Gallbladder Perforation Treated Using a Combination of Percutaneous Transhepatic and Endoscopic Transpapillary...

Gallbladder perforation is an uncommon but serious complication of acute cholecystitis. When associated with a subcapsular hepatic abscess, definitive surgical management is typically recommended; however, surgery and direct abscess drainage may not be feasible in patients with high operative risk or unfavorable anatomy. Percutaneous transhepatic gallbladder drainage (PTGBD) provides external decompression of the gallbladder, whereas endoscopic transpapillary gallbladder drainage (ETGBD) provides internal drainage through the cystic duct. We report the case of an 88-year-old man with acute cholecystitis complicated by gallbladder perforation and a subcapsular hepatic abscess. Computed tomography revealed gallbladder distension and a subcapsular low-attenuation area along the anterior liver surface. Magnetic resonance cholangiopancreatography demonstrated communication between the gallbladder and the subcapsular collection. Emergent cholecystectomy was contraindicated because of advanced age, reduced activities of daily living, renal dysfunction, cerebrovascular disease, and respiratory dysfunction. Direct percutaneous abscess drainage was also not feasible because of intervening pulmonary and vascular structures. Although PTGBD initially improved the inflammatory response, C-reactive protein levels subsequently rebounded, indicating inadequate infection control. Cholangiography via the PTGBD catheter confirmed contrast leakage from the gallbladder fundus into the subcapsular cavity. ETGBD was therefore performed to enhance internal drainage through this communication, and a 5-Fr plastic stent was successfully placed with the aid of a novel sphincterotome. Following the procedure, inflammatory markers normalized, and follow-up imaging confirmed abscess resolution. The patient was discharged on day 56 without recurrence. This case suggests that combined PTGBD and ETGBD may be an effective non-operative strategy in selected high-risk patients with gallbladder perforation and a communicating subcapsular hepatic abscess when surgery and direct abscess drainage are not feasible.