Clin Endosc.  2020 Jan;53(1):97-100. 10.5946/ce.2019.032.

A Rare Fatal Bile Peritonitis after Malposition of Endoscopic Ultrasound-Guided 5-Fr Naso-Gallbladder Drainage

• Kim TH
• Bae HJ
• Hong SG

• KMID: 2500912
• DOI: http://doi.org/10.5946/ce.2019.032

Abstract

Endoscopic ultrasound (EUS)-guided gallbladder (GB) drainage has recently emerged as a more feasible treatment than percutaneous transhepatic GB drainage for acute cholecystitis. In EUS-guided cholecystostomies in patients with distended GBs without pericholecystic inflammation or prominent wall thickening, a needle puncture with tract dilatation is often difficult. Guidewires may slip during the insertion of thin and flexible drainage catheters, which can also cause the body portion of the catheter to be unexpectedly situated and prolonged between the GB and intestines because the non-inflamed distended GB is fluctuant. Upon fluoroscopic examination during the procedure, the position of the abnormally coiled catheter may appear to be correct in patients with a distended stomach. We experienced such an adverse event with fatal bile peritonitis in a patient with GB distension suggestive of malignant bile duct stricture. Fatal bile peritonitis then occurred. Therefore, the endoscopist should confirm the indications for cholecystostomy and determine whether a distended GB is a secondary change or acute cholecystitis.

Keyword

Bile peritonitis; Distension; Endoscopic ultrasound-guided gallbladder drainage; Indication

Figure

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  Fig. 1. Abdominal computed tomography scan showing that both intrahepatic bile ducts were dilated (A), and distension of the gallbladder with minimal wall thickening was observed (B). The coronal image shows an abrupt narrowing of the distal common bile duct suggestive of bile duct malignancy (C).

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  Fig. 2. Endoscopic ultrasound-guided gallbladder drainage. The endoscopic ultrasound shows a distended gallbladder with wall thickening (A). Tract dilatation was performed with a needle knife and 6-mm Hurricane dilation catheter consecutively (B, C). Catheter coiling was presumed to be well situated in the stomach as shown by fluoroscopic imaging (D).

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  Fig. 3. Abdominal X-ray and follow-up computed tomography scan. The abdominal X-ray shows diffuse free air and marked prolonged malposition of the body of the 5-Fr naso-biliary catheter (white arrows) between the duodenum (blue circle indicating stomach) and gallbladder (black circle) (A). An abdominal computed tomography scan confirmed the prolonged malposition of the catheter in the peritoneal cavity (white arrows). A small portion of another drainage catheter in the left lower abdomen (red arrow) was observed, implanted to drain the fluids collected in the peritoneal cavity (B, C).

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