Biliary Peritonitis After Percutaneous Nephrolithotomy:Case Studies and Management Concerns

Sutchin R. Patel, M.D., and Stephen Y. Nakada, M.D.

Abstract

Purpose: To evaluate cases of gallbladder injury, a rare and potentially serious complication, in the setting ofpercutaneous nephrolithotomy.Patients and Methods: We report two cases of gallbladder injury after percutaneous nephrolithotomy andreview the literature on this rare complication.Results: Both cases of gallbladder injury at our institution along with the four other case reports in the litera-ture all necessitated cholecystectomy. Medial right-sided collecting system access during percutaneous ne-phrolithotomy may increase the risk for biliary injury.Conclusions: Both recognized and unrecognized gallbladder injury may lead to biliary peritonitis necessitatingsubsequent cholecystectomy.

Introduction

Gallbladder injury during collecting system access forpercutaneous nephrolithotomy is a rare but potentially

serious complication. We report gallbladder puncture duringpercutaneous access and an unrecognized biliary injury afterpercutaneous nephrolithotomy.

Patients and Methods

We retrospectively reviewed two cases of gallbladder in-jury after percutaneous nephrolithotomy at our institution.We performed a MEDLINE literature search for all reportedcases of gallbladder injury after percutaneous nephroli-thotomy to better evaluate risk factors and outcomes in thesepatients.

Results

Case 1

A 49-year-old woman with a right partial staghorn calculuswas scheduled to undergo right percutaneous nephrolitho-tomy. With consultation, an interventional radiologist per-formed an upper-pole access into the collecting systemwithout any difficulty, a 30F access sheath was placed, andpercutaneous nephrolithotomy was performed without anydifficulty. A 16F reentry Malecot was left in place at the endof the procedure, with antegrade contrast injection showinggood nephrostomy tube placement and flow into the blad-der. The patient did well postoperatively. An antegradestudy showed delayed drainage, so the nephrostomy tube

was downsized to 8F, and the patient was dischargedhome on the first postoperative day with plans for a re-peated nephrostomy tube study and tube removal withinthe week.

The patient presented to the emergency department onpostoperative day 3 with increased right upper quadrantpain. On physical examination, she was afebrile, tachycardic,and had right upper quadrant tenderness. She had signs of anileus and was admitted for pain control and hydration. Thepatient’s pain initially improved with her return of bowelfunction but ultimately worsened with generalized abdomi-nal tenderness on postoperative day 5. CT revealed fluidin the pelvis, the right paracolic gutter, and surrounding theliver as well as gallbladder wall thickening with no gallstones(Fig. 1).

General surgery was consulted, and exploratory laparos-copy was performed followed by a laparoscopic cholecys-tectomy. Intra-abdominal bilious fluid was noted and wassuctioned, followed by irrigation of the peritoneal contents.Examination of the gallbladder revealed a hematoma alongthe mucosal aspect of the gallbladder fundus with a serosaldefect marking the puncture site. A Jackson-Pratt drain wasleft at the end of the procedure.

The patient’s remaining hospital course was unremarkable,and she was discharged home after drain and nephrostomytube removal two days after the cholecystectomy.

Case 2

A 55-year-old woman with a history of bilateral nephro-lithiasis was scheduled to undergo right percutaneous

Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

JOURNAL OF ENDOUROLOGYVolume 24, Number 11, November 2010ª Mary Ann Liebert, Inc.Pp. 1729–1731DOI: 10.1089=end.2010.0144

1729

nephrolithotomy for a 10-cm right renal stone burden. Shehad a surgical history of a perforated gastric ulcer with openrepair and had recently had a nephrostomy tube placed intothe right renal pelvis at an outside institution.

Interventional radiology was consulted to obtain upper-pole caliceal access. The original nephrostomy tube was usedto inject contrast followed by air to identify the upper-polecalix. During attempted access of the upper pole, the gall-bladder was punctured and opacified with contrast. With theneedle in place, 20 mL of bile were aspirated, and the needlewas removed. A subsequent attempt at upper-pole accessbeneath the 12th rib was successful and the tract was dilated, a30F access sheath was placed, and successful percutaneousnephrolithotomy was performed. A 24F reentry Malecotcatheter was placed at the end of the procedure, and injectionof contrast showed patency of the collecting system with flowinto the bladder. Postoperative chest radiography revealed nopneumothorax.

The patient’s postoperative course was complicated byright upper quadrant discomfort that worsened on postop-erative day 2. On physical examination, the patient’s entireabdomen was diffusely tender, prompting a general surgeryconsultation.

Abdominal CT revealed retained contrast within the gall-bladder, no gallstones, and fluid along the porta hepatis withperihepatic ascites (Fig. 2). Laparoscopy revealed significantintra-abdominal adhesions and bilious ascites throughout theintra-abdominal cavity. A laparoscopic cholecystectomy withperitoneal irrigation was performed. The patient recoveredwithout any further complication, had removal of the ne-phrostomy tube on postoperative day 3, and was dischargedhome.

