Post written by Lady Katherine Mejia Perez, MD, and Victoria Gomez, MD, from the Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida.

We report an interesting case of a 75-year-old woman with decompensated cirrhosis with recurrent calculous cholecystitis who was being managed with an indwelling percutaneous cholecystostomy tube (PCT) due to poor surgical candidacy. The tube significantly impacted her quality of life, causing chronic pain, and she had several dislodgements. However, as she was not an ideal surgical candidate; an elective cholecystectomy was not in her future. After discussion with our surgical and interventional radiology colleagues, we decided to internally drain the gallbladder using an endoscopic-ultrasound-guided method. We deployed a fully covered lumen-apposing metal stent (LAMS) (HotAxios Stent, 15×10 mm, Boston Scientific, Natick, Mass). However, the challenging part was visualizing the gallbladder and ensuring it would remain distended during insertion of the LAMS. In order to do this, we used the percutaneous tube to our advantage and instilled copious amounts of sterile saline to keep it nice and plump during the procedure. At 1-week follow-up, the patient was asymptomatic and the PCT was successfully removed in clinic.

This case demonstrates how EUS-guided internal gallbladder drainage was successfully achieved in a patient with long-term troublesome PCT. LAMSs are being increasingly used in patients with acute cholecystitis to internally drain the gallbladder. This case posed a particular challenge because of the non-distended gallbladder. We demonstrated how the use of saline solution injection through the PCT aided to distend the gallbladder, optimizing visualization and stent deployment.

EUS-guided internal gallbladder drainage is an alternative for patients deemed unfit for surgical treatment of recurrent cholecystitis. In the setting of a collapsed gallbladder, copious injection of normal saline can provide adequate distention for safe stent deployment. However, as these procedures are not benign, all options, advantages, and limitations must be presented to the patients and families.

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