Cholecystostomy Tube Placement Research Articles

Percutaneous cholecystostomy tube placement as a bridge to cholecystectomy for grade III acute cholecystitis: A national analysis

IntroductionPercutaneous cholecystostomy (PCT) is an alternative to cholecystectomy (CCY) in high-risk surgical candidates with severe acute cholecystitis. A subset of these patients ultimately undergo delayed CCY. We therefore compared outcomes of delayed CCY in patients with grade III acute cholecystitis who received a PCT on index admission, to those who did not. MethodsNon-elective adult hospitalizations for grade III acute cholecystitis that underwent delayed CCY were identified in the 2016–2020 Nationwide Readmission Database. Patients who received a PCT during their index admission comprised the PCT group (others: Non-PCT). Outcomes were assessed for the CCY hospitalization. Entropy balancing was used to generate sample weights to adjust for differences in baseline characteristics. Regression models were created to evaluate the association between PCT and the outcomes of interest. ResultsOf an estimated 13,782 patients, 13.3 % comprised PCT. Compared to Non-PCT, PCT were older (71.1 ± 13.1 vs 67.4 ± 15.3 years) and more commonly in the highest income quartile (22.5 vs 16.1 %, both p < 0.001). After risk adjustment, PCT was associated with reduced odds of respiratory (AOR 0.67, CI 0.54–0.83) and infectious (AOR 0.77, CI 0.62–0.96) complications after eventual CCY. Finally, PCT had comparable pLOS (β +0.31, CI [−0.14, 0.77]) and operative hospitalization costs (β $800, CI [−2300, +600]). ConclusionIn the present study, PCT was associated with decreased odds of perioperative complications and comparable resource utilization upon readmission CCY. Our findings suggest that PCT may be helpful in bridging patients with grade III acute cholecystitis to eventual CCY.

Improving Outcomes in EGS: Construct of a Collaborative Quality Initiative.

Emergency general surgery conditions are common, costly, and highly morbid. The proportion of excess morbidity due to variation in health systems and processes of care is poorly understood. We constructed a collaborative quality initiative for emergency general surgery to investigate the emergency general surgery care provided and guide process improvements. We collected data at ten hospitals from 7/2019-12/2022. Five cohorts were defined: acute appendicitis, acute gallbladder disease, small bowel obstruction, emergency laparotomy, and overall aggregate. Processes and inpatient outcomes investigated included operative vs. non-operative management, mortality, morbidity (mortality and/or complication), readmissions, and length of stay. Multivariable risk adjustment accounted for variations in demographic, comorbid, anatomic, and disease traits. Of the 19,956 emergency general surgery patients, 56.8% were female and 82.8% were white, and the mean (SD) age was 53.3 (20.8) years. After accounting for patient and disease factors, the adjusted aggregate mortality rate was 3.5% (95% CI, 3.2-3.7), morbidity 27.6% (95% CI, 27.0-28.3), and the readmission rate was 15.1% (95% CI, 14.6-15.6). Operative management varied between hospitals from 70.9% to 96.9% for acute appendicitis and 19.8% to 79.4% for small bowel obstruction. Significant differences in outcomes between hospitals were observed with high- and low-outlier performers identified after risk adjustment in the overall cohort for mortality, morbidity, and readmissions. The use of a Gastrografin challenge in patients with a small bowel obstruction ranged from 10.7% to 61.4% of patients. In patients who underwent initial non-operative management of acute cholecystitis, 51.5% had a cholecystostomy tube placed. The cholecystostomy tube placement rate ranged from 23.5% to 62.1% across hospitals. A multihospital emergency general surgery collaborative reveals high morbidity with substantial variability in processes and outcomes among hospitals. A targeted collaborative quality improvement effort can identify outliers in emergency general surgery care and may provide a mechanism to optimize outcomes. III, therapeutic/care management.

