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.
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.
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.
The 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%.
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 black persons).
If treated early, otherwise healthy patients have a full recovery and return to normal activity.
In patients of advanced age, those who are immunocompromised, or those with significant comorbid conditions (including patients with advanced diabetes mellitus, in whom the condition is more prevalent), the development of empyema of the gallbladder and the resultant sepsis constitute a serious life-threatening event. 
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.
The major complications associated with empyema of the gallbladder are localized or free perforation and/or generalized sepsis.
Possible surgical complications include the following:
Subhepatic and/or liver abscess
Cystic stump leak
Common bile duct injury
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