Gallbladder Empyema


Article Author:
Abdul Waheed
George Mathew


Article Editor:
Kevin King


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
7/4/2019 1:35:34 AM

Introduction

Empyema of the gallbladder is the most severe form of acute cholecystitis. Empyema of the gallbladder is usually the result of a progression of acute cholecystitis in a background of bile stasis and cystic duct obstruction. This is a surgical emergency which requires prompt treatment with antibiotics and urgent aspiration/removal of the gallbladder to reduce the risk of septic shock. [1][2][3]

Etiology

Frequently empyema of the gallbladder is associated with calculus cholecystitis where there is an obstructed cystic duct and stasis of bile. The stagnant bile in the gallbladder has superinfection with microorganisms that lead to suppuration in an acutely inflamed gallbladder. Hence the gallbladder lumen becomes filled with exudative material and very often frank pus. Rarely empyema of the gallbladder may present in association with common bile duct stones or carcinoma of the gallbladder. Empyema can also occur in calculus cholecystitis.[4][5]

Epidemiology

Empyema of the gallbladder is estimated to occur in 5 % to 15% of cases diagnosed to have acute cholecystitis. It is noted to be the more morbid condition when occurring in, the older age group. There is the higher preponderance of males who develop this disease. Patients with an increased risk of acute cholecystitis such as those with associated diabetes, immunosuppressant therapy, or hemoglobinopathies have a higher chance of developing empyema of the gallbladder. Mortality is rare except in patients with advanced age, compromised immunity or significant comorbidities. The incidence of postoperative complications regardless of the surgical approach is estimated to be 10% to 20%.[6]

Pathophysiology

The stagnant bile due to cystic duct obstruction in the background of gallstone disease can become infected. Severe infection is caused commonly by pathogenic Escherichia coli, KlebsiellaStreptococcus faecalis, and anaerobes such as Bacteroids and Clostridia. Pus formation follows this infection, tightly filling the lumen of the gallbladder. In a tense and edematous gallbladder, necrosis of the wall and perforation may ensue if drainage or removal of the gallbladder is not performed promptly. If not treated rapidly, patients can develop generalized sepsis or gangrene of the gallbladder resulting in perforation of the gallbladder. Rarely a fistula between the gallbladder and duodenum can occur as a sequela of inadequately treated empyema of the gallbladder. Untreated cases develop symptoms of localized sepsis due to micro perforation or generalized sepsis due to macro perforation.[7]

Histopathology

Pathological examination of the emphysematous gallbladder show marked edema and inflammation. The wall of the gallbladder may be covered externally by a fibrinous exudate. There is obvious pus which can be seen in the lumen of the gallbladder which at times appears creamy. On culture, this pus may not always grow organisms if the patient has been on antibiotic therapy. Microscopic examination of the mucosa can reveal ulceration and evidence of inflammation. There may be associated mucosal hemorrhage.

History and Physical

Patients with empyema of the gallbladder have symptoms similar to acute cholecystitis. Tenderness in the right upper quadrant and a positive Murphy's sign are the most common and predominant presenting symptoms. As the pathology progresses, there may be a palpable gallbladder detected which is acutely tender even on light palpation. With the worsening of the disease, high fever, chills, rigors, and signs of systemic sepsis follows. Patients who are on immunosuppressants or suffer from associated diabetes may have a more prolonged course with few associated typical signs and symptoms as described above.

Evaluation

In patients present with an initial stage of empyema, symptoms, physical signs and investigations may be unremarkable to distinguish from an acute cholecystitis. Frequently the patient has a raised white cell count on laboratory evaluation indicating an underlying infective cause. An ultrasound which is the most commonly used radiological investigation in gallbladder disease is not diagnostic can raise the suspicion of an empyema when there is very edematous gallbladder, or there are echogenic contents in the gallbladder associated with gallstones. A CT scan can be helpful when ultrasonogram is not contributory. A CT scan may reveal an enlarged or distended gallbladder with edematous walls and at times pericholecystic collection. When the diagnosis is more difficult an MRI can be of help. A heavily T2 weighted sequence on MRI can help in distinguishing pus from sludge.An MRI may also show a fluid level with a layering of purulent bile. An increasing white blood count with a shift to the left in a patient with acute cholecystitis is suggestive of adverse changes. The other relevant investigations are liver enzyme levels as well as PT (prothrombin time) and aPTT (activated partial thromboplastin time). Radiological findings alone may be insufficient for an accurate diagnosis of empyema of the gallbladder. A combination of clinical, radiological, and laboratory findings are crucial to arrive at a correct final diagnosis of empyema of the gallbladder.[8]