The Utility of Routinely Performing a Short-Interval Cholecystogram following Cholecystostomy Tube Placement

Abstract Purpose The purpose of this study is to evaluate the utility of routinely performing short-interval cholecystogram (SIC) following percutaneous cholecystostomy tube (PCT) placement and to identify predictive factors for early PCT dislodgment. Materials and Methods We conducted retrospective review of 224 adult patients who underwent PCT placement for acute cholecystitis at a single tertiary care medical center. SIC was defined as occurring at least 1 day after PCT placement and prior to the patient being discharged from the hospital. Early PCT dislodgment was defined as occurring within 2 months of placement. Results Among 224 patients, 181 (80%) patients underwent SIC on average 3 days after PCT. Of these, 175 (97%) had PCT appropriately positioned, while 6 (3%) showed tube malposition outside the gallbladder. Patients who underwent a SIC demonstrated a similar rate of early tube dislodgment compared to those discharged without this procedure (12.6 vs. 14.3%, p = 0.81). Notably, patients with a body mass index exceeding 40 kg/m2 had a higher likelihood of early cholecystostomy tube dislodgment (29 vs. 14%, p = 0.038). Conclusion Routinely performing a SIC following PCT may offer limited benefit. We recommend selectively performing this study on patients with clinically suspected tube dislodgement.

Bedside Ultrasound-Guided Percutaneous Cholecystostomy in Critically Ill Patients—Outcomes in 51 Patients

Abstract Purpose The aim of this study was to report technical and clinical success of bedside ultrasound-guided percutaneous cholecystostomy (PC) tube placement in intensive care unit (ICU). Materials and Methods This is a retrospective study of 51 patients (36 males:15 females, mean age: 67 years) who underwent ultrasound-guided PC from May 2015 to January 2020. The indication for cholecystostomy tube placement, comorbidities, imaging finding, technical success, clinical success, timing of surgery post-cholecystostomy tube placement, indwelling catheter time, complications, and follow-up were recorded. Results Indications for cholecystostomy tube placement were acute calculous cholecystitis (n = 43; 84.3%), perforated cholecystitis (n = 5; 9.8%), and emphysematous cholecystitis (n = 3; 5.9%). Most of the patients had multiple comorbidities; these were diabetes mellitus, hypertension, cardiovascular disease, chronic renal disease, underlying malignancy, and multisystem disease with sepsis. All patients had undergone PC through transhepatic approach under ultrasound guidance in ICU. Technical success rate of the procedure was 100%. Clinical success rate was 92.1% (47/51) and among these 44/51 (86.2%) patients underwent definitive elective cholecystectomy, 3/51 (5.9%) patients had elective tube removal. Three of fifty-one (5.9%) patients did not improve; among these two underwent emergency surgery, while there was 1/51 (1.9%) mortality due to ongoing sepsis and multiorgan dysfunction. There were no procedure-related mortalities or procedure-related major complications. One patient had bile leak due to multiple attempts for cholecystostomy placement. Mean tube indwelling time was 13 days (range: 3–45 days). Conclusion Ultrasound-guided PC can be safely performed in ICU in critically ill patients unfit for surgery with high technical and clinical success rates. Early laparoscopic cholecystectomy should be preferred after stabilization of clinical condition following cholecystostomy.

The impact of interval cholecystectomy timing after percutaneous transhepatic cholecystostomy on post-operative adverse outcomes.

This study aims to explore how timing of interval of cholecystectomy (IC) after percutaneous transhepatic cholecystostomy tube (PTC) placement impacts post-operative outcomes. A retrospective database analysis of New York State SPARCs database of IC between 2005 and 2015. The timing forIC ranged between > 1week and < 2years. Patients undergoing this procedurewere further divided into quartiles using 4-time intervals; 1-5weeks (Q1), 5-8weeks (Q2), 8-12weeks(Q3), and > 12weeks(Q4). The study's primary outcome was hospital length of stay (LOS). Secondary outcomes included discharge status, 30-day readmission, 30-day ED visit, and 90-day reoperation, surgery type, complication, and bile duct injury. Multivariable regression models were used to compare patients across the four-time intervals after adjusting for confounding factors. A total of 1038 patients with a history of PTC followed by IC between > 1week and < 2years were included in the final analysis. The median time to IC was 7.7weeks. Q2 and Q3 both had a significantly higher median LOS of 3days versus Q1 and Q4 at median of 5days (p < 0.0001). Patients from racial and ethnic minorities (e.g., African Americans and Hispanics) were more likely to get their IC after 12weeks (p < 0.05). Further, Black patients had a significantly higher median LOS than White, non-Hispanic patients (8days vs 4days, p < 0.0001) and were more likely to have open procedure. Multivariable regression analysis identified shorter LOS during Q2 (Ratio, 0.76, 95%, 0.67-0.87, p < 0.0001), and Q3 (Ratio 0.75, 95% CI, 065-0.86, p < 0.0001) compared to those who got their IC in Q4. Similar findings exist when comparing Q2 and Q3 to those receiving treatment during Q1. A time interval of 5-12weeks between PTC and IC was associated with a decreased LOS. This study also suggests the persistence of racial disparities among these patients.

