An Unusual Abscess Associated with Gallbladder Perforation Successfully Treated with Percutaneous Transhepatic Gallbladder Drainage and Endoscopic Ultrasound-guided Abscess Drainage

Abstract

Abscesses associated with gallbladder perforation are often confined to the peri-gallbladder region. We herein report a rare case of gallbladder perforation in which the abscess cavity extended into the left upper quadrant. A 79-year-old woman developed gallbladder perforation secondary to acalculous cholecystitis. Computed tomography revealed fluid collection extending from the peri-gallbladder to the dorsal left hepatic lobe in contact with the stomach. We successfully treated percutaneous transhepatic gallbladder drainage and simultaneous endoscopic ultrasound-guided transgastric internal and external abscess drainage. This minimally invasive approach is considered safe and feasible for managing such a rare case.

Keywords: EUS; abscess; drainage; gallbladder perforation; interventional EUS.

Figure 1.

A: Abdominal contrast-enhanced computed tomography (CECT) showing gallbladder swelling, wall thickening, and elevated internal CT values (arrows). B, C: Fluid collection extending from the peri-gallbladder to the dorsal aspect of the left lateral hepatic lobe with elevated CT values in both the gallbladder (*) and fluid retention cavity (**). D: Air distribution is observed in the fluid retention cavity close to the stomach (dotted circle).

Figure 2.

A: Endoscopic image showing the accumulation of blood in the stomach. B: The orifice of duodenal papilla (arrows). C: Blood outflow from the orifice of duodenal papilla (arrowheads).

Figure 3.

A: Endoscopic ultrasound (EUS) image showing abscess in the dorsal aspect of the left lateral hepatic lobe. B: EUS image showing the puncture of the abscess. C: Deployment of the pigtail stent with another guidewire left in place. D: Fluoroscopic image showing the pigtail stent and nasocystic tube placed in the abscess. E: Endoscopic image showing internal and external drainage tubes.

Figure 4.

Computed tomography image showing shrinkage of the abscess cavity on day 7 after endoscopic ultrasound-guided transgastric abscess drainage.

Figure 5.

The clinical course of the patient. ALP: alkaline phosphatase, CRP: C-reactive protein, EUS-D: endoscopic ultrasound-guided drainage, MEPM: meropenem, PTGBD: percutaneous transhepatic gallbladder drainage, T-Bil: total bilirubin, WBC: white blood cell

Figure 6.

A: Computed tomography image showing disappearance of the abscess cavity two months after ultrasonography-guided transgastric abscess drainage. B: Cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) tube showing no defects in the gallbladder and bile ducts.