Discussion

Four cases of gallbladder injury during percutaneousnephrolithtomy are reported in the literature with all of thecases necessitating cholecystectomy (three open, one laparo-scopic).1–4 Biliary peritonitis can be a surgical emergency witha mortality rate of up to 20%.5 Most authors believe thatgallbladder injuries are generally managed by cholecystecto-my.5 Some patients with biliary ascites without peritonitis,however, may be treated with percutaneous cholecystotomytube placement and drainage.

Chiverton and associates6 describe a series of 60 patientswho underwent percutaneous cholecystolithotomy for thetreatment of symptomatic gallstones. Gallbladder access wasperformed with the patient in the supine position after oralcholecystography, which allowed fluoroscopic localization ofthe gallbladder, as well as under ultrasonographic guidance.On gallbladder access, bile was aspirated to minimize leak-age and subsequent peritoneal irritation; a pigtail drain wasleft in place for 10 days after treatment of the gallstones. Theauthors reported two postoperative bile leaks in their series.One was controlled with a percutaneous drain placement intothe gallbladder because the initial drain had become dis-lodged. The second leakage resulted in a subphrenic fluidaccumulation that was percutaneously drained. Neither ofthese two complications resulted in cholecystectomy, whichmay be attributed to the fact that the patients’ gallbladderswere drained of bile on access and that a drain was left inplace at the end of the procedure.

We present two cases of biliary peritonitis after right per-cutaneous nephrolithotomy. Both cases resulted in laparo-scopic cholecystectomy, highlighting the gravity of gallbladderpuncture or injury during the procedure. Both patients’ post-operative course was significant for right upper quadrant ab-dominal pain, eventually developing into peritonitis.

FIG. 1. Case 1—CT reveals thickened gallbladder wall withpericholecystic fluid.

FIG. 2. Case 2—(Left)Retained contrast in thegallbladder on fluoroscopy;upper pole access withprevious interpolarnephrostomy tube inplace. (Right) CT revealsprevious residual contrastin the gallbladder alongwith pericholecystic fluid.

1730 PATEL AND NAKADA

Just as lateral collecting system access (lateral to the pos-terior axillary line) increases the risk of colonic injury, medialpercutaneous access is associated with an increased risk ofhemorrhage via injury to the branch of the posterior seg-mental artery and may also increase the risk of gallbladderinjury.7–9 The majority of patients with colonic injuries can betreated without open surgical intervention if the penetration isretroperitoneal and the patient does not have peritonitis orsepsis.7 The intraperitoneal leakage of bile, in cases of biliaryinjury, leading to peritonitis may not allow for conservativemanagement of this complication.

The location of both of our initial access placements wasslightly medial because we targeted the upper-pole calix. Thedepth of puncture is also an important factor because both ofour medial accesses were likely relatively deep in order toinjure the gallbladder. Although the details regarding col-lecting system access in relation to gallbladder injury are notwell reported in the literature, gallbladder injury may alsooccur during a lower-pole access.4

Conclusions

If gallbladder injury is recognized during collecting systemaccess during percutaneous nephrolithotomy, we recommendthat general surgery should be consulted because a chole-cystectomy may be necessary. In patients with persistent orworsening right upper quadrant pain after right percutaneousnephrolithotomy, it is important to consider the possibility ofan unrecognized gallbladder injury during access, and thereshould be a low threshold for further imaging of the abdomen.

Disclosure Statement

Dr. Patel has no competing financial interests; Dr. Nakadais a consultant=advisor for Cook Urological.

References

1. Saxby MF. Biliary peritonitis following percutaneous ne-phrolithotomy. Br J Urol 1996;77:465–466.

2. Kontothanassis D, Bissas A. Biliary peritonitis complicat-ing percutaneous nephrostomy. Int Urol Nephrol 1997;29:529–531.

3. Martin E, Lujan M, Paez A, et al. Puncture of the gall bladder:An unusual cause of peritonitis complicating percutaneousnephrostomy. Br J Urol 1996;77:464–465.

4. Fisher MB, Bianco FJ Jr, Carlin AM, Triest JA. Biliary perito-nitis complicating percutaneous nephrolithotomy requiringlaparoscopic choecystectomy. J Urol 2004;171:791–792.

5. Ackerman NB, Sillin LF, Suresh K. Consequences of intra-peritoneal bile: Bile ascites versus bile peritonitis. Am J Surg1985;149:244–246.

6. Chiverton SG, Inglis JA, Hudd C, et al. Percutaneous cho-lecystolithotomy: The first 60 patients. BMJ 1990;300:1310–1312.

7. Traxer O. Management of injury to the bowel during percu-taneous stone removal. J Endourol 2009;23:1777–1780.

8. Srivastava A, Singh KJ, Suri A, et al. Vascular complicationsafter percutaneous nephrolithotomy: Are there any predictivefactors? Urology 2005;66:38–40.

9. El-Nahas AR, Shokeir AA, El-Assmy AM, et al. Post-percutaenous nephrolithotomy extensive hemorrhage:A study of risk factors. J Urol 2007;177:576–579.

Address correspondence to:Stephen Y. Nakada, M.D.

Department of UrologyUniversity of Wisconsin School of Medicine and Public Health

G5=339 Clinical Science Center600 Highland Avenue

Madison, WI 53792-3236

E-mail: nakada@urology.wisc.edu

Abbreviation Used

CT¼ computed tomography

BILIARY PERITONITIS AFTER PCNL 1731