National Cholecystostomy Tube Placement and Cholecystectomy Trends From 2010 to 2018

National Cholecystostomy Tube Placement and Cholecystectomy Trends From 2010 to 2018

Impact of COVID-19 Pandemic on Management and Outcomes of Acute Cholecystitis at US Academic Centers.

The COVID-19 pandemic has had wide-ranging effects on management of medical conditions. Many hospitals encountered staffing shortages, limited operating room availability, and shortage of hospital beds. There was increased psychological stress and fear of contracting COVID-19 infection, leading to delay in medical care for various disease processes. The objective of this study was to examine changes in management and outcomes attributed to the COVID-19 pandemic in patients presenting with acute calculus cholecystitis at US academic centers. Using the Vizient database, patients with the diagnosis of acute calculus cholecystitis who underwent intervention during the 15 months before the pandemic (prepandemic, October 2018 to December 2019) were compared with 15 months during the pandemic (pandemic, March 2020 to May 2021). Outcomes measures included demographics, characteristics, type of intervention, length of stay, in-hospital mortality, and direct cost. There were 146,459 patients with acute calculus cholecystitis identified (prepandemic: 74,605 vs pandemic: 71,854). Patients in the pandemic group were more likely to undergo medical management (29.4% vs 31.8%; p < 0.001) or percutaneous cholecystostomy tube placement (21.5% vs 18%; p < 0.001) and less likely to undergo laparoscopic cholecystectomy (69.8% vs 73.0%; p < 0.001). Patients in the pandemic group who underwent procedural intervention had longer length of stay (6.5 days vs 5.9 days; p < 0.001), higher in-hospital death (3.1% vs 2.3%; p < 0.001), and higher cost ($14,609 vs $12,570; p < 0.001). In this analysis of patients with acute calculus cholecystitis, there were distinct changes in the management and outcomes of patients due to the COVID-19 pandemic. Changes in the type of intervention and outcomes are likely related to delayed presentation with increases in the severity and complexity of the disease.

Abstract No. 520 National Trends of Cholecystostomy Tube Placement and Cholecystectomy from 2000 to 2018

Abstract No. 520 National Trends of Cholecystostomy Tube Placement and Cholecystectomy from 2000 to 2018

Practice Patterns of Endoscopists Performing Endoscopic Gallbladder Drainage

Background and AimsThe standard of care for treatment of patients with acute cholecystitis is cholecystectomy. However, many patients are unfit for surgery due to substantial medical comorbidities, or surgery is technically challenging due to anatomic considerations. Options for patients who are not surgical candidates include percutaneous cholecystostomy tube placement by interventional radiology, endoscopic gallbladder drainage (EGBD), or conservative management. Over the last decade, techniques of EGBD have been employed for temporary or definitive gallbladder drainage in patients with acute cholecystitis who are not surgical candidates. Despite growing interest and clinical use of EGBD, little is known about practice patterns of EGBD. Our aim was to survey endoscopists to evaluate the practice patterns and technical considerations regarding EGBD. MethodsAn 18-item survey was distributed to all members of the American Society of Gastrointestinal Endoscopy. Each response was included in the final analysis. Descriptive statistics were calculated using frequencies and percentages. ResultsResponses were received from 217 endoscopists. Of these, 178 perform endoscopic ultrasound-guided gallbladder draining and 178 perform endoscopic transpapillary gallbladder drainage. The preferred approach for EGBD was endoscopic ultrasound-guided gallbladder drainage in 58.8%, endoscopic retrograde cholangiopancreatography (ERCP)-guided transpapillary gallbladder stent placement in 30.2%, and no preference in 11%. ConclusionDespite growing interest in EGBD, significant heterogeneity in practice patterns exists. Further study is needed to better understand these differences and provide data for future guidelines.

