Non-surgical candidates with acute cholecystitis can be managed endoscopically with EUS-guided transmural drainage or ERCP with transpapillary stenting. EUS-guided transmural drainage has a higher technical and clinical success rate compared to ERCP with transpapillary stenting. When these two options fail, a long-term percutaneous gallbladder drain often is the only option. However, one can also consider placing a transpapillary nasal gallbladder drain. A 64-year-old man with unresectable hylopalangeal carcinoma on palliative chemotherapy presented with abdominal pain, nausea, and fever. He had been undergoing multiple ERCPs with intrahepatic biliary stent exchanges. CAT scans showed a distended gallbladder, pericholecystic fluid and wall thickening consistent with cholecystitis. It also showed the colon position between the gallbladder and duodenum. Despite antibiotics, he had worsening leukocytosis. He was deemed a non-surgical candidate by the hepatobiliary surgeons. Percutaneous drain versus endoscopic options were discussed. EUS-guided gallbladder drainage, due to higher technical and clinical success, was attempted first. However, despite rotating through the stomach and duodenum, we were unable to find a window free of colonic wall to allow safe puncture. Thus, ERCP with transpapillary stenting was pursued. At ERCP, an occlusion cholangiogram showed a trace amount of contrast entering the cystic duct. An O2-5 angled guide wire was able to be carefully negotiated through a very difficult cystic duct into the gallbladder. Contrast injection helped outline the cystic duct structure. Purulence emerged on catheter withdrawal. The structure was dilated with a 4-4 balloon, followed by placement of a 7 French 15 centimeter soft double pigtail stent into the gallbladder, due to a recent inventory switch of our prior stiffer stents. A kink in the stent was noted at withdrawal of the duodenoscope, but we anticipated this undoing itself. Post-procedure, his white blood cell count normalized and pain resolved. He was discharged home on antibiotics. However, five days later, he was readmitted with fever, pain, and a CAT scan showing persistent cholecystitis. He underwent a second ERCP, at which point the previously placed gallbladder stent was again noted to have a complete kink in it. Due to prior difficulty cannulating the cystic duct, we tried to place a guide wire alongside the gallbladder stent. However, this was unsuccessful. Therefore, the stent was cut with endo scissors and pus poured out. The cut stent was then cannulated with a guide wire, after which the stent was removed with a snare, leaving the guide wire in place in the gallbladder. The cystic duct stricture was again dilated to four millimeters without ability to break the waste on the balloon, and a second guide wire was placed into the gallbladder. Over the guide wires, a stiffer 7-french 10-centimeter double pigtail stent was placed. Given the frank purulence, we placed a nasal gallbladder drain to allow irrigation and suctioning. The cystic duct had to be dilated twice before we were finally able to get the nasal gallbladder drain in. 120 cc of pus was suctioned. The next day, his pain resolved and white blood cell count normalized again. He really wanted to avoid the drain, and so although aspiration of the drain was not completely bilious, we decided to place two pigtail stents to allow safer removal of the nasal gallbladder drain. Due to difficulty cannulating the cystic duct, a cholangioscope was used to place a guide wire directly into the gallbladder. Then, a 7-french 10-centimeter double pigtail stent was placed alongside the previous stent. He was discharged home on antibiotics, however six days later got readmitted with fever and abdominal pain concerning for recurrent cholecystitis despite two transpapillary stents. He again expressed his wish to avoid external drainage. Since he had responded nicely to a nasal gallbladder drain, our thought was to leave this in for at least two weeks to allow complete healing from cholecystitis. On repeat ERCP, one of the two cystic duct stents was removed and a new nasal gallbladder drain was placed. He was discharged home in two days and taught to flush and aspirate the drain with 20 cc of saline every four to six hours. Ten days later, the gallbladder aspirate became consistently and purely bilious, suggesting healing of the gallbladder wall. The nasal gallbladder drain was injected with contrast and demonstrated a small and contracted gallbladder. The nasal gallbladder drain was removed and a 7-french 10-centimeter double pigtail stent was placed alongside the prior stent. Since the procedure four months ago, the patient has been clinically free of cholecystitis. He is returned for planned ERCP every two months for biliary stent exchange with plans for periodic gallbladder stent exchanges as well. Clinical Implications. In the rare situation where there is no window for an EUS-guided gallbladder drainage, ERCP with transpapillary stenting is a feasible option for cholecystitis in non-surgical patients. Soft stents should be avoided as they may be more prone to kinking, leading to rapid occlusion. If one stent fails, a second stent can help. And finally, a nasal gallbladder drain can be the last option. A nasal gallbladder drain should be given adequate time before removal until the aspirate returns consistently bilious. Patients can be taught to flush and suction the nasal gallbladder drain at home. In conclusion, when EUS-guided gallbladder drainage is not an option and ERCP with transpapillary stenting fails, ERCP with two weeks of transpapillary nasal gallbladder drainage should be considered for patients who wish to avoid percutaneous drainage.

acute cholecystitis

non-surgical candidates

EUS-guided transmural drainage

ERCP with transpapillary stenting

gallbladder stent