Endoscopic Drainage of an Intrahepatic Abscess Secondary to a Perforated Gallbladder.

CASE REPORT

A 68-year-old woman presented with abdominal pain, nausea, vomiting, and altered mental status. Subsequent imaging demonstrated a well-circumscribed nonenhancing fluid collection within the hepatic parenchyma adjacent to the gallbladder. Management was discussed in a multidisciplinary manner, and a decision was made to pursue endoscopic management with a single anesthetic. Endoscopic retrograde cholangiopancreatography with biliary sphincterotomy and clearance of the bile duct, endoscopic ultrasound puncture of the gallbladder from the duodenum and placement of a lumen-apposing stent (ie, creation of a cholecystoduodenostomy), and placement of a double pigtail into the hepatic abscess were performed. The procedure was successful without any intraoperative or postoperative complications. Follow-up imaging demonstrated near-resolution of the abscess. Repeat endoscopy was performed to remove the remaining stones from the gallbladder. At follow-up, the patient remained well and was symptom-free (Video 1, watch the video at http://links.lww.com/ACGCR/A11).

Video 1

First described stent-in-stent technique for the management of acute cholecystitis complicated by perforation and resultant intra-hepatic abscess. Watch the video at http://links.lww.com/ACGCR/A11.

Endoscopic management of gallbladder disease has recently come into favor, with the current literature supporting its efficacy and safety profile.[1] Endoscopic management of complications from gallbladder disease, however, has yet to be described. We present a novel approach to endoscopic management of an intrahepatic abscess in the setting of a perforated gallbladder. The advent of endoscopic ultrasound has broadened the horizon of interventional endoscopy by allowing endoscopists to visualize and access organs and adjacent intra-abdominal pathology near the gastrointestinal tract. Recently, the utility of endoscopic ultrasound has expanded from a mainly diagnostic role (ie, staging gastrointestinal malignancy and tissue acquisition for the diagnosis of gastrointestinal malignancy) to include a more therapeutic role (ie, drainage of intra-abdominal fluid collections, alternative approach to biliary and pancreatic duct drainage).

DISCLOSURES

Author contributions: PJ Parekh drafted the manuscript and is the article guarantor. PJ Parekh, MH Shakhatreh, MR Desai, and P. Yeaton critically revised the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.