Gallbladder Empyema Treatment & Management
- Author: Benjamin Pace, MD, FACS; Chief Editor: Julian Katz, MD more...
Intravenous antibiotic therapy is an adjunct to urgent decompression and/or resection of the gallbladder when empyema is likely. The choice of antibiotic is based on the organisms presumed to be involved (see Causes). Early in the course of the disease, good results are achieved with the adjuvant administration of ampicillin or a first- or second-generation cephalosporin. In more advanced cases associated with perforation and/or generalized sepsis, triple antibiotic therapy that includes an aminoglycoside (usually gentamicin), ampicillin or a cephalosporin, and metronidazole (anaerobic coverage) is advised.
Antibiotic coverage is modified by culture results and the bacterial resistance encountered in the local hospital setting.
Urgent decompression is the goal of therapy for empyema of the gallbladder. In patients who are hemodynamically unstable or in individuals in whom surgery is contraindicated because of significant comorbid conditions, transhepatic drainage of the gallbladder under radiologic guidance may serve as a temporizing or final procedure. Though rapid and marked improvement in the patient's condition usually follows, complete resolution without further septic complication (mandating further intervention) is unpredictable.
Surgical decompression and resection of the affected gallbladder is the criterion standard of therapy. An advanced laparoscopic surgeon may treat empyema of the gallbladder (without significant gangrenous changes or perforation) with a laparoscopic procedure. Initial decompression may be accomplished under radiographic guidance immediately before the procedure or via intraoperative, laparoscopically guided needle drainage, which allows for more facile manipulation of the gallbladder during the cholecystectomy portion of the procedure.
The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of empyema vary widely. However, they are all significantly higher than the comparative rates reported in the same studies for laparoscopic treatment of uncomplicated acute cholecystitis. Laparoscopic subtotal cholecystectomy is acceptable only if the encountered pericholecystic inflammation is so severe as to preclude safe dissection via either a laparoscopic procedure or an open procedure.
Importantly, the complications are related to the advanced disease process and not to the approach. In skilled hands, no increase is observed in the incidence of laparoscopic surgical misadventure with empyema of the gallbladder. Thus, despite the higher incidence of conversion to an open procedure (40-80%), it is quite reasonable to initially proceed with a laparoscopic procedure.
When empyema of the gallbladder is considered, urgent consultation with gastroenterologists and surgeons is essential.
Wang CH, Chou HC, Liu KL, Lien WC, Wang HP, Wu YM. Long-Term Outcome of Patients with Acute Cholecystitis Receiving Antibiotic Treatment: A Retrospective Cohort Study. World J Surg. 2013 Nov 1. [Medline].
Nigri GR, Aurello P, Ramacciato G. An abdominal mass. J Gastrointest Surg. 2011 Oct. 15(10):1902-3. [Medline].
Kwon YJ, Ahn BK, Park HK, Lee KS, Lee KG. What is the optimal time for laparoscopic cholecystectomy in gallbladder empyema?. Surg Endosc. 2013 Oct. 27(10):3776-80. [Medline].
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. 2008 Jul. 22(7):1697-700. [Medline].
Cull JD, Velasco JM, Czubak A, Rice D, Brown EC. Management of Acute Cholecystitis: Prevalence of Percutaneous Cholecystostomy and Delayed Cholecystectomy in the Elderly. J Gastrointest Surg. 2013 Nov 6. [Medline].
Cox MR, Wilson TG, Luck AJ, Jeans PL, Padbury RT, Toouli J. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg. 1993 Nov. 218(5):630-4. [Medline].
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. 1999 Oct. 178(4):303-7. [Medline].
Empyema of the gallbladder - a forgotten disease. Lancet. 1984 Mar 17. 1(8377):606. [Medline].
Fabre JM, Fagot H, Domergue J, Guillon F, Balmes M, Zaragosa C, et al. Laparoscopic cholecystectomy in complicated cholelithiasis. Surg Endosc. 1994 Oct. 8(10):1198-201. [Medline].
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. 2002 Jun. 12(3):193-8. [Medline].
Hemmer PH, Zeebregts CJ, Roelofsen E, Klaase JM. Gallbladder carcinoma presenting as an empyema with Staphylococcus aureus. ANZ J Surg. 2004 Apr. 74(4):289. [Medline].
Kato T, Yamagami T, Iida S. Percutaneous drainage under real-time computed tomography-fluoroscopy guidance. Hepatogastroenterology. 2005 Jul-Aug. 52(64):1048-52. [Medline].
Kiviluoto T, Sirén J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet. 1998 Jan 31. 351(9099):321-5. [Medline].
Koperna T, Kisser M, Schulz F. Laparoscopic versus open treatment of patients with acute cholecystitis. Hepatogastroenterology. 1999 Mar-Apr. 46(26):753-7. [Medline].
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].
Lim MS, Davaraj B, Kandasami P. Endoscopic drainage of empyema of the gallbladder through a concurrent cholecystoduodenal fistula. Asian J Surg. 2006 Jan. 29(1):55-7. [Medline].
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. 1997 Jun. 173(6):513-7. [Medline].
Thornton JR, Heaton KW, Espiner HJ, Eltringham WK. Empyema of the gall bladder - reappraisal of a neglected disease. Gut. 1983 Dec. 24(12):1183-5. [Medline].
Tseng LJ, Tsai CC, Mo LR, et al. Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy. Hepatogastroenterology. 2000 Jul-Aug. 47(34):932-6. [Medline].
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. 1993 Feb. 41(2):157-62. [Medline].
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. 2001 Apr. 154(1-2):45-53. [Medline].