Percutaneous Cholecystostomy in Pregnancy

Right upper quadrant pain unstable patient. What procedure is indicated? • Xray of the Week

Figure 1. What action should be taken for this patient with right upper quadrant pain who is also hemodynamically unstable?

Figure 2.

A. MRI of abdomen. The patient is pregnant (orange arrows), therefore ionizing radiation with CT scan or fluoroscopy can not be used for imaging guidance. Gallbladder with wall thickening (green arrow) and adjacent fluid (yellow arrow) indicate acute cholecystitis. A nuclear medicine hepatobiliary scan was also performed (not shown) and demonstrated no radiopharmaceutical present in the gallbladder due to cystic duct obstruction.

B. Ultrasound of gallbladder used for guidance of percutaneous needle (red arrow) placement for cholecystostomy.

C. Ultrasound of gallbladder demonstrating drainage catheter in the lumen (blue arrow).

Discussion:

Cholecystitis is the second most common surgical emergency seen in pregnancy after appendicitis. [1] Surgical intervention is typically safe for both the mother and fetus, due to improved morbidity when utilizing the laparoscopic approach rather than open cholecystectomy. [2]. In cases of high risk pregnancy or when treating an unstable peripartum patient, percutaneous cholecystostomy is an important important image-guided, minimally invasive alternative to surgical cholecystectomy [3-6]. This technique has proven effective for cases of acute cholecystitis occurring during the third trimester, allowing for management until delivery when surgery becomes safer. [7]. Percutaneous cholecystostomy is usually followed by laparoscopic cholecystectomy in the postpartum period once the patient has been stabilized [3,7].

In pregnancy, ultrasound is used for imaging guidance due to lack of ionizing radiation encountered with CT scan or fluoroscopy [5]. The transhepatic or transperitoneal insertion of an access needle is followed by gallbladder catheterization with either the Seldinger technique or a trocar system [8-11]. Figures 1 and 2 are imaging studies on a pregnant patient with acute cholecystitis and was too unstable to undergo surgery. The patient underwent a percutaneous cholecystostomy using the Seldinger technique and US guidance. After the patient delivered and was stable, the patient had a laparoscopic cholecystectomy and fully recovered.

Major complications of percutaneous cholecystostomy include hemorrhage, pneumothorax, biliary leak, and peritonitis, with the transhepatic approach having increased risk of pleural or hepatic damage [8,9,11].

References:

1. Angelini DJ. Obstetric triage revisited: update on non-obstetric surgical conditions in pregnancy. J Midwifery Womens Health. 2003;48(2):111-118. doi:10.1016/s1526-9523(02)00417-8.

2. Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North Am. 2014;94(2):455-470. doi:10.1016/j.suc.2014.01.005

3. Hojberg Y, Patel K, Shebrain S. Utilizing Percutaneous Cholecystostomy Tube as a Temporary Minimally Invasive Approach for Acute Cholecystitis during Third Trimester of a High-Risk Pregnancy. Case Rep Gastroenterol. 2022;16(1):49-54. Published 2022 Feb 14. doi:10.1159/000522060

4. Baron TH,Grimm IS,Swanstrom LL.Interventional approaches to gallbladder disease.N Engl J Med.2015;373(4):357–65. doi:10.1056/NEJMra1411372

5. Moirano J, Khoury J, Yeisley C, Noor A, Voutsinas N. Interventional Radiology and Pregnancy: From Conception through Delivery and Beyond. Radiographics. 2023;43(8):e230029. doi:10.1148/rg.230029

6. Rana P, Gupta P, Chaluvashetty SB, et al. Interventional radiological management of hepatobiliary disorders in pregnancy. Clin Exp Hepatol. 2020;6(3):176-184. doi:10.5114/ceh.2020.99508

7. Caliskan K. The use of percutaneous cholecystostomy in the treatment of acute cholecystitis during pregnancy. Clin Exp Obstet Gynecol. 2017;44(1):11-13. https://pubmed.ncbi.nlm.nih.gov/29714857/

8. Ginat D and Saad W. Cholecystostomy and Transcholecystic Biliary Access. Tech Vasc Interv Radiol. 2008;11(1):2-13. doi:10.1053/j.tvir.2008.05.002

9. Little MW. Percutaneous cholecystostomy: The radiologist’s role in treating acute cholecystitis. Clin Radiol. 2013;68(7): 654-660. doi:10.1016/j.crad.2013.01.017

10. Venara A, Carretier V, Lebigot J, E Lermite. Technique and indications of percutaneous cholecystostomy in the management of acute cholecystitis in 2014. J Visc Surg. 2014;151(6):435-439. doi:10.1016/j.jviscsurg.2014.06.003

11. Beland MD, Patel L, Ahn SH, Grand DJ. Image-Guided Cholecystostomy Tube Placement: Short- and Long-Term Outcomes of Transhepatic Versus Transperitoneal Placement. AJR Am J Roentgenol. 2019;212: 201-204. doi:10.2214/AJR.18.19669

Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

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