Acute cholecystitis in patients with multiple comorbidities and advanced malignancy presents unique diagnostic and therapeutic challenges. Contrast-enhanced ultrasound (CEUS) has emerged as a valuable tool for diagnosing complicated cholecystitis and guiding interventional procedures. A 69-year-old male with locally advanced pancreatic head carcinoma, chronic ischemic heart disease, and COPD who developed complicated acute cholecystitis with pericholecystic abscess. CEUS confirmed the diagnosis and guided percutaneous cholecystostomy placement via a transperitoneal approach. Intracavitary CEUS through the drainage catheters was subsequently used to verify correct positioning, assess gallbladder perforation, evaluate cystic duct patency, and monitor treatment response. The patient showed progressive clinical and laboratory improvement, with successful resolution of the acute episode without requiring emergency surgery.

Peroral cholangioscopy (POCS) and peroral pancreatoscopy (POPS) enable direct intraductal visualization for pancreatobiliary disease diagnosis and management. Nonetheless, conventional devices have relatively large diameters, limiting their use in narrow ducts. This single-center, retrospective, observational study aimed to evaluate the feasibility and safety of a novel ultraslim catheter-type POCS/POPS (UCPOCS/UCPOPS) (distal outer diameter: 2.3 mm) in 12 patients who underwent UCPOCS or UCPOPS from November 2022 to August 2024. UCPOCS was performed in eight patients with bile duct stones (n = 3), biliary strictures (n = 2), intrahepatic cholangiocarcinoma (n = 1), post-hepatectomy biliary bleeding (n = 1), and acute cholecystitis requiring endoscopic naso-gallbladder drainage (n = 1). UCPOPS was performed in four patients for postoperative pancreatic duct evaluation (n = 2) and intraductal papillary mucinous neoplasm assessment (n = 2). Technical success, defined as successful scope insertion into the target duct, was achieved in all cases. Clinical success was achieved in 11/12 cases (91.7%), including diagnostic clinical success in 10/11 diagnostic cases (90.9%) and procedural utility success in 1/1 procedural utility case (100%). The smallest successfully visualized duct measured 1.8 mm in diameter based on fluoroscopic estimation at the intended insertion site. One patient developed mild post-endoscopic retrograde cholangiopancreatography pancreatitis, which resolved with conservative management; no other adverse events were observed. The median total procedure time and scope insertion time were 42 and 7 min, respectively. These findings indicate that the UCPOCS or UCPOPS is a feasible and safe intraductal visualization tool for pancreatobiliary diseases, particularly in patients with narrow ducts or challenging anatomy. Trial Registration: N/A.

BackgroundCryoablation is a well-established intervention for various pathologies. Cryoablation has been investigated as an alternative for cholecystitis in poor surgical candidates and as an adjunct to resection for invasive gallbladder cancer (GBC).MethodsA systematic search was performed in PubMed and Embase to identify studies investigating cryoablation in cholecystitis and GBC. Pooled overall (OS) and disease-free survival (DFS) analysis was conducted for the GBC population.ResultsFour studies in patients with cholecystitis (n = 29, mean age: 63.5 ± 16.8 years; 69% males) used 1-2 freeze cycles, and between 1 and 7 probes. The mean duration of cholecystostomy in place prior to cryoablation was 73.7 ± 37.1 days. Average hospital stay was 3.9 ± 7.5 days. At a follow-up of 15.6 ± 7.7 months, the efficacy of cryoablation varied between 86% and 100%. Complications included infection (6.9%), scrotal edema (3.4%), transient biliary obstruction (3.4%), anaphylaxis/death (3.4%), and hemorrhage/acute tubular necrosis (3.4%). In patients with GBC (n = 12, mean age: 57.9 ± 5.6 years), all four studies used one probe and most studies used 2 freeze cycles. At a follow-up of 13.1 ± 11.1 months, four patients (33.3%) with GBC had complications including pulmonary embolism, pleural effusion, exacerbation of congestive heart failure, and one biliary stricture, while one patient died at 3 months after the procedure. Gallbladder cancer recurred in 36.3% with median DFS of 10 (4-17) months. The OS was 88.8% at 6 months and 83.3% at 1-year post-procedure.ConclusionCryoablation is a technically feasible, definitive treatment option for poor surgical candidates with cholecystitis, targeting the same patient population typically selected for percutaneous cholecystostomy placement. Cryoablation is an experimental adjunct in GBC. Current evidence is limited, based on retrospective data and a very limited number of patients. Further prospective studies are needed to validate its efficacy and improve its safety in high-risk patients.

