eMedicine Specialties > Gastroenterology > Biliary

Empyema, Gallbladder: Differential Diagnoses & Workup

Author: Benjamin Pace, MD, Director of Surgery, Chief of Breast Service, Queens Hospital Center
Coauthor(s): Bruce Morel, MD, FACS, Clinical Assistant Professor, Department of Surgery, Mount Sinai School of Medicine; Sita Chokhavatia, MD, MBBS, Associate Fellowship Director, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Jun 17, 2008

Differential Diagnoses

Cholecystitis
Cholelithiasis

Workup

Laboratory Studies

  • Laboratory tests for presumed empyema of the gallbladder include CBC with differential, liver chemistries, prothrombin time (PT), and activated partial thromboplastin time (aPTT).
  • Persistent and even increasing leukocytosis at levels greater than 15,000/dL (with a left shift on differential) despite appropriate antibiotic therapy is characteristic of empyema of the gallbladder. However, this scenario may occur in association with gangrenous cholecystitis and with several other differential diagnoses.
  • When arising from complicated acute cholecystitis, liver chemistry findings associated with empyema of the gallbladder are usually within reference ranges, which helps differentiate this condition from empyema of the gallbladder and/or cholangitis secondary to distal biliary tract obstruction. One exception is empyema of the gallbladder in which the enlarged "penile" gallbladder compresses the common/hepatic bile ducts (Mirizzi syndrome), giving rise to mildly elevated alkaline phosphatase and bilirubin levels.
  • Serial blood cultures are beneficial in patients with bacteremia; positive results help direct antibiotic therapy.

Imaging Studies

  • Ultrasound of the gallbladder is indicated in presumed empyema of the gallbladder. The finding of an enlarged, distended gallbladder and associated pericholecystic fluid points to an acute inflammatory process involving the gallbladder. Though suggestive, this does not adequately differentiate uncomplicated acute cholecystitis from the complication with empyema and/or gangrene. Most importantly, it contraindicates further conservative management and signals the need for prompt intervention.
  • While ultrasound is the preferred examination for probable cases of empyema, the condition is frequently discovered on CT scans performed with other differential diagnoses in mind.

Procedures

  • Endoscopic retrograde cholangiopancreatography (ERCP) is not indicated if empyema of the gallbladder is thought likely because it may delay definitive diagnosis and operative treatment.

Histologic Findings

Findings include a pus-filled gallbladder, with or without calculi, and an acute suppuration of the gallbladder wall, with or without areas of gangrene and perforation.

More on Empyema, Gallbladder

Overview: Empyema, Gallbladder
Differential Diagnoses & Workup: Empyema, Gallbladder
Treatment & Medication: Empyema, Gallbladder
Follow-up: Empyema, Gallbladder
References
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References

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Further Reading

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Keywords

empyema of the gallbladder, acute cholecystitis, calculous cholecystitis, acalculous cholecystitis, gangrenous cholecystitis, cholelithiasis, chololithiasis, sepsis, Escherichia coli, E coli, Klebsiella pneumoniae, K pneumoniae, Streptococcus faecalis, S faecalis, Bacteroides, Clostridia

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Contributor Information and Disclosures

Author

Benjamin Pace, MD, Director of Surgery, Chief of Breast Service, Queens Hospital Center
Benjamin Pace, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, and Medical Society of the State of New York
Disclosure: no financial interest  None None

Coauthor(s)

Bruce Morel, MD, FACS, Clinical Assistant Professor, Department of Surgery, Mount Sinai School of Medicine
Bruce Morel, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Sita Chokhavatia, MD, MBBS, Associate Fellowship Director, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Mount Sinai School of Medicine
Sita Chokhavatia, MD, MBBS is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Medical Editor

Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University
Maurice A Cerulli, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Medical Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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