Percutaneous Cholecystostomy Tubes versus Medical Management for Acute Cholecystitis

Background Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage. Materials and methods Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA. Results 776,766 patients were included in the analysis. The population receiving PCT placement was on average 16 years older (69.9 vs 53.6 years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically. Discussion Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities.

First case report of acute cholangitis secondary to Cronobacter sakazakii

Introduction Cronobacter sakazakii is an opportunistic Gram-negative, rod-shaped bacterium which may be a causative agent of meningitis in premature infants and enterocolitis and bacteremia in neonates and adults. While there have been multiple cases of C. sakazakii infections, there have been no acute cholangitis cases reported in humans. Case presentation An 81-year-old male with a past medical history of basal cell carcinoma, alcoholic liver cirrhosis, transjugular intrahepatic portosystemic shunt procedure, complicated by staphylococcus bacteremia, pituitary tumor, glaucoma, and hypothyroidism presented to the emergency room with the complaint of diffuse and generalized 10/10 abdominal pain of 1 day’s duration. There was a concern for pancreatitis, acute cholangitis, and possible cholecystitis, and the patient underwent a percutaneous cholecystostomy tube placement. Blood cultures from admission and biliary fluid cultures both grew C. sakazakii. The patient was treated with a carbapenem and clinically improved. Conclusions The case study described a patient with multiple medical comorbidities that presented with C. sakazakii bacteremia and cholangitis. While this bacterium has been implicated in other infections, we believe this is the first time the bacteria is being documented to have caused acute cholangitis.

Calcitriol-Mediated Hypercalcemia from Hepatic Granulomatosis Following Percutaneous Cholecystostomy Tube

Granulomatous conditions can present with calcitriol-mediated hypercalcemia via increased 1-hydroxylase activity—activity that is not inhibited by calcium or calcitriol—indicating a lack of feedback inhibition. Differential diagnosis of granulomatosis is quite broad and can require extensive workup as highlighted by this case. Our patient is a 69-year-old white female admitted to the hospital with altered mental status and hypotension. Initial evaluation was concerning for infection, due to leukopenia and thrombocytopenia. CT abdomen revealed cholecystitis, percutaneous cholecystostomy tube was placed, and the patient’s mental status improved. One month after discharge, the patient presented to the hospital with a corrected calcium of 15.2 mg/dl. PTH was 22 pg/mL with normal renal function and phosphorus. The patient was treated with intravenous fluids, calcitonin, and zoledronic acid. Calcitriol was 69 pg/ml (18–75 pg/ml) and corrected calcium responded by time of discharge. During outpatient follow up, she was found to have corrected calcium 11.2 mg/dl and calcitriol 166 pg/ml with appropriately low PTH. Additional workup of apparent calcitriol-mediated hypercalcemia with whole-body CT imaging, tuberculosis screening, and flow cytometry only notable for possible right cervical lymphadenopathy on CT. Subsequent lymph node biopsy was benign. The patient completed a 30-day course of prednisone 20 mg daily followed by prednisone taper and her corrected calcium and calcitriol levels normalized. However, after discontinuation of prednisone, lab work demonstrated increase in calcium and liver enzymes. Repeat CT scan showed multiple hypoechoic areas with subsequent biopsy consistent with necrotizing hepatic granulomatosis. PAS-A, Fite, and AFB stains were negative for fungi and mycobacteria. Removal of cholecystostomy tube resulted in complete resolution of hypercalcemia and elevated calcitriol levels. Foreign body-induced granulomatosis is associated with PTH-independent hypercalcemia. Silicone has been implicated in foreign body granuloma. Hepatic granulomatosis is associated with percutaneous tube, especially with prolonged placement (approximately 11 months in this case). Removal of the foreign body is associated with improvement in hypercalcemia. Follow-up liver ultrasound demonstrated complete resolution of hepatic granulomas at three months following removal of the cholecystostomy tube.

Thinking ahead: gallbladder intussusception following transperitoneal percutaneous cholecystostomy tube placement

Percutaneous cholecystostomy (PC) is a common minimally invasive, image-guided procedure performed primarily on high-risk patients with acute cholecystitis for gallbladder decompression. Herein, we present a case of a patient undergoing PC placement using a transperitoneal approach. On subsequent upsizing attempts, the gallbladder fundus was found to invaginate during advancement of replacement drains, causing gallbladder intussusception. The use of a balloon and locked pigtail catheter were required to reposition the gallbladder to proper position. The patient’s planned percutaneous cholecystoscopy was delayed by 4 weeks until intended upsizing could be performed. This case demonstrates the advantage of achieving transhepatic gallbladder access to support tract formation and limit procedural complications.