Multi-institutional Retrospective Study of Percutaneous Cholangioscopy-Assisted Lithotripsy for Inoperable Calculous Cholecystitis

PurposeThis study aimed to assess the safety and efficacy of percutaneous lithotripsy for gallstone eradication in patients with calculous cholecystitis with stones >1 cm. Materials and MethodsMulti-institutional institutional review board approved retrospective review of patients who presented with calculous cholecystitis and were not determined to be surgical candidates. All patients underwent percutaneous cholecystostomy tube placement for acute infection, which was later exchanged for a large sheath for ShockPulse (Olympus, Tokyo, Japan) lithotripsy and stone destruction. Review parameters included procedural technical and clinical data, including clinical presentation, mean length of hospital stay, and postintervention symptom reduction. ResultsTwelve patients (mean age, 74.6 years; range, 52–94 years; 6 men and 6 women) underwent large-bore sheath (24–30 F) cholangioscopy-assisted gallstone destruction via rigid lithotripsy. The size of the gallstones ranged from 1.2 to 4.0 cm. All patients had prior cholecystostomy access for a mean of 25 weeks before gallstone extraction to ensure tract maturation via transhepatic or transperitoneal access. The technical success rate in single-session stone removal was 100%, with no major procedure-related adverse events. All patients were symptom- and pain-free after the procedure. The mean procedure time was 111.5 minutes, and the mean fluoroscopy time was 19.2 minutes. The median length of hospital stay was 1 day after the procedure. The mean time from percutaneous lithotripsy to biliary tube removal was 35 days (range, 17–45 days). ConclusionsFluoroscopy-guided percutaneous rigid lithotripsy is a safe and effective procedure for gallstone destruction and extraction in patients who are poor surgical candidates with large lumen-occupying cholelithiasis.

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

S1738 Hemorrhagic Cholecystitis: A Rare Cause of Brisk Upper Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding is a commonly seen problem in the hospital and timely identification of the source is important in brisk bleeds to allow for prompt interventions. Unfortunately, the cause of the bleeding can sometimes be difficult to identify and can require thinking outside the box. We present a rare case of hemorrhagic cholecystitis manifesting as hematochezia and hypotension in the setting of chronic liver disease. Case Description/Methods: A 55-year-old man with history of alcoholic cirrhosis (Meld-Na 24, Child-Pugh C) initially presented to an outside hospital with one week of nausea, vomiting, abdominal pain and watery diarrhea in the setting of alcohol withdrawal. He underwent an esophagogastroduodenoscopy (EGD) revealing a single gastric varix with red nipple without active bleeding and no esophageal varices. His liver function began to worsen and improved with supportive care. His improvement interestingly correlated with acute onset of hematochezia. A repeat EGD and colonoscopy revealed numerous blood clots in the colon without an active source of bleeding. He was transferred to our academic medical center for higher level of care. Upon arrival, he continued to have hematemesis and hematochezia. Repeat EGD/colonoscopy showed small non-bleeding gastric varices as well as massive maroon-colored clots throughout the colon and terminal ileum but no signs of active bleeding. CT angiography (CTA) revealed hyperdense material within the gallbladder lumen and extrahepatic biliary ductal systems suspicious for hemobilia and acute hemorrhagic cholecystitis. Pt underwent capsule endoscopy revealing an irregular oozing of blood in the proximal small intestine. A push enteroscopy then revealed actively oozing blood from the ampulla of Vater (Figure). Patient subsequently underwent successful cholecystostomy tube placement and cystic artery embolization with resolution of his bleeding. Discussion: Hemorrhagic cholecystitis is an infrequent complication of cholecystitis with few published case reports. Due to the rarity of hemorrhagic cholecystitis causing brisk upper gastrointestinal bleeding with hematochezia, the cause of the bleeding was overlooked despite numerous endoscopies and not found until a capsule endoscopy was performed. This case teaches us to keep our differentials broad when the cause of the gastrointestinal bleeding is unclear. Prompt recognition can lead to earlier diagnosis and intervention to improve outcomes in this patient population.Figure 1.: Enteroscopy demonstrating bleeding at the Ampulla of Vater.

Outcomes Following Percutaneous Cholecystostomy Tube Placement for Acalculous Versus Calculous Cholecystitis.

