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Gallbladder Empyema

Empyema Gall Bladder

Gallbladder empyema is a complication of acute cholecystitis characterized by extensive pus formation from invading bacteria and distension of the gallbladder, which may lead to life-threatening sepsis in the absence of early therapy. The clinical presentation is not significantly different from acute cholecystitis, comprising fever, chills, and right upper quadrant abdominal pain, as main symptoms. Imaging studies are used to support clinical suspicion.


Presentation

The inflammation of the gallbladder (mostly due to the presence of a gallstone), known as acute cholecystitis, can further lead to the development of various complications, one of the most important being gallbladder empyema [1]. It is seen in approximately 2-11% of patients who suffer from cholecystitis [2] and is caused by bacterial superinfection of the bile that is trapped in the gallbladder, leading to pus formation and distension of the gallbladder lumen (together with increased wall thickness) [3] [4]. For this reason, the term suppurative cholecystitis is often used as a synonym in the medical literature [3] [4]. Males have shown to be at an increased risk for the development of gallbladder empyema compared to women, whereas diabetes mellitus was also identified as a predisposing factor [2] [5]. The clinical presentation is largely similar to acute cholecystitis - fever, chills, and pain in the right upper quadrant of the abdomen, which could be accompanied by severe weakness (prostration) [3] [4]. Symptoms may rapidly develop, and in the setting of sepsis (predominantly caused by gram-negative pathogens) or perforation, the condition might be life-threatening [4] [5]. For this reason, early recognition is necessary in order to facilitate proper therapy [1] [4].

Fever
  • The clinical presentation is largely similar to acute cholecystitis - fever, chills, and pain in the right upper quadrant of the abdomen, which could be accompanied by severe weakness (prostration).[symptoma.com]
  • 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.[emedicine.medscape.com]
  • […] or signs of infection • Fever or WBC with dilated GB concerning for empyema • Cholecystectomy for GB hydrops if patient is symptomatic • Urgent cholecystectomy for empyema (Left) Oblique ultrasound shows an enlarged gallbladder in a 5 year old with fever[clinicalgate.com]
  • Acute viral hepatitis: acute severe jaundice hepatitis can be similar to the right upper quadrant abdominal pain and fever, increased white blood cell count and jaundice.[healthfrom.com]
  • However, if localized reely perforation has occurred and the patient has generalized sepsis, fevers, temperature, 103 F, chills and rigors, and confusion may be observed in association with hypotension and severe tachycardia.[laparoscopyhospital.com]
Malaise
  • Other symptoms were poor appetite, nausea, vomiting and general malaise for one week.[austinpublishinggroup.com]
  • Fever , malaise Nausea and vomiting References: [8] [1] [9] [10] [2] Subtypes and variants Acalculous cholecystitis Definition : : acute necroinflammatory disorder of the gallbladder, usually seen in critically ill patients .[amboss.com]
  • But in malignancy, patients may present with weakness, malaise, anorexia and a palpable right upper quadrant mass [ 1 ]. Elevated liver enzymes, especially alkaline phosphatase levels are commonly observed [ 3 ].[omicsonline.org]
  • Clinical features and treatment The onset of malaise, fever, and rigors is followed by pain, vomiting, jaundice, and itching. The urine turns dark and the faeces pale.[emedmd.com]
Hunting
  • Hunt DR, Chu FC. Gangrenous cholecystitis in the laparoscopic era. Aust N Z J Surg 2000; 70: 428-30.[jpma.org.pk]
Acute Abdomen
  • abdomen Differential diagnosis of RUQ pain Abdominal Acute cholangitis Acute hepatic capsule swelling (e.g., acute hepatitis, perihepatitis, congestive hepatopathy ) Gastroesophageal reflux , gastritis , gastrointestinal ulcers Early appendicitis Acute[amboss.com]
Murphy's Sign
  • […] or perforation US : Markedly distended GB with echogenic pus in lumen – GB wall appears thickened – Sonographic Murphy sign often positive – Gallstones usually (but not always) present PATHOLOGY • GB hydrops caused by chronic GB outlet obstruction (most[clinicalgate.com]
  • The initial diagnosis of acute cholecystitis should be made based on clinical criteria, and in the setting of very high fever, abdominal pain that is accompanied by rebound tenderness (and a positive Murphy's sign - palpation of the inflamed gallbladder[symptoma.com]
  • She was tender and had a positive murphy’s sign on clinical examination coupled with tachycardia and a low-grade fever.[scopemed.org]
  • Physical examination shows abdominal distension, present hypoactive peristalsis, widespread tympanic percussion, voluntary muscle stiffness, painful on palpation of the entire abdomen, positive Murphy’s sign and rebound, with tachycardia 130 bpm, tachypnea[new.medigraphic.com]
  • Positive Murphy sign (pain on compression of the GB with the ultrasonographic probe). Pericholecystic fluid in severe cases. Echo-poor halo in or around the GB wall or striated GB wall indicative of edema. GB distension.[wsoonli15.wordpress.com]
Biliary Colic
  • Clinically, pre-operative diagnosis of acute inflammation and empyema or gangrene is often difficult because of the similarity of symptoms with biliary colic due to uncomplicated acute cholecystitis. 7-9 Biliary colic is a self-limiting transient obstruction[jpma.org.pk]
  • Management Biliary Colic Initial Management Patients with biliary colic should be prescribed analgesia , typically NSAIDs and PRN opioids, along with an appropriate antiemetic .[teachmesurgery.com]
  • When the gallbladder is not developed, such as liver function can be divided by liver damage or liver function disorders, it may be chronic cholecystitis. cholecystokinin test: If the gallbladder contraction amplitude is less than 50%, and biliary colic[healthfrom.com]
  • Recurrent biliary colic equals chronic cholecystitis.[rcemlearning.co.uk]
  • Gallstones may cause acute or chronic cholecystitis, biliary colic, pancreatitis or obstructive jaundice. Biliary colic is the most common presentation, caused by a gallstone impacting in the cystic duct or the ampulla of Vater.[patient.info]
Gallbladder Enlargement
  • Other auxiliary checks (1) acute cholecystitis: ultrasound: B-found gallbladder enlargement, wall thickness, cavity bile thick and so often can make a diagnosis in time. radiation examination: abdominal plain film with the significance of the positive[healthfrom.com]
Microscopic Hematuria
  • Right kidney stones: fever rare, patients with more low back pain, radiation to the perineum, kidney area have percussion pain, gross hematuria or microscopic hematuria. X-ray plain film can show positive stones.[healthfrom.com]

