GALLBLADDER EMPYEMA

dr. Efman EU Manawan. Sp.B-KBD

Background
 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.
Pathophysiology
 In the bacterially contaminated gallbladder, the stagnation and marked inflammation associated with
acute cholecystitis fills the gallbladder lumen

 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
Etiology
 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. 

 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
Epidemiology
 International
 incidence of empyema of the gallbladder associated with acute cholecystitis, findings from limited series indicate a
range of 5-15%.

 Race-related Demographics
 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).
Prognosis
 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, the development of empyema of the gallbladder and the resultant sepsis constitute a serious life-
threatening event

 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

 Progression to death is unusual in otherwise healthy individuals but may occur in patients of advanced age
History
 The clinical history of a patient with empyema of the gallbladder is similar to that of a patient with acute
cholecystitis (from which the empyema derives)

 As the disease progresses, severe pain and associated high fever, chills, and even rigors may be reported

 Patients with diabetes or immunosuppression may exhibit few signs and symptoms.
Physical Examination
 Present no differently than any patient with acute cholecystitis, with symptoms that include fever
(temperature, >101°F), stable blood pressure, and mild tachycardia. 

 If localized or free perforation has occurred and/or the patient has generalized sepsis, fevers (temperature,
103°F), chills and/or rigors, and confusion may be observed in association with hypotension and severe
tachycardia.\

 Mild-to-moderate tenderness in the right upper abdomen and a positive Murphy sign 

  As the disease progresses, empyema of the gallbladder may be associated with a palpable distended
gallbladder that is markedly tender on even superficial palpation.
Differential Diagnosis
 Cholecystitis
 Cholelithiasis
Laboratory Studies
 Increasing leukocytosis at levels greater than 15,000/dL

 This scenario may occur in association with gangrenous cholecystitis and with several other differential
diagnoses

 When arising from complicated acute cholecystitis, liver chemistry findings associated with empyema of the
gallbladder are usually within reference ranges, 

 One exception is empyema of the gallbladder in which the enlarged "penile" gallbladder compresses the
common/hepatic bile ducts (Mirizzi syndrome), giving rise to mildly elevated alkaline phosphatase and
bilirubin levels.

 Serial blood cultures are beneficial in patients with bacteremia; positive results help direct antibiotic therapy
Imaging Studies
 Ultrasonography of the gallbladder is indicated in presumed empyema of the
gallbladder

 The finding of an enlarged, distended gallbladder and associated pericholecystic

fluid points to an acute inflammatory process involving the gallbladder

 the condition is frequently discovered on computed tomography (CT) scans

performed with other conditions on the differential diagnosis in mind

 On diffusion-weighted (DWI) magnetic resonance imaging (MRI), diffusion

restriction in non-neoplastic lesions sometimes provides additional information
that can help to establish a correct diagnosis
Procedures
 Endoscopic retrograde cholangiopancreatography (ERCP) is not indicated if empyema of the gallbladder
is thought likely because it may delay definitive diagnosis and operative treatment.

 Histologic findings include a pus-filled gallbladder, with or without calculi, and an acute suppuration of
the gallbladder wall, with or without areas of gangrene and perforation.
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

 Early in the course of the disease, good results are achieved with the adjuvant administration of a second-generation
cephalosporin

 More advanced cases associated with perforation and/or generalized sepsis, broader spectrum coverage with piperacillin
tazobactam is advised.

 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
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

 The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of
empyema vary widely.

 The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of
empyema vary widely.
Medication Summary
 The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Cephalosporins, 2nd Generation

Cefuroxime
 Binds to penicillin-binding proteins and inhibits final transpeptidation step of peptidoglycan synthesis,
resulting in cell-wall death

 Resists degradation by beta-lactamase; proper dosing and appropriate route of administration are
determined by condition of patient, severity of infection, and susceptibility of microorganism
 Penicillins, Extended-Spectrum
Piperezacilin tazobakram
1. Inhibits biosynthesis of cell wall mucopeptide synthesis by binding to 1 or
more of the penicillin-binding proteins and is effective during active-
multiplication stage.
TERIMA KASIH