eMedicine Specialties > Gastroenterology > Biliary

Empyema, Gallbladder: Treatment & Medication

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

Treatment

Medical Care

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 Care

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.1

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.

Consultations

When empyema of the gallbladder is considered, urgent consultation with gastroenterologists and surgeons is essential.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Base selection of antibiotics on blood culture sensitivity whenever feasible. Indicated as an adjunct to decompression/resection of the gallbladder with empyema.


Gentamicin (Garamycin)

Aminoglycoside antibiotic for gram-negative coverage bacteria, including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least a trough level drawn on the third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.

Adult

Loading dose and maintenance dose: 1-2.5 mg/kg IV and 1-1.5 mg/kg IV, respectively, q8h
Serious life-threatening infections and normal renal function: 3 mg/kg/dose IV q8h
Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion

Pediatric

Not established

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; because aminoglycosides enhance effects of neuromuscular blocking agents, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non-dialysis dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment


Ampicillin (Omnipen, Polycillin)

Indicated as single-agent therapy in early empyema of the gallbladder. Bactericidal activity against susceptible organisms. Dosing depends on severity of infection.

Adult

1-2 g IV q4-6h; not to exceed 14 g/d

Pediatric

100-200 mg/kg/d IV divided q4-6h; not to exceed 2-3 g/d

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash, and differentiate from hypersensitivity reaction


Cefazolin (Ancef, Kefzol)

Indicated as single-agent therapy in early empyema of the gallbladder. First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, thus inhibiting bacterial growth. Dosing depends on severity of infection.

Adult

1-2 g IV/IM q6-12h; not to exceed 12 g/d

Pediatric

25-100 mg/kg/d IV divided q8h

Probenecid prolongs effects; coadministration with aminoglycosides may increase renal toxicity; may yield false-positive urine-dip test results for glucose

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged or repeated use


Metronidazole (Flagyl)

Indicated in severe infection in combination with aminoglycoside and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents.

Adult

Loading dose: 15 mg/kg or 1 g IV over 1 h for 70-kg patient
Maintenance dose: 6 h following IV loading dose, infuse 7.5 mg/kg or 500 mg IV q6-8h over 1 h for 70-kg patient; not to exceed 4 g/d

Pediatric

30 mg/kg/d IV divided q6h; not to exceed 4 g/d

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

More on Empyema, Gallbladder

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

References

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  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].

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  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].

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  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].

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Further Reading

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

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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