Treatment / Management

Prompt parenteral antibiotic therapy with urgent removal or drainage of the gallbladder should be the goal to prevent increased morbidity and the rare possibility of mortality. Although the conventional practice is to perform an open cholecystectomy, it is possible to achieve a laparoscopic removal of the gallbladder by experienced surgeons. Surgeons who undertake laparoscopic approach should have a low threshold to convert to open procedure when encountered with technical difficulties. The conversion rate from laparoscopic to open cholecystectomy is higher in empyema of the gallbladder than that in uncomplicated acute cholecystitis. The higher rate of conversion is attributed to reduced visualization or distortion of the anatomical structures in the Calot's triangle as well as increased bleeding due to inflamed friable tissue. An initial decompression of the distended gallbladder either under the radiological guidance or intraoperative laparoscopically guided, facilitates the more straightforward dissection of the gallbladder. Postoperative complication rates irrespective of approach either laparoscopic or open is higher than for cholecystitis for gallstone disease. Postoperative complications which include wound infection, bleeding, cystic duct stump leak, and common bile duct injury, subhepatic abscess, have all been reported. A subtotal cholecystectomy is rarely is performed when the surgeon encounters pericholecystic inflammation that makes a safe dissection of the Calot's triangle impossible. In the elderly patients or those who are too ill to undergo surgery due to associated comorbidity, a percutaneous or transhepatic radiologically guided drainage is a temporizing procedure. This initial drainage procedure often leads to a dramatic improvement in the condition of the patient which then permits an elective cholecystectomy when the patient's condition improves.[9][6]

Differential Diagnosis

Complications

Postoperative and Rehabilitation Care

Following surgery and removal of the gallbladder, IV antibiotics are required until the fever subsides and the WBC returns to normal. Most patients are discharged home on antibiotics for 1 week.

Pearls and Other Issues

Empyema of the gallbladder may present with symptoms indistinguishable from acute cholecystitis. A high index of suspicion, as well as a combination of clinical, radiological, and laboratory parameters, helps in early diagnosis. Early and prompt surgical intervention in the form of cholecystectomy if not feasible, cholecystostomy prevents high morbidity and rare mortality.

Enhancing Healthcare Team Outcomes

Empyema of the gallbladder is a serious disorder that requires prompt diagnosis and treatment. The infection can quickly become systemic and cause multiple organ failure. Most patients require aggressive hydration, IV antibiotics and surgery. Because the disorder is associated with serious complications during surgery, an interprofessional team approach is recommended. Besides the surgeon, the radiologist may be required to drain any residual collections. The patient may be monitored in the ICU where the nurse is responsible for monitoring the patient closely for any respiratory distress and renal dysfunction. These patients are also prone to wound infections, DVT, and pneumonia- hence vigilance is necessary.

The pharmacist should manage the medications and ensure that polypharmacy does not occur, which can exacerbate the already compromised patient. Finally, there is a growing body of evidence indicating that after optimal hydration of the patient, the surgeon should remove the gallbladder within 48-72 hours.[10] (Level V)

Outcomes

When the condition is diagnosed and treated early, the prognosis is excellent. However, in patients who are immunocompromised, old or those with diabetes, empyema of the gallbladder can be unpredictable and cause severe sepsis. Further, the rate of conversion of a laparoscopic procedure into an open procedure is also higher in gallbladder empyema. [9](Level III)


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Gallbladder Empyema - Questions

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A 46-year-old female patient was admitted in the ward for fever, chills, and right upper quadrant pain. Her vitals include pulse:105/minute, blood pressure: 100/70 mm Hg, respiratory rate: 25/minute, and temperature: 99.3 degrees Fahrenheit. She had similar episodes of right upper abdominal pain, that occurred after a heavy meal in the past. On admission, the ultrasound showed gall bladder wall thickening and pericholecystic fluid, for which she was managed with crystalloids and antibiotics. Today morning she further deteriorated, following which an MRI was done. The MRI shows fluid filled levels in a distended gall bladder. Which of the following would indicate such a complication of the primary condition?



