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case presentation

On September 20,2013 a ambulatory patient 82 years of age is walked into a fluoroscopy room accompanied by his son. The procedure, its risks and benefits were explained thoroughly and consent was signed to commence the exam. On september 19, 2013, the day prior, a CT scan of the abdomen/pelvis and a sonogram of the abdomen were taken. Results showed that the gallbladder appears to be distended with thickening of the wall suspicious for acute cholecystitis.

Cholecystitis is inflammation of the gallbladder. ┬áReferring to “http://biology.about.com/library/organs/bldigestliver3.htm” The function of the gallbladder is to store and excrete bile, however if the gallbladder is inflamed then bile cannot travel out of the gallbladder. Cholecystitis can be caused by numerous pathology such as infection or trauma, but the most often occurrence is the cystic duct is blocked by a gallstone which causes the gallbladder to become irritated and swollen. Major signs of cholecystitis are pain in the right upper abdomen, fever and increasing pain after taking in deep breaths. To diagnose cholecystitis your doctor will first perform a physical exam to check for tenderness. He/she may ask for blood to be drawn to run for tests. Otherwise a CT scan or ultrasound will be performed to check for gallstones or buildup of fluid. The size and shape of the gallbladder is another important factor in diagnosing cholecystitis.
The patient was placed in supine position on the CT table, consciously sedated with 50 mcg of fentanyl, a lightly sedating narcotic, intravenously by the interventional radiology nurse. The patient was also administered 1 mg of Versed which is a drug derivative of midazolam which induces a drowsy and calm feeling throughout the exam.  Vital signs were closely monitored throughout the procedure and the CT of the abdomen was obtained. According to Igor Fishkin MD, CT results re-demonstrated a distended gallbladder with thickening of the walls.
Following the CT exam, with reoccurring results it was time for a CT guided percutaneous cholecystostomy and ┬ásample of fluid from the gallbladder to be sent to the lab. In a normal cholecystostomy according to “http://radiopaedia.org/articles/percutaneous-cholecystostomythe” the gallbladder is punctured with an 18 or 19 gauge needle under ultrasound guidance. Bile can then be aspirated for microbiological studies. A 0.035 guidewire is used to exchange the needle for a dilator and an 8 French or larger pigtail drain is placed within the gallbladder. The drain can often be visualised under ultrasound. Aspiration of bile/pus from the drain confirms satisfactory position.
According to the report by Doctor Fishkin .MD “A safe spot for needle insertion was chosen and marked on the skin. The right upper quadrant of the abdomen was prepped and draped in the usual sterile fashion.” Equipment that was used for this fluid extraction was a 5 French micro-puncture set and an 8 french APD(all-purpose draining) catheter. Approximately 300 cc’s of a cloudy greenish fluid were aspirated out of said catheter. A sample of this fluid will be sent to the laboratory for study and future diagnosis.
Post Cholecystosmy, typically 2-4 hours of bed rest with regular monitoring of vital signs is routinely done. Catheter is flushed and aspirated regularly with saline 6 to 8 hours after exam. A cholecystogram which is an injection of contrast through fluoroscopy is performed when the patient is stable. This procedure is to done to help establish satisfactory catheter position and the state of the gallbladder. It also allows assessment of any residual calculi in the biliary tree. The catheter can be removed once the tract is mature (usually 3-4 weeks). A trial of clamping the catheter for 24 hours is usually done prior to removing the catheter.
Pending results of laboratory studies, if the patient is diagnosed with Cholecystitis, he will need to undergo a procedure called a┬ácholecystectomy. A cholecystectomy is the removal of the gallbladder by surgery. ┬áSometimes the physician may need to reduce the swelling of the gallbladder before attempting to remove it. ┬áTo perform a Laparoscopic cholecystectomy, a small camera is inserted through one of three to four incisions in the abdomen. ┬áThe doctor will use air or carbon dioxide to inflate the patientÔÇÖs stomach in order to have a clear view of the surgical instruments and the gallbladder and have a clean removal through one of the incisions. ┬áPost-surgery, the liver will produce bile and transport it to the small intestine through the common bile duct it just wonÔÇÖt be stored in the gallbladder. ┬áOn average it will only take one week to fully recover from Laparoscopic Cholecystectomy surgery.

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