Acute cholecystitis affects approximately 200,000 individuals annually in the United States and may result in significant morbidity if not appropriately managed. The Infectious Diseases Society of America (IDSA) recommends cefazolin, ceftriaxone, or cefuroxime as first-line therapy for mild-to-moderate community-acquired biliary infections; however, adherence to these guidelines remains variable. Within our institution's Emergency General Surgery process improvement program, antibiotic stewardship in acute biliary disease was identified as an opportunity for quality optimization. We performed a retrospective review of the EGS Registry at our military treatment facility from 2017 to 2021. Adult patients with mild-to-moderate acute cholecystitis were included. A total of 143 patients met the inclusion criteria; 62% were female, with a mean age of 52 ± 18 years. Guideline-recommended antibiotics were administered to 45% of patients. Adherence to IDSA guideline-recommended antibiotic therapy for mild-to-moderate acute cholecystitis was suboptimal at our institution, highlighting the need for standardized protocols and ongoing provider education to improve antibiotic stewardship.

Acute cholecystitis (AC) is one of the most prevalent gastrointestinal emergencies, with laparoscopic cholecystectomy representing the definitive treatment per current guidelines. However, a substantial proportion of patients-particularly elderly individuals with major comorbidities, multiorgan dysfunction, or advanced malignancy-are considered poor surgical candidates in whom operative intervention carries prohibitive risk. Although percutaneous transhepatic gallbladder drainage (PT-GBD) has traditionally served as the first-line non-surgical alternative, its significant morbidity and technical limitations in patients with coagulopathy, massive ascites, or an unsafe percutaneous window have driven the development of endoscopic drainage modalities. This review critically appraises the comparative evidence for two endoscopic gallbladder drainage strategies: endoscopic transpapillary gallbladder drainage (ET-GBD), performed via endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), most commonly using lumen-apposing metal stents (LAMS). In appropriately selected high-risk surgical candidates, EUS-GBD with LAMS has emerged as a preferred endoscopic option, supported by high technical success rates, low recurrent AC rates, AGA expert guidance, and FDA regulatory reclassification of the AXIOS stent for gallbladder drainage. Nevertheless, ET-GBD retains distinct clinical indications, including concurrent biliary intervention, large-volume ascites, high bleeding risk, anticipated surgical candidacy, and resource-limited settings. Optimal management requires a systematic, algorithm-driven multidisciplinary approach integrating comorbidity profile, biliary anatomy, cystic duct patency, and institutional expertise.