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A 70-year-old man who recovering from a myocardial infarction and has a history of asthma present to the hospital with symptoms and signs suggestive of acute cholecystitis. His abdominal ultrasonogram shows a distended gallbladder with gallstones and possible obstructed cystic duct. 24 hours later he develops rigors and chills , tachycardia, and hypotension. Abdominal examination reveals acute tenderness on light palpation. What is the correct management?



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A 66-year-old female with diabetes mellitus type 2 presents with a history of right upper quadrant pain and fever with chills. In the past, she was found to have gallstones on abdominal ultrasound. The patient appeared toxic and had a blood pressure of 90/60 mmHg. An urgent CT scan of the abdomen shows a distended gallbladder with edematous walls and a small localized pericholecystic collection with no evidence of gas. The white cell count is 16,000/micLThe liver function tests are within normal range. What are the diagnosis and treatment?



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A female presents with right upper quadrant abdominal pain. On examination, the patient is febrile with a temperature of 102 Fahrenheit, has right upper quadrant abdominal pain and a positive Murphy's sign. The providers evaluating the patient is concerned that the gallbladder is the source of the patient's symptoms and orders labs and an emergent right upper quadrant abdominal ultrasound examination. The ultrasound has a positive sonographic Murphy's sign, significant gallbladder wall edema, and pericholecystic fluid. Given the lab results, ultrasound report, and patient repeat evaluation and vital signs, the provider is concerned that the patient has empyema of the gallbladder. In addition to starting immediate parental antibiotics, which of the following is correct regarding intervention to treat the condition?



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A 65-year-old diabetic patient was brought to the emergency department with the complaints of right upper quadrant pain and high-grade fever. On physical examination, there is tenderness in the right upper quadrant on inspiration, and deep palpation also reveals an ill-defined mass in the same location. Based on the imaging obtained afterward, a diagnosis of gall bladder empyema was made. The chief resident decided to inform the patient and the family about the possible diagnosis. The patient and family are very concerned about the condition, how it happened, and what the outcome of treatment will be. The chief resident has cared for patients with gall bladder empyema several times during their surgical training and feels confident in their of the material and ability to provide the patient and family with the answers and information they need. Which of the following is the correct information to tell the patient and family about the condition?



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Gallbladder Empyema - References

References

Supit C,Supit T,Mazni Y,Basir I, The outcome of laparoscopic subtotal cholecystectomy in difficult cases - A case series. International journal of surgery case reports. 2017     [PubMed]
Pant G,Kumar A,Verma N,Sharma A, Gallbladder empyema complicating acute myeloid leukaemia in an adolescent boy. BMJ case reports. 2018 Aug 14     [PubMed]
Mehta V,Yarmish G,Greenstein J,Hahn B, Gallbladder Empyema. The Journal of emergency medicine. 2016 Jun     [PubMed]
Elshaer M,Gravante G,Thomas K,Sorge R,Al-Hamali S,Ebdewi H, Subtotal cholecystectomy for     [PubMed]
Abraham S,Rivero HG,Erlikh IV,Griffith LF,Kondamudi VK, Surgical and nonsurgical management of gallstones. American family physician. 2014 May 15     [PubMed]
Ambe PC,Jansen S,Macher-Heidrich S,Zirngibl H, Surgical management of empyematous cholecystitis: a register study of over 12,000 cases from a regional quality control database in Germany. Surgical endoscopy. 2016 Dec     [PubMed]
Khan ML,Abbassi MR,Jawed M,Shaikh U, Male gender and sonographic gall bladder wall thickness: important predictable factors for empyema and gangrene in acute cholecystitis. JPMA. The Journal of the Pakistan Medical Association. 2014 Feb     [PubMed]
Watanabe Y,Nagayama M,Okumura A,Amoh Y,Katsube T,Suga T,Koyama S,Nakatani K,Dodo Y, MR imaging of acute biliary disorders. Radiographics : a review publication of the Radiological Society of North America, Inc. 2007 Mar-Apr     [PubMed]
Aksoy F,Demiral G,Ekinci Ö, Can the timing of laparoscopic cholecystectomy after biliary pancreatitis change the conversion rate to open surgery? Asian journal of surgery. 2018 Jul     [PubMed]
Limbosch JM,Druart ML,Puttemans T,Melot C, Guidelines to laparoscopic management of acute cholecystitis. Acta chirurgica Belgica. 2000 Sep-Oct     [PubMed]

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