Percutaneous cholecystostomy: who responds?

Our purpose was to identify clinical or radiologic features predictive of response to percutaneous cholecystostomy performed for the treatment of acute cholecystitis.

The clinical records and radiologic images of patients who underwent percutaneous cholecystostomy for suspected acute cholecystitis between January 1987 and July 1994 were retrospectively reviewed. A response to percutaneous cholecystostomy was defined as an improvement in clinical symptoms and signs or reduction in fever and WBC to normal within 72 hr of percutaneous cholecystostomy. The number and type of radiologic investigations were reviewed by two radiologists. The presence of gallstones, gallbladder wall thickening, distention, and pericholecystic fluid was recorded. The clinical and radiologic findings were analyzed for their relationship to response to percutaneous cholecystostomy.

Sixty-one percutaneous cholecystostomies were performed in 37 male and 24 female patients and were technically successful in 59. Thirty-one patients had gallstones, 28 did not. Thirty-one patients were in the intensive care unit, and 15 were ventilated. Complications occurred in six (10%): misplacement of the percutaneous cholecystostomy catheter in the colon (one), exacerbation of sepsis (three), and bile leakage (two). The mortality rate was 2%--one of the patients with septic shock succumbed to a cardiac arrest 3 days after the procedure. Forty-three patients (73%) responded to percutaneous cholecystostomy. Patients with gallstones and symptoms and signs localized to the right upper quadrant of the abdomen were more likely to respond (p = .006). The only individual radiologic feature predictive of a positive response was the presence of pericholecystic fluid in patients with gallstones (p = .03). The presence of all four radiologic findings was also associated with a positive response (p = .039). The results of bile cultures were not predictive of response. Of the 16 nonresponders, six had documented biliary sepsis and cholecystitis.

Clinical symptoms and signs referable to the gallbladder, the presence of pericholecystic fluid in patients with gallstones, and the presence of an increasing number of radiologic findings in any one patient are predictive of a positive response to percutaneous cholecystostomy.