Endoscopic guide wire gallbladder decompression in a critically ill, septic patient.

A 57-year-old man with postischemic dilated cardiomyopathy underwent a heart transplant at our center in February 2013. His early postoperative course was complicated by primary graft non-function requiring intensive care treatment. Six days after transplantation, he developed severe hypoperfusion that required maximal extracorporeal membrane oxygenation (ECMO), placement of an intraaortic balloon pump, and vasoactive drug support. The patient’s bilirubin level increased from 0.8mg/dL to 7.5mg/dL and his white blood cell (WBC) count from 9×109/L to 37×109/L. Abdominal ultrasound revealed normal-caliber intrahepatic ducts and a 10-cm sludge-filled gallbladder (●" Fig.1a). A diagnosis of acute biliary septic shock was suspected and an urgent endoscopic retrograde cholangiopancreatography (ERCP) was requested for gallbladder decompression. A cholangiogram confirmed the normalcaliber intrahepatic ducts and a dilated