Acute acalculous cholecystitis (AAC) is often diagnosed in critically ill patients. Percutaneous cholecystostomy tube (PCT) placement facilitates less invasive gallbladder decompression in patients who are poor surgical candidates. Specific guidelines for optimal management of AAC patients following PCT placement remain to be defined. We hypothesize that AAC patients are at lower risk of recurrent cholecystitis than acute calculous cholecystitis (ACC) patients and do not require cholecystectomy after PCT placement. A retrospective review of patients who underwent PCT placement for AAC or ACC between 6/1/2007 and 5/31/2019 was performed. Primary outcome was recurrent cholecystitis and interval cholecystectomy for patients surviving 30days after PCT placement. Secondary outcome was 30day mortality. A cox regression model calculated the adjusted hazard ratio (AHR) for the outcomes. Eighty-four AAC and 85 ACC patients underwent PCT placement. Compared to ACC patients, more AAC patients were male (72.6 vs. 48.2%; p < 0.01), younger (median age 62 vs. 73years; p < 0.01), and required intensive care (69.0 vs. 52.9%; p = 0.04), with lower median Charlson Comorbidity Index (4.0 vs. 6.0; p < 0.01). 30day mortality was higher among AAC patients than ACC patients (45.2 vs. 21.2%; p < 0.01). 2/24 (8.3%) AAC patients and 5/31 (16.1%) ACC patients developed recurrent cholecystitis at a median 208.0days (IQR:64.0-417.0) after PCT placement and 115.0days (IQR:7.0-403.0) following PCT removal. Cox regression analysis demonstrated that AAC patients had lower likelihood of interval cholecystectomy compared to ACC patients (AHR 2.35; 95% CI:1.11,4.96). Recurrent cholecystitis is rare in patients surviving 30days following PCT placement. When compared with ACC patients, fewer AAC patients require cholecystectomy.

Timing of cholecystectomy following cholecystostomy tube placement for acute cholecystitis: a retrospective study aiming to identify the optimal timing between a percutaneous cholecystostomy and cholecystectomy to reduce the number of poor surgical outcomes.

Our study aims to identify the optimal timing between a percutaneous cholecystostomy (PC) and cholecystectomy to reduce the number of poor surgical outcomes. Biliary disease is a common surgical disease and laparoscopic cholecystectomy is the preferred strategy for the management of acute cholecystitis. However, in high-risk surgical patients, a PC tube may be placed instead. In the 2018 Tokyo Guidelines, the optimal timing of cholecystectomy following a PC has been identified as an important future research question. This is a retrospective study that focuses on identifying the ideal timing of cholecystectomy after PC tube placement to minimize complications. Poor surgical outcomes were measured as 90-day reoperations, 30-day readmissions, 30-day emergency department (ED) visits, length of stay (LOS), and discharge destination. Patients were selected from the New York SPARCS database from 2005 to September 30, 2015. 1213 records that consisted of both PC and cholecystectomy were collected. No significant differences in 30-day readmissions, 90-day reoperations, and 30-day ED visits in relation to timing between PC and cholecystectomy were found. Additionally, the decision to replace or not replace dislodged PC tubes was not associated with 90-day reoperation, 30-day readmission, 30-day ED visit, LOS, or discharge destination. However, discharge destination and LOS were significantly different between early intervention of 3days or less between PC and cholecystectomy and late intervention of more than 14days with late intervention being associated with shorter LOS and more home discharges. Performing a cholecystectomy more than 14days after a PC is associated with better surgical outcomes.

Percutaneous Cholecystostomy Tubes versus Medical Management for Acute Cholecystitis.

Cholecystitis is one of the most common infections treated surgically in the United States. Surgical risk is prohibitive in some patients, leading to alternative therapeutic strategies, including medical management (antibiotics) with or without percutaneous cholecystostomy tube (PCT) drainage. Using the Healthcare Cost and Utilization Project (HCUP) National Readmission Database (NRD), we performed a retrospective review to compare medically managed patients with or without PCT placement by evaluating 60-day readmissions rates, health care costs, and hospital length of stay (LOS). Both study groups were matched using the Elixhauser comorbidity index, age, and sex. Univariate and multivariate statistical analyses were performed using STATA. 776,766 patients were included in the analysis. The population receiving PCT placement was on average 16years older (69.9 vs 53.6years; P < .01), less likely to be female (40.7% vs 59.3%; P < .01), and had almost twice as many comorbidities (3.36 vs 1.81; P < .01) compared to the population receiving medical management. After matching our data to account for these incongruities, PCT patients were still 10.4 times more likely to be readmitted, had a 11.6% increase in the cost of care, and a 37.6% increase in LOS compared to those managed medically. Percutaneous cholecystostomy tube placement for cholecystitis is associated with a higher readmission rate, increased charges, and increased LOS compared to antibiotic therapy alone, even after correcting for age, sex, and comorbidities.

