eMedicine Specialties > Gastroenterology > Biliary

Empyema, Gallbladder

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

Introduction

Background

Acute cholecystitis in the presence of bacteria-containing bile may progress to suppurative infection in which the gallbladder fills with purulent material, a condition referred to as empyema of the gallbladder. (The underlying cause of cholecystitis involves obstruction of the cystic duct, which causes the buildup of infected fluid.) Systemic antibiotics and urgent drainage or resection are required to reduce the incidence of complications and to avoid or treat associated sepsis.

Pathophysiology

In the bacterially contaminated gallbladder, the stagnation and marked inflammation associated with acute cholecystitis fills the gallbladder lumen with exudative material principally comprised of frank pus. This process may be associated with calculous cholecystitis, acalculous cholecystitis, or carcinoma of the gallbladder. Left untreated, generalized sepsis ensues, with progression in the gallbladder to patchy gangrene, microperforation, macroperforation, or, rarely, cholecystoduodenal fistula. Patients at increased risk for cholecystitis include those with diabetes, immunosuppression, obesity, or hemoglobinopathies.

Frequency

International

True incidence of empyema of the gallbladder associated with acute cholecystitis is difficult to assess, although findings from limited series indicate a range of 5-15%.

Mortality/Morbidity

The rate of laparoscopic cholecystectomy procedures converted to an open procedure is significantly higher in patients with empyema of the gallbladder. The postoperative complication rate (regardless of approach) for empyema of the gallbladder is 10-20% and includes wound infection, bleeding, subhepatic abscess, cystic stump leak, common bile duct injury, and systemic complications, including acute renal failure and/or respiratory insufficiency associated with sepsis.

Progression to death is unusual in otherwise healthy individuals but may occur in patients of advanced age, in patients with compromised immunity, or in individuals with significant comorbid conditions.

Race

American Indians and Central American Indians have an increased risk of cholelithiasis/cholecystitis, as do patients with hemoglobinopathies, such as sickle cell anemia (more likely in blacks).

Clinical

History

The clinical history of a patient with empyema of the gallbladder is similar to that of a patient with acute cholecystitis (from which the empyema derives). As the disease progresses, severe pain and associated high fever, chills, and even rigors may be reported. Patients with diabetes or immunosuppression may exhibit few signs and symptoms.

Physical

  • Patients with an early empyema of the gallbladder often present no differently than any patient with acute cholecystitis, with symptoms that include fever (temperature, >101°F), stable blood pressure, and mild tachycardia.
  • However, if localized or free perforation has occurred and/or the patient has generalized sepsis, fevers (temperature, 103°F), chills and/or rigors, and confusion may be observed in association with hypotension and severe tachycardia.
  • Early on, abdominal examination findings are similar to those of patients with acute cholecystitis, with mild-to-moderate tenderness in the right upper abdomen and a positive Murphy sign (ie, arrest of inspiration as the gallbladder descends to touch a hand previously placed deep in the mid right abdomen).
  • As the disease progresses, empyema of the gallbladder may be associated with a palpable distended gallbladder that is markedly tender on even superficial palpation.

Causes

The most frequent etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis in the face of contaminated bile. The most frequently isolated organisms include Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis, and anaerobes, including Bacteroides and Clostridia species. Suppurative inflammation ensues, tightly filling the gallbladder with purulent debris. Localized or free perforation occurs if drainage or resection is not performed at this juncture. Generalized sepsis frequently accompanies this progression.

A similar pattern is infrequently observed in association with acute acalculous cholecystitis. Rarely, obstruction of the distal common bile duct may result in pus formation within the extrahepatic biliary tree, which can then decompress into the gallbladder. This distends and infects that organ, with ensuing empyema.

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

  1. Philips JA, Lawes DA, Cook AJ, Arulampalam TH, Zaborsky A, Menzies D, et al. The use of laparoscopic subtotal cholecystectomy for complicated cholelithiasis. Surg Endosc. Jul 2008;22(7):1697-700. [Medline].

  2. Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RT, Toouli J. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg. Nov 1993;218(5):630-4. [Medline].

  3. Eldar S, Eitan A, Bickel A, Sabo E, Cohen A, Abrahamson J, et al. The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis. Am J Surg. Oct 1999;178(4):303-7. [Medline].

  4. Empyema of the gallbladder - a forgotten disease. Lancet. Mar 17 1984;1(8377):606. [Medline].

  5. Fabre JM, Fagot H, Domergue J, Guillon F, Balmes M, Zaragosa C, et al. Laparoscopic cholecystectomy in complicated cholelithiasis. Surg Endosc. Oct 1994;8(10):1198-201. [Medline].

  6. Gharaibeh KI, Qasaimeh GR, Al-Heiss H. Effect of timing of surgery, type of inflammation, and sex on outcome of laparoscopic cholecystectomy for acute cholecystitis. J Laparoendosc Adv Surg Tech A. Jun 2002;12(3):193-8. [Medline].

  7. Hemmer PH, Zeebregts CJ, Roelofsen E, Klaase JM. Gallbladder carcinoma presenting as an empyema with Staphylococcus aureus. ANZ J Surg. Apr 2004;74(4):289. [Medline].

  8. Kato T, Yamagami T, Iida S. Percutaneous drainage under real-time computed tomography-fluoroscopy guidance. Hepatogastroenterology. Jul-Aug 2005;52(64):1048-52. [Medline].

  9. Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. Jan 31 1998;351(9099):321-5. [Medline].

  10. Koperna T, Kisser M, Schulz F. Laparoscopic versus open treatment of patients with acute cholecystitis. Hepatogastroenterology. Mar-Apr 1999;46(26):753-7. [Medline].

  11. Lee KT, Wong SR, Cheng JS, Ker CG, Sheen PC, Liu YE. Ultrasound-guided percutaneous cholecystostomy as an initial treatment for acute cholecystitis in elderly patients. Dig Surg. 1998;15(4):328-32. [Medline].

  12. Lim MS, Davaraj B, Kandasami P. Endoscopic drainage of empyema of the gallbladder through a concurrent cholecystoduodenal fistula. Asian J Surg. Jan 2006;29(1):55-7. [Medline].

  13. Lo CM, Fan ST, Liu CL, et al. Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. Am J Surg. Jun 1997;173(6):513-7. [Medline].

  14. Thornton JR, Heaton KW, Espiner HJ, Eltringham WK. Empyema of the gall bladder - reappraisal of a neglected disease. Gut. Dec 1983;24(12):1183-5. [Medline].

  15. Tseng LJ, Tsai CC, Mo LR, et al. Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy. Hepatogastroenterology. Jul-Aug 2000;47(34):932-6. [Medline].

  16. Van Steenbergen W, Rigauts H, Ponette E, Peetermans W, Pelemans W, Fevery J. Percutaneous transhepatic cholecystostomy for acute complicated calculous cholecystitis in elderly patients. J Am Geriatr Soc. Feb 1993;41(2):157-62. [Medline].

  17. Zheng QY, Johnson KR. Hearing loss associated with the modifier of deaf waddler (mdfw) locus corresponds with age-related hearing loss in 12 inbred strains of mice. Hear Res. Apr 2001;154(1-2):45-53. [Medline].

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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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