Cholecystostomy for acalculous cholecystitis with haemobilia in a lung transplant patient; a case report.

Editor,

We report on a 64 year old gentleman who developed an early broncho-pleural fistula following a double lung transplant for end-stage COPD/Bronchiectasis and was transferred to his referring institution for palliative management.

Ten weeks post-transplant, the patient developed sudden-onset severe epigastric/right upper quadrant abdominal pain. He was tachycardic, normotensive, and had a palpable tender mass in the right hypochondriac region. Blood tests revealed an elevated white cell count and an acute derangement of his liver function tests.

Urgent Computed Tomography (CT) scan of chest, abdomen and pelvis showed a distended gallbladder of mixed attenuation with no peri-inflammatory changes as shown in Figure 1. There was no previous history of gallstones and no gallstones were seen in imaging.

Fig 1

CT scan of abdomen demonstrating a distended gallbladder of mixed attenuation with no peri-inflammatory changes

Due to the critically ill nature of the patient, an urgent percutaneous cholecystostomy was undertaken by ultrasound guidance and a pigtail catheter inserted, which drained a mixture of bile and blood. He was empirically treated with Tazocin (Piperacillin and Tazobactam) 4.5g three times a day.

CMV Polymerase Chain Reaction analysis was positive for both serum and bile and a diagnosis of CMV acalculous cholecystitis with haemobilia was established. The patient was treated with intravenous ganciclovir for 25 days followed by 18 days of oral valganciclovir. T-Tube cholangiogram 2 weeks following initial insertion demonstrated no flow out of the common bile duct into the duodenum. A Magnetic Resonance Cholangiopancreatography (MRCP) scan (with a view of proceeding to ERCP) demonstrated a normal biliary tree, but showed debris in the gallbladder suggestive of post-haemorrhagic components. A repeat T-tube cholangiogram one week later showed an obstruction at the gallbladder neck. This was managed with two instillations of 25000I/U of streptokinase into the cholecystostomy drain 12 hours apart. Repeat T-tube cholangiogram following this demonstrated normal flow of contrast through the common bile duct into the duodenum. The pig tail drain was subsequently removed (day 42) and the patient made a good post-procedure recovery.

CMV infection is common in transplant patients and develops in 3 ways: primary infection (transmission from a seropositive donor allograft to a seronegative recipient), reactivation of latent infection (CMV resembles other members of the herpesviridae in establishing latent infection and so immunodeficiency predisposes to reactivation of CMV) and re-infection (donor-transmitted infection superimposed on reactivation of latent infection).1 CMV can affect almost any organ system, with infection of the gastrointestinal tract being the most common manifestation of tissue-invasive CMV. It is a rare cause of acalculous cholecystitis in immunocompromised patients with human immunodeficiency virus,2 and has been reported in patients following solid organ transplant.3

Ganciclovir remains first-line treatment for CMV disease,4 given at a dose of 5mg/kg twice-daily (dose-adjusted for renal impairment). As the drug has no hepatobiliary excretion,5 drainage of the gallbladder is mandatory. Treatment duration is patient-specific and should be based on virologic and clinical improvement.

The management of critically ill patients who develop cholecystitis is complex, with percutaenous cholecystostomy an option in the critically ill patient and in patients who are at high risk of general anaesthesia.The procedure allows immediate decompression and drainage of an acutely inflamed gallbladder and can either be used as a temporary bridging measure or as definitive management.

This case is unique in that there are no previous reports of acute CMV cholecystitis developing following lung transplant, and because, as the patient was not fit for cholecystectomy, he was managed with percutaneous cholecystos-tomy. This case emphasises the usefulness of percutaneous cholecystostomy in the critically ill patient who is unsuitable for surgery.