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Background
Acute cholecystitis, a prevalent disease often linked to cholelithiasis or critical illness, is addressed by the 2018 Tokyo Guidelines, offering a diagnostic framework for typical and atypical cases. Percutaneous cholecystostomy (PC) is generally considered the gold-standard treatment for nonsurgical candidates; however, percutaneous cholecystoduodenostomy (PCD) can be more convenient, and equally effective.

Educational Goals / Teaching Points
1. Review the Tokyo Guidelines for acute cholecystitis and the diagnostic criteria. 2. Discuss the gastrointestinal anatomy involved in PCD and the procedural steps involved. 3. Multimodal case review of acute cholecystitis and a patient successfully managed with cholecystoduodenostomy.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The diagnosis of acute cholecystitis is substantiated by ultrasound, CT, MRI, or HIDA. These imaging findings, in conjunction with the Tokyo criteria, are used to make decisions on the clinical management of acute cholecystitis. While surgical cholecystectomy is the preferred treatment, it might be unsuitable for nonsurgical candidates. PC is commonly employed; however, its ability to completely alleviate acute cholecystitis is constrained by external drainage limits, potentially impacting patient wellbeing. Some institutions employ endoscopic cholecystoduodenostomy by gastroenterologists to address these challenges in nonsurgical patients with an occluded cystic duct, replacing the catheter to create a direct gallbladder-duodenum connection, bypassing the extrahepatic biliary tree. However, access to this procedure is often limited to centers with advanced endoscopists and even then may be limited by sedation requirements for endoscopy. There are few case reports of PCD performed by interventional radiology (IR) to replace the external drainage catheter and establish a direct connection between the gallbladder and the duodenum, bypassing the extrahepatic biliary tree. This procedure typically uses a mature PC tract for sheath insertion, followed by puncture through the gallbladder wall and into the duodenum with a 21-g needle. A wire basket inserted into the duodenum from a transnasal approach may be used for localization and wire snaring. Once wire access is established and tract dilatation is performed, a plastic stent or large-bore lumen-apposing metal stent (LAMS) can be inserted and deployed to create the cholecystoduodenostomy.

Conclusion
Although PCD is performed infrequently, it holds promise as a suitable choice, particularly for patients with continuous discharge necessitating the presence of an external cholecystostomy tube. This procedure warrants further investigation given the prevalence of the disease and greater access to IRs throughout the country.