Open Cholecystostomy Under Local Anesthesia for Acute Cholecystitis in the Elderly and High-Risk Surgical Patients.

The morbidity and mortality rates associated with cholecystectomy for acute cholecystitis are higher in the critically ill elderly population. As an alternative to cholecystectomy, we report the results of treatment of acute cholecystitis in the elderly after open cholecystolithotomy with cholecystostomy tube placement under local anesthesia. A case series was performed on 5 patients from August 2007 to April 2010 who presented with acute cholecystitis and underwent an open cholecystolithotomy and tube placement. Thirty-day mortality, intra- and immediate-postoperative complications, clinical improvement after drainage, additional biliary procedures needed, and outcome after cholecystostomy tube removal were recorded. Open cholecystolithotomy and tube placement were performed successfully in all patients and permitted resolution of the acute attack in all after a mean period of 3.75days. Thirty-day mortality was 0%. Patients did not experience any intraoperative complications. We observed 100% rate of successful short-term outcomes in our patients including resolution pain, and objectively, normalization of leukocytosis, and defervescence. None of the patients required emergency cholecystectomy. All patients had their cholecystostomy tubes removed at a mean postoperative day 27. There were no cases of biliary leakage or tube dislodgement. There were no recurrences of acute cholecystitis within the mean follow-up of 20.75months. Emergency open cholecystolithotomy and cholecystostomy tube placement represent an effective, safe, and definitive alternative treatment strategy for acute gallstone cholecystitis in selected elderly patients with a mortality rate of 0% in the authors' experience.

Is Partial Cholecystectomy a Better Alternative to Percutaneous Cholecystostomy Tube Placement? A Population-Based Outcomes Analysis of Partial Cholecystectomy and Percutaneous Cholecystostomy Tube Placement in 20,141 Patients with Acute Cholecystitis

Is Partial Cholecystectomy a Better Alternative to Percutaneous Cholecystostomy Tube Placement? A Population-Based Outcomes Analysis of Partial Cholecystectomy and Percutaneous Cholecystostomy Tube Placement in 20,141 Patients with Acute Cholecystitis

S1545 Acute Acalculous Cholecystitis Leading to the Diagnosis of Systemic Lupus Erythematosus

Introduction: Acute acalculous cholecystitis (AAC) involves inflammation of the gallbladder without the presence of gallstones, and is commonly seen in ill hospitalized patients. We present a case of acalculous cholecystitis as the initial presentation of systemic lupus erythematosus (SLE). Case Description/Methods: A 34-year-old woman presented with two weeks of fever, epigastric pain with nausea, and a 10-pound weight loss. Review of systems was positive for dry eyes, dry mouth, and myalgias. Past medical history was notable for miscarriage. Complete blood count was notable for thrombocytopenia, normocytic anemia, and neutropenia (with absolute neutrophil count of 660 10*3/uL). Comprehensive metabolic panel was notable for an elevated protein gap and slightly abnormal AST 161 IU/L and ALT 61 IU/L. CT abdomen demonstrated gallbladder wall thickening, with no evidence of cholelithiasis. RUQ ultrasound confirmed the absence of gallstones. HIDA scan showed non-visualization of the gallbladder consistent with cystic duct obstruction. Erythrocyte sedimentation rate was elevated at 56 mm/hr and ferritin was greater than 4000 ng/ml. Further testing revealed positive testing for ANA, double-stranded DNA, anti-ro, and lupus anticoagulant. Given the predominant autoimmune symptoms, she was started on prednisone 60 mg for newly diagnosed lupus with improvement of her symptoms. After discharge she was started on plaquenil and azathioprine, and steroids were tapered. Repeat testing confirmed persistent antibodies for antiphospholipid syndrome. She was lost to follow up 6 months after discharge. Discussion: GI manifestations of lupus can be vast, and include oral ulcers, mesenteric vasculitis, intestinal pseudo-obstruction, protein losing enteropathy, lupus associated pancreatitis, and serositis. Hepatobiliary manifestations include primary sclerosing cholangitis and autoimmune cholecystitis. The pathogenesis of AAC in SLE typically involves vasculitis, serositis, or thrombosis, and gallbladder histology often shows vasculitis of small vessel arteries and venules. Treatment typically involves percutaneous cholecystostomy tube placement or cholecystectomy; however, there have been case reports of successful treatment of AAC in SLE with high dose corticosteroids, often in combination with antibiotics or other immunosuppressants. Our case demonstrates the importance of considering underlying autoimmune conditions in patients presenting with gastrointestinal symptoms.

