Percutaneous cholecystostomy in critically ill patients: Early response and final outcome in 82 patients

OBJECTIVE. Patients in the intensive care unit are at increased risk of developing acute calculous and acalculous cholecystitis. Diagnosis based on clinical and sonographic findings is difficult in the presence of severe intercurrent disease. We did a study to evaluate the efficacy of percutaneous cholecystostomy as a diagnostic and therapeutic maneuver in 82 patients in the intensive care unit who had persistent unexplained sepsis. SUBJECTS AND METHODS. Eighty-two patients with unexplained sepsis underwent percutaneous cholecystostomy after a complete clinical, laboratory, and radiologic search showed no source of sepsis outside the gallbladder. All patients were febrile, 65 had an increased WBC count, and 37 were receiving vasopressors. Sonographic abnormalities included a distended gallbladder (71 patients), sludge (63 patients), gallstones (26 patients), wall thickening (34 patients), pericholecystic fluid (25 patients), and Murphy's sign (19 patients). RESULTS. Sonographic findings were not helpful in predicting response to percutaneous cholecystostomy. A dramatic improvement in clinical condition was observed in 48 patients (59%) within 48 hr. Signs of improvement included defervescence (41 patients), discontinuance of vasopressors (26 patients), and reduction in WBC count (33 patients). No clinical response was observed in 34 patients (41%). No complications related to catheter insertion occurred. CONCLUSION. Because acute cholecystitis is difficult to diagnose in patients in the intensive care unit, percutaneous cholecystostomy serves as a diagnostic and therapeutic maneuver in patients with unexplained sepsis when the gallbladder is the suspected source of sepsis. A response rate to percutaneous cholecystostomy of 59% was seen in this study. The gallbladder was cleared as a potential source of sepsis in the remaining patients.