Background: Acute cholecystitis affects approximately 200,000 hospitalizations annually in the United States, and emergency cholecystectomy is its definitive treatment. Whether weekend hospital admission, which is often associated with reduced staffing and diagnostic resources, adversely affects surgical outcomes in this population is unclear. We evaluated the association between weekend hospital admission and in-hospital mortality and key secondary outcomes following emergency cholecystectomy. Methods: This retrospective cohort study used the National Inpatient Sample (NIS) from January 2018 through December 2022. Adults (≥18 years) with acute cholecystitis (identified by ICD-10-CM codes) who underwent nonelective cholecystectomy (identified by ICD-10-PCS codes) were included; elective admissions, pediatric patients, and admissions with missing discharge weights were excluded. The analytic cohort comprised 194,787 unweighted admissions, representing a weighted national estimate of approximately 973,935 hospitalizations. Weekend admission was defined as admission on Saturday or Sunday (vs. Monday through Friday). The primary outcome was in-hospital mortality. Secondary outcomes, defined from secondary (not principal) diagnosis fields and interpreted as coded in-hospital diagnoses, included prolonged length of stay (>75th percentile), sepsis, surgical site infection, bile duct injury, venous thromboembolism, respiratory failure, acute kidney injury, blood transfusion, and cardiac complications. Multivariable logistic regression with hospital-year cluster-robust standard errors was used, adjusting for pre-exposure patient and hospital characteristics; the Benjamini-Hochberg false discovery rate was applied across secondary outcomes. Results: Among 194,787 admissions (weekday, 73.2%; weekend, 26.8%), in-hospital mortality was 0.62% in weekday and 0.53% in weekend patients. After adjustment, weekend admission was not associated with in-hospital mortality (aOR 0.87; 95% CI, 0.75-1.00; p = 0.06). Weekend admission was associated with modestly lower odds of prolonged length of stay (aOR 0.90; 95% CI, 0.88-0.93; p < 0.001). Weekend admission was not associated with sepsis (5.3% vs. 5.3%; aOR 1.01; 95% CI, 0.96-1.06; p = 0.65), respiratory failure (aOR 1.05; 95% CI, 1.00-1.10; p = 0.06), overall complications, or the remaining secondary outcomes after correction for multiple comparisons. Findings were consistent across design-based survey-weighted, inverse-probability-weighted, transfer-excluded, and principal-diagnosis sensitivity analyses. Conclusions: Weekend admission was not associated with higher in-hospital mortality or with a higher risk of sepsis following emergency cholecystectomy in the United States; weekend patients had modestly shorter hospital stays. These findings provide no evidence of higher coded in-hospital mortality or coded in-hospital complications among weekend admissions in contemporary US practice.

Background/Objectives: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) with Lumen-Apposing Metal Stent (LAMS) is an established option for high-surgical-risk patients, with high technical and clinical success. Indications include acute cholecystitis and palliation of jaundice in malignant distal biliary obstruction (MDBO). Both trans-gastric and trans-duodenal approaches are used, but the optimal route remains debated. The aim of the study was to compare trans-gastric and trans-duodenal access in terms of technical success, adverse events, readmissions, and reinterventions. Methods: We implemented a single-centre retrospective study of consecutive EUS-GBD procedures with LAMS at a tertiary endoscopy unit (January 2020-January 2026). Demographic, clinical, and procedural data were analyzed using appropriate statistical tests. Results: Seventy patients were included (51.4% male; mean age 77 ± 12 years). Indications were acute cholecystitis (64.3%) and MDBO (35.7%). Trans-gastric access was used in 48.5% of cases. A Hot-Axios LAMS was deployed in 77.2% of cases, mostly >10 mm. Technical success was achieved in 98.5% of cases. Naso-cystic drainage (NCD) was used through the LAMS in 47.1% of patients, while a double pig-tail plastic stent was used in 7.2% of patients. Adverse events were rare (1.4% misdeployment). LAMS obstruction occurred in 10% of patients, with reintervention required in 12.8% of patients. No differences were found between access routes in indication, technical success, LAMS type/size, or adjunctive drainage. However, trans-gastric access was associated with a higher reintervention rate (p = 0.01). Conclusions: EUS-GBD is a safe and effective procedure. While both approaches are comparable in most outcomes, the trans-gastric route may carry a higher risk of reintervention and should be avoided when alternative access is feasible.