Workup

Physicians need to conduct a thorough clinical assessment through a detailed patient history and a comprehensive physical examination. The initial diagnosis of acute cholecystitis should be made based on clinical criteria, and in the setting of very high fever, abdominal pain that is accompanied by rebound tenderness (and a positive Murphy's sign - palpation of the inflamed gallbladder during inspiration that results in pain), as well as poor general condition, can point to gallbladder empyema [1] [4]. Imaging studies, however, are the cornerstone in visualizing gallbladder empyema and establishing a firm diagnosis [3] [5] [6]. Abdominal ultrasonography (US), regarded as the first-line study in patients with hepatobiliary system pathology, will be able to identify gallstones, and thus raise valid suspicion, but more advanced methods, such as computed tomography (CT) and magnetic resonance imaging (MRI), may be necessary to make a definite diagnosis [3] [5] [6]. In addition to gallstones, thickening of the gallbladder wall, distension, and reactive hyperemia are other notable findings on the US and CT [6]. MRI, on the other hand, is a superior method compared to US and CT, as it can discriminate pus and bile on T2-weighed studies, in which case percutaneous needle aspiration of pus and subsequent microbiological investigation might be recommended to reveal the underlying bacterial microorganism responsible for the infection [3] [5]. Apart from significant leukocytosis, other laboratory findings are nonspecific [1] [4].

Treatment

  • The treatment can be surgical laparoscopic decompression and resection of the affected gallbladder is the criterion standard of therapy.[laparoscopyhospital.com]
  • This study is conducted to evaluate the feasibility of percutaneous transhepatic gallbladder drainage prior to laparoscopic cholecystectomy for the treatment of gallbladder empyema.[ncbi.nlm.nih.gov]
  • Key words: pyogenic hepatic abscess gallbladder, pyogenic abscess of the liver, pyogenic liver abscess, pyogenic hepatic abscess treatment, pyogenic hepatic abscess drainage[scopemed.org]
  • The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of empyema vary widely.[emedicine.medscape.com]
  • This delays the surgical treatment. 7 It is necessary to prioritise the patients for cholecystectomy, who are at more risk to develop empyema or gangrene of the gall bladder if the surgical treatment is delayed.[jpma.org.pk]

Prognosis

  • Treatment and prognosis Management options for suppurative cholecystitis include both emergent cholecystectomy and percutaneous catheter drainage, also termed percutaneous cholecystostomy (which can later be followed by a cholecystectomy) 1,5-6 .[radiopaedia.org]
  • Prognosis If treated early, otherwise healthy patients have a full recovery and return to normal activity.[emedicine.medscape.com]
  • Prognosis after surgical removal of the gallbladder is very good. Very few people experience side effects from this procedure, while the rest do not need to make any changes to their lifestyle after this procedure.[ahealthgroup.com]
  • Prognosis The prognosis for recovery is generally good, except in those cases with complications, such as a brain abscess or blood poisoning, or cases caused by certain types of streptococci.[encyclopedia.com]
  • 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[statpearls.com]

Etiology

  • Etiology The most frequent etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis in the face of contaminated bile.[emedicine.medscape.com]
  • Etiology The incidence of acute cholecystitis and bile stasis and bacterial infection are closely related.[healthfrom.com]
  • 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.[emedicine.medscape.com]
  • Alltogether the commonest etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis when confