Endoscopic ultrasound (EUS) guided gallbladder drainage

The gallbladder acts as a reservoir for bile that has been produced by the liver. It is common for stones to form in the gallbladder, known as gallstones. Sometimes, usually when the gallbladder is blocked by a gallstone, the bile in the gallbladder can become infected with a build-up of pus. This is called cholecystitis.

If your gallbladder is infected, you will be very unwell with fever and abdominal pain. You are likely to be in hospital already and to have been given antibiotics to treat the infection. If the antibiotics are not enough to settle the infection there is a risk that the gallbladder can burst, and so doctors may decide that your gallbladder needs to be drained.

The ideal treatment for cholecystitis is an immediate keyhole operation to remove the gallbladder, but often a patient is too unwell, or has other medical problems that make an immediate operation unsafe. In these situations, the treatment for many years has been to drain the gallbladder using a long tube which is placed through the skin and into the gallbladder to drain the infected material away. The tube is placed between the ribs at the bottom of the right side of the chest. This tube must then stay in place for up to six weeks. This is called a percutaneous gallbladder drain.

Endoscopic ultrasound (EUS) guided gallbladder drainage involves the insertion of a stent (a flexible metallic tube) to drain infected material into the stomach or small bowel and is a suitable alternative for some patients. Ultrasound uses sound waves to produce images of the organs inside the body.

It has been shown in clinical trials that EUS guided gallbladder drainage is a more effective treatment for cholecystitis than a percutaneous gallbladder drains as it is more comfortable and reduces the likelihood of complications (such as being admitted to hospital again with a blocked or dislodged drain). The stent is often left in permanently so if the surgeons are unable to remove the gallbladder, the stent can help reduce the change of further gallbladder infections.

All treatments and procedures have risks and we will talk to you about the risks of EUS guided gallbladder drainage.

Uncommon complications which can occur during any EUS procedure include chest infections, damage or perforation (a hole) in the wall of the oesophagus, stomach or duodenum, allergy to sedative medication, bleeding and damage to teeth.

There are also specific risks which can occur during or after EUS guided gallbladder drainage.

Problems that may happen straight away

There is a risk of bleeding from the stent as it goes through the wall of the stomach or duodenum (the first part of the small bowel immediately past the stomach): this can occur in 1 in every 100 procedures. You will stay in hospital after the procedure to be observed and if the bleeding is severe, you may need an operation to stop it.

There is a theoretical chance that the stent may be placed in the wrong place. If this happens you may need a percutaneous gallbladder drain and an operation performed by a surgeon in operating theatres to remove the stent.

Problems that may happen later

In approximately 1 in every 20 procedures the stent can become blocked. If this happens you would need to return to hospital for a further endoscopy procedure to unblock the stent by placing a smaller plastic stent through the first stent.

Occasionally (less than 1 in 100 procedures) the stent can fall out. This would result in bile leaking into the abdomen which could lead to pain or infection and the need for another drain to be placed.

The main alternative to EUS guided gallbladder drainage is the placement of a drainage tube through your abdominal wall (described above in "How can endoscopic ultrasound guided gallbladder drainage help?").

Other treatment options include an emergency operation to remove the gallbladder. However, a drainage procedure is usually a better option for patients who are very unwell as a result of the gallbladder infection, or who have other medical problems that would make an operation higher risk.

Since X-rays are sometimes taken during the procedure, please tell us if there is any possibility you may be pregnant.

We will need to know about all the medications you take, in particular blood thinners, such as clopidogrel, warfarin, heparin, rivaroxaban, apixaban or dabigatran, which may need to be stopped or adjusted up to one week before the procedure.

If you take clopidogrel or other blood thinners it may be necessary to check with your Cardiologist (or other specialist) to be sure that these can be stopped before your procedure.

If you are a diabetic and take insulin, it is important that you continue taking your insulin, but it is suggested that you reduce your dose on the day and night before the procedure. If you are concerned, then contact your local diabetes nurse for advice. Remember to check your blood sugar every three to four hours.

If you are taking tablets for your diabetes, please do not take them on the day of the procedure until after the procedure has been done. Please bring your diabetic tablets or insulin to the hospital with you if you are not already in hospital.

Please continue to take any other medication (including laxatives). If you are in hospital when the procedure is being done, then doctors on the ward will manage your medicines for you.

You should not eat anything for six hours before the appointment.

You may drink water only up until four hours before the procedure (your usual prescription medicines can still be taken after that with a sip of water).

You will be admitted to the ward overnight following the procedure and so you will need to bring an overnight bag. You may be given heparin injections to thin the blood to prevent blood clots while you are in hospital.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please speak with a senior member of staff again.

The procedure is done in the Endoscopy Department and is performed by a specially trained team led by a Gastroenterologist. The procedure is done under sedation or with an anaesthetist putting you to sleep. You will spend up to 45 minutes in the procedure room.

The procedure is performed using a thin flexible tube containing a miniature camera (endoscope) with an ultrasound probe on the end. The endoscope is put in your mouth and passed down your oesophagus. Using ultrasound guidance, a special type of stent (a lumen-apposing metal stent) is placed into your gallbladder through the wall of either your stomach or duodenum.

The lumen-apposing metal stent creates an opening between the gallbladder and the stomach or duodenum. This allows the pus and infected bile to flow out of your gallbladder and into the bowel, which should usually lead to a rapid improvement in the infection and pain. You will continue to be treated with antibiotics.

You may wake up with some pain in your abdomen. We will prescribe pain medication if required. If your pain is severe or it worsens, then the doctors may check to see if there has been a complication, and so may request a CT (computerised tomography) scan.

When you have recovered from the procedure, you will be sent back to the ward. The next morning the team will determine whether you can go home that day: this will usually depend on the severity of your gallbladder infection as you might need more time on intravenous antibiotics.

If you are taking blood thinning medication, we will tell you when you can restart the medication following your procedure. This information will also be provided in your discharge paperwork.

The evidence we have tells us that this is a safe procedure. However, the following symptoms might suggest a complication:

• severe persistent pain
• light-headedness, or fainting
• shivering or fever
• vomiting of blood
• passing of blood or black tar-like stools
• feeling generally very unwell.

If you have any problems, please contact the Hepatobiliary Team Pathway Co-ordinator or Specialist Nurse in the first instance.

If you have a problem outside of office hours which cannot wait until the next day, please contact the hospital switchboard and ask to be put through to the on-call Gastroenterology Registrar. In an emergency, please visit your nearest Accident and Emergency Department. Contact information is provided below.

Endoscopy Booking Team (Monday to Friday 09:00-17:00)
Direct line: 020 3456 7022
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 67022
E-mail: uclh.endoscopy@nhs.net

Endoscopy Recovery (Monday to Friday 09:00-17:00)
Direct line: 020 3447 3282
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 73282

Hepatobiliary Pathway Co-ordinator (Monday to Friday 09:30-17:30)
Direct line: 020 3447 9229
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 79229

Hepatobiliary Clinical Nurse Specialist (Monday to Friday 09:00-17:00)
Mobile: 07967 760146

On-call Gastroenterology Registrar (out of hours emergencies only)
Switchboard: 0845 155 5000 / 020 3456 7890

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU