What is the management for a clogged percutaneous (percutaneous) cholecystostomy (chole) tube?

Management of Clogged Percutaneous Cholecystostomy Tube

For a clogged percutaneous cholecystostomy tube, the recommended management is to attempt flushing with normal saline followed by instillation of Alteplase (1 mg/mL) if saline is unsuccessful, with appropriate dwell time to restore tube patency. 1

Initial Assessment and Management

• Evaluate for signs of worsening cholecystitis or sepsis including fever, abdominal pain, distention, jaundice, nausea, and vomiting 2
• Assess liver function tests (direct/indirect bilirubin, AST, ALT, ALP, GGT) and inflammatory markers (CRP, PCT) in critically ill patients to evaluate severity 2
• First attempt to flush the tube with 0.9% Sodium Chloride (normal saline) using gentle pressure 1
• If unsuccessful with saline, proceed to thrombolytic therapy using Alteplase 1

Thrombolytic Therapy Protocol

• Reconstitute Alteplase to a concentration of 1 mg/mL using Sterile Water for Injection (not Bacteriostatic Water) 1
• Dosing:
  • For patients ≥30 kg: instill 2 mg in 2 mL into the occluded tube 1
  • For patients <30 kg: instill 110% of the internal lumen volume of the catheter, not exceeding 2 mg in 2 mL 1
• Allow 30 minutes of dwell time, then attempt to aspirate 1
• If tube remains occluded after 120 minutes, a second dose may be administered following the same procedure 1
• Once patency is restored, aspirate 4-5 mL of fluid (3 mL in patients <10 kg) to remove thrombolytic and residual clot material 1

Imaging Evaluation

• If tube remains occluded despite thrombolytic therapy, consider imaging assessment:
  • Abdominal triphasic CT as first-line imaging to detect collections and ductal dilation 2
  • Consider contrast-enhanced MRCP for exact visualization of biliary anatomy if biliary injury is suspected 2

Management Based on Underlying Condition

• If tube occlusion is associated with persistent or worsening symptoms:
  • For minor bile duct injuries (Strasberg A-D), consider ERCP with biliary sphincterotomy and stent placement 2
  • For major bile duct injuries, consider referral to a center with expertise in hepatopancreatobiliary procedures 2
  • For recurrent cholecystitis after tube placement, consider interval cholecystectomy if patient is a surgical candidate 3

Long-term Management Considerations

• Percutaneous cholecystostomy tubes may need to be replaced if repeatedly occluded 4
• Consider interval cholecystectomy in patients who have recovered from the acute episode, as recurrent gallbladder disease occurs in up to 41% of patients managed non-operatively 3
• In high-risk patients unfit for surgery, the tube may remain as definitive management with periodic exchanges 5

Complications to Monitor

• Tube-related complications include dislodgment (most common), blockage, and bleeding 3
• Monitor for signs of biliary peritonitis which would require urgent abdominal cavity lavage and drainage 2
• Watch for empyema formation which may require additional drainage procedures 6

Prevention of Future Occlusions

• Regular flushing of the tube with small amounts of sterile saline (5-10 mL) can help prevent occlusion 4
• Ensure proper tube fixation to prevent dislodgment, which can lead to occlusion 3
• Consider scheduled tube exchanges every 2-3 months for long-term management 7