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MANAGING LARGE STONE IN ACUTE CHOLECYSTITIS: AXIOS STENT AND LITHOTRIPSY IN A CRITICALLY ILL PATIENT
Aziz Eshov
*1, Jordan King
1,2, Jayanta Datta
3, Samit Datta
11Gastroenterology, Skagit Regional Health, Mount Vernon, WA; 2Pacific Northwest University of Health Sciences, Yakima, WA; 3The Ohio State University, Columbus, OH
INTRODUCTIONEndoscopic ultrasound-guided biliary drainage with a lumen-apposing metal stent (EUS-GBD with LAMS) is a newer intervention for patients with acute cholecystitis who are not candidates for cholecystectomy. Using a LAMS with EUS-GBD is a simple one-step delivery process. EUS-GBD with LAMS has been shown to be an appropriate alternative to ERCP with cystic duct intervention and PT-GBD with high clinical and technical success. Stent occlusion from stone is a possible complication and management has been poorly described in the literature. We present a case of a patient who underwent EUS-GBD with LAMS for septic shock and subsequently required cholangioscopy with stone destruction due to stent occlusion from a large stone.
CASE DESCRIPTIONAn 87-year-old female with a history of atrial fibrillation initially presented with septic shock initially thought to be due to a urologic source with ureteral stent placement. WBC worsened from 18.4k to 29.3k and patient required 2 vasopressors. CT showed calcified gallstone measuring 2.8x4.1cm (Figure 1) and NM HIDA scan showing cystic duct obstruction at 120 minutes. Patient was a poor surgical candidate due to her medical comorbidities and septic shock and a EUS-GBD with a 10x10mm LAMS was placed. Within 24 hours, her pressor requirement was weaned and her WBC count normalized to 6.1 on discharge. Patient’s mental status rapidly improved and was tolerating diet the next day.
Following discharge, patient presented 6 weeks later with RUQ pain and imaging concerning for distended gallbladder and stone potentially obstructing the LAMS with associated pancreatitis. Patient was taken for an ERCP with plans for electrohydraulic lithotripsy (EHL) via the LAMS. A large stone was encountered and treated with EHL with a large amount of stone extracted (Figure 2). Patient’s symptoms rapidly improved and was able to immediately tolerate diet after the procedure and was subsequently discharged the following day.
DISCUSSIONCholecystectomy remains to be the standard management of acute cholecystitis. Current guidelines for management of non-surgical candidates primarily recommend percutaneous drainage via cholecystostomy tube. Newer literature has shown promising results for EUS-GB drainage with high technical and clinical success rates with fewer adverse events. However, large gallstones may persist leading to recurrent symptoms. This case report showed successful management of critically ill patient on 2 vasopressors due to acute cholecystitis by using EUS-LAMS gallbladder decompression. Additionally, it demonstrated the use of stent lumen to access the gallbladder with EHL to fragment and remove persistent gallstones that caused recurrent symptoms post LAMS. This case highlights the effectiveness of using EUS-LAMS to treat acute cholecystitis for non-surgical candidates and management of large gallstones.
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