Figure C). EUS-GBD with creation of a cholecystoduodenostomy was successfully performed using a 15 mm by 10 mm lumen-apposing metal stent (LAMS) with drainage of sludge, stones, and pus, and the LAMS was anchored with two 7 French double pigtailed plastic stents (Figure D). Cultures grew Escherichia Coli and Candida Albicans. Post-procedurally, patient’s course was notable for marked improvement in tidal volumes, oxygenation, pain and was subsequently discharged.

Discussion: EUS-GBD is a particularly effective strategy in patients with acute cholecystitis who are deemed inoperable and is safe even in patients with hypoxia related to gallbladder distention.



Disclosures:


Mitchelle Zolotarevsky, MD¹, David Weinstein, MD², Susan Taylor, APN², Melissa Mullens, PA-C², Simon Che, MD², Kevin Ricci, MD², Jacqueline Kalmoe, MD², Edward C. Villa, MD³. P0882 - Endoscopic Ultrasound Gallbladder Drainage to Treat...Hypoxia?, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.