S2614 An Unconventional Presentation of Hemophagocytic Lymphohistiocytosis

Introduction: Hemophagocytic Lymphohistiocytosis (HLH) characterized as a cytokine storm secondary to a dysregulated immune state predominantly affects the pediatric population but, reports of adult cases are increasing. The cytokine storm mediated by natural killer cells, macrophages and cytotoxic lymphocytes can be triggered by a genetic variation, infection, malignancy, or rheumatologic disease. This case discusses an unconventional presentation of HLH. Case Description/Methods: A 61 year-old male with a past medical history of coronary artery disease, aortic stenosis, type 2 diabetes mellitus and chronic hepatitis with cirrhosis (of unknown etiology from prior workup) presented with lethargy and fevers. Physical exam was significant for jaundice and tender hepatosplenomegaly. Bloodwork showed: lymphopenia, neutropenia, direct hyperbilirubinemia, and transaminitis. Right upper quadrant ultrasound showed a diffusely echogenic nodular liver with gallbladder dilation in the absence of biliary ductal dilation. Patient was empirically treated for ascending cholangitis with broad spectrum antibiotics and was later found to have E.coli bacteremia. Given patients septic state he underwent percutaneous cholecystostomy tube placement without complication. A complete infectious, hematologic, and hepatologic workup found negative/normal: CMV, EBV, TB, HIV, COVID-19, parvovirus B19, viral hepatitis, DAT, ANA, RF, ANCA, AMA, ASMA, ceruloplasmin, alpha-1 antitrypsin, and C282Y/S/6/5/C. Fibrinogen, ferritin, D-dimer, triglycerides, CXCL-9, and CD-25 were found to be abnormal. Patient's former records were reviewed and showed: cirrhosis with lymphocytic infiltrate on liver biopsy, a normal endoscopy, and an inconclusive bone marrow biopsy only showing clusters of histiocytes. The patient met criteria for HLH and was started on dexamethasone and etoposide. The patients condition continued to worsen and he was transferred to a tertiary care center where he was diagnosed with T-cell histiocyterich diffuse large B-cell lymphoma on repeated biopsy with HLH. Discussion: In patients with high-grade fevers of unknown etiology and multi-organ failure, HLH should be on the differential despite the rarity of adult cases. This case represents an unconventional presentation of HLH in the setting of a confounding bacteremia from ascending cholangitis and underlying B-cell Lymphoma.

Retrospective evaluation of image-guided cholecystostomy tube utilization and outcomes during the first wave of the COVID-19 pandemic

Objectives: During the COVID-19 pandemic, there was a perceived increase in the number of cholecystostomy tube placements. We have retrospectively analyzed the incidence and outcomes of cholecystostomy tube placement during the COVID-19 pandemic surge. Material and Methods: Cholecystostomy tube placement and overall interventional radiology (IR) case volume were analyzed at our tertiary care center during the pandemic (March 15, 2020–July 30, 2020) and compared to the same time period in 2019. In addition, an age- and gender-matched control study of outcomes for 40 patients (25 from our home institution and 15 from our affiliated hospitals) grouped by COVID-19 status who received percutaneous cholecystostomy tubes between March 15, 2020, and July 30, 2020, was performed. Results: We observed a significant increase in relative cholecystostomy tube volume during the pandemic, despite a decrease in total IR case volume. There was no significant difference in pre- or post-procedural laboratory data, vital signs, imaging, or mortality between COVID-positive and COVID-negative patients who received cholecystostomy tubes. Conclusion: Percutaneous cholecystostomy tube placement is likely a safe treatment for acalculous cholecystitis in patients with COVID-19 with equivalent outcomes to patients without COVID-19.