Gallbladder Empyema Treatment & Management

Updated: Nov 13, 2016
  • Author: Benjamin Pace, MD, FACS; Chief Editor: Praveen K Roy, MD, AGAF  more...
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Treatment

Medical Care

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

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 Etiology). Early in the course of the disease, good results are achieved with the adjuvant administration of a second-generation cephalosporin. In more advanced cases associated with perforation and/or generalized sepsis, broader spectrum coverage with piperacillin tazobactam is advised.

Antibiotic coverage is modified by culture results (as soon as available) and the known 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. Although rapid and marked improvement in the patient's condition usually follows, complete resolution without further septic complication (mandating further intervention) is unpredictable. [3]

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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. [4] 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. [5]

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.

Following surgical decompression and resection of the gallbladder with empyema, intravenous antibiotic therapy is maintained until fever resolves and the white blood cell count returns to normal. Discharge home, on oral antibiotic therapy, is guided by the results of intraoperative bile cultures.

For patients with complications (eg, intra-abdominal infections, wound infections, sepsis), therapy and follow-up care are patient specific and, therefore, individualized.

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