Epstein-Barr virus (EBV), presenting as infectious mononucleosis (IM), affects almost all people by age 20. It has several systemic manifestations that are associated with pharyngitis and fever. We present a rare presentation of EBV infection manifesting as hepatitis and jaundice without prior IM symptoms. A 46-year-old female presented with abdominal pain and jaundice. Laboratory findings showed elevated liver enzymes and bilirubin. There was no evidence of other diseases on laboratory findings, imaging, or symptoms. EBV IgM was the only laboratory-positive value. The patient continued symptomatic treatment and fully recovered within about 10 months. EBV manifesting as isolated hepatitis occurs rarely in the population. Cases of hepatitis not preceded by IM have not been reported previously.

Streptococcus gordonii is an alpha-hemolytic Gram-positive bacterium most commonly present in the oral cavity and gastrointestinal tract. Despite an increase in the incidence of infective endocarditis, S. gordonii cases reported on a native aortic valve are relatively uncommon. Reported cases have been linked to spondylodiskitis, intra-abdominal infection, and oral procedures. A 79-year-old male was admitted for acute kidney injury, diarrhea, and dehydration, and was found to have S. gordonii bacteremia with endocarditis. A 1.7 cm × 0.9 cm vegetation on the native aortic valve was revealed, and subsequent multiple septic emboli on brain magnetic resonance imaging (MRI) were discovered after an incident of acute mental status change. The patient was successfully treated with intravenous ceftriaxone and later required aortic valve replacement. A possible source of the bacteremia was a trigger point injection to the lumbar spine, which was consistent with MRI lumbar spine findings of a spinal abscess. However, other possible sources include a dental procedure, cholecystitis with concern for cholelithiasis, and colonoscopy with polypectomy, both incidences within eight weeks of the hospitalization. This case illustrates the importance of thorough history taking and consideration for an echocardiogram to rule out endocarditis if S. gordonii bacteremia is present, in addition to close monitoring and outpatient follow-up post-diagnosis. Considering an increasing number of procedures involving the oral cavity, spine, and abdominal area, we hope that this case will bring awareness to the diagnosis of S. gordonii endocarditis.

Difficult acute cholecystitis frequently precludes attaining the critical view of safety during minimally invasive cholecystectomy. Established bail-out options-subtotal cholecystectomy (fenestrating/reconstituting), cholecystostomy drainage with delayed cholecystectomy, or conversion to open-remain widely accepted with distinct limitations.We present an operative framework and a technical description of subserosal cholecystectomy (SSC), supported by an operative video. The technique dissects the edematous, avascular subserosal plane between the outer fibrofatty serosal layer and the inner perimuscular fibrous serosal-lamina-propria-mucosal layer. Preserving the outer serosal rind theoretically allows for full dissection and control of the cystic structures in an otherwise inflamed and a scarred, adherent surgical field. Intact cystic duct and artery are clipped in this plane; if cystic duct disrupts during the subserosal dissection, it is managed like in subtotal cholecystectomy -ligation by needle suturing or left open/fenestration with surgical drain.Patient selection is critical: SSC is suitable in early phase of stage II acute cholecystitis (per our pathophysiological staging below, with corresponding intraoperative findings like hyperemia or distended gallbladder). In advanced stage II or stage III, where brawny fibrosis obliterates the plane, subserosal dissection is unfeasible, and subtotal cholecystectomy is the best approach.We propose SSC as a conceptual complement to the bail-out armamentarium based on limited experience and pending comparative outcome data relative to established bail-out techniques. Further prospective or multi-case studies are warranted to define its safety, outcomes, complications, and role as an effective bail-out technique.

Acute gangrenous cholecystitis is a severe complication of acute cholecystitis. We report a 70-year-old male with type 1 diabetes mellitus who presented with intractable vomiting without abdominal pain. CT imaging showed gallbladder wall thickening and concern for gallbladder perforation. Patient underwent a laparoscopic cholecystectomy, which revealed a gangrenous gallbladder with surrounding purulent drainage. The patient recovered after an extended hospital course. This case highlights the importance of considering atypical presentations of severe intra-abdominal pathology in diabetic patients.