Percutaneous cholecystostomy (PC) is a technique which consists of percutaneous catheter placement in the gallbladder lumen under the guidance of imaging modalities and has become an alternative to surgical cholecystectomy in recent years.[1] It is also a well-accepted procedure for acute cholecystitis in high-risk patients.[2]

Herein, we report a case of acute cholecystitis in a patient suffering from recent non-ST elevation myocardial infarction (NSTEMI) before CABG.

Before CABG, the patient suffered from abdominal pain, nausea, and vomiting and a bedside consultation was performed by the gastroenterology department. He had pain with deep palpation in the right upper quadrant. Abdominal ultrasonography showed an increased diameter of the gallbladder with a minimal thickening. The lumen of the gallbladder had lots of millimetric gallstones and mud. C-reactive protein (CRP) level significantly increased from 0.9 mg/dL to 1.16 mg/dL, 18.6 mg/dL, and 19.8 mg/dL, respectively on consecutive alternate days. Other laboratory test results were as follows: alkaline phosphatase (ALP) 70 U/L, aspartate aminotransferase (AST) 19 U/L, alanine aminotransferase (ALT) 12 U/L, gammaglutamyl- transferase (GGT) 12 U/L, and amylase 86 U/L. The complete blood count analysis showed an increasing tendency in the white blood cell (WBC) count from 8,700/?L to 10,900/?L, and 11,400/?L on consecutive alternate days. Based on the laboratory and ultrasonographic findings, the patient was diagnosed with acute cholecystitis caused probably by a millimetric gallstone particle obstructing the ductus cysticus. Oral intake was not allowed and intravenous fluid replacement was applied. Antibiotherapy was initiated and the gastrointestinal system was given a rest for a few days.

Ultrasonography and laboratory studies were repeated every two- or three-days. Ultrasonography revealed an increased thickness of wall of the gallbladder. Also, the pericholecystic fluid was seen which was not observed previously. Considering whole these findings, progression of the acute cholecystitis was suspected. The gastroenterology department reevaluated the patient and surgery was considered initially. However, due to comorbidities of the patient, they decided not to operate the patient and referred the patient to the invasive radiology department for PC. A written informed consent was obtained from the patient.

Percutaneous cholecystostomy was applied under the guidance of ultrasonography. After the procedure, the complaints of the patient improved dramatically. During the procedure, 200 mL bile fluid was drained. In the following days, about 50 to 200 mL bile fluid was drained each day. The WBC count was in normal range. Abdominal ultrasonography revealed a decreased size of the gallbladder. The CRP levels dramatically decreased from 19.8 mg/dL, 4.9 mg/dL, and 7.11 mg/dL, respectively. The gastroenterology department suggested that CABG should be done, when the CRP became lower than 5 mg/dL and WBC count was in normal range.

After clinical stabilization, two vessels CABG were performed with saphenous veins for the LAD and CxOM2 arteries 12 days after PC intervention. Left internal mammary artery (LIMA) graft was not used due to decreased flow. There were no major perioperative complications. He was extubated on the postoperative first day. Blood gas analysis showed a partial pressure of carbon dioxide (pCO2) level of 55 to 60 mmHg. Due to existing COPD, these levels were thought to be well-tolerated and it was the case in our patient. In the following days, the patient was transferred to the ward. The percutaneous gallbladder catheter was withdrawn on the postoperative sixth day. No complication was seen, and the patient was discharged with complete recovery on the postoperative eighth day.

Percutaneous cholecystostomy is a well-accepted procedure for acute cholecystitis in high-risk patients.[2] It can be used effectively in high-risk patients with cardiac problems, including acute myocardial infarction and other comorbidities.[2,7]

In the present case, surgical cholecystectomy was not considered as an option due to NSTEMI and severe COPD. Therefore, the gallbladder was relieved by draining with PC. Following the intervention, the patient became stable based on clinical, ultrasonographic, and laboratory findings. Subsequently, an elective CABG was performed and the patient was discharged without any postoperative complication.

In conclusion, we believe that percutaneous cholecystostomy is an applicable and feasible method for acute cholecystitis in high-risk patients who are candidates for elective coronary artery bypass grafting.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

1) Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol 2002;43:229-36.

2) Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999;134:727-31.

3) Passage J, Joshi P, Mullany DV. Acute cholecystitis complicating cardiac surgery: case series involving more than 16,000 patients. Ann Thorac Surg 2007;83:1096-101.

4) Diehl AK, Haffner SM, Hazuda HP, Stern MP. Coronary risk factors and clinical gallbladder disease: an approach to the prevention of gallstones? Am J Public Health 1987;77:841-5.

5) Méndez-Sánchez N, Bahena-Aponte J, Chávez-Tapia NC, Motola-Kuba D, Sánchez-Lara K, Ponciano-Radríguez G, et al. Strong association between gallstones and cardiovascular disease. Am J Gastroenterol 2005;100:827-30.

6) Cher DJ. Myocardial infarction and acute cholecystitis: an application of sequence symmetry analysis. Epidemiology 2000;11:446-9.

7) Bakkaloglu H, Yanar H, Guloglu R, Taviloglu K, Tunca F, Aksoy M, et al. Ultrasound guided percutaneous cholecystostomy in high-risk patients for surgical intervention. World J Gastroenterol 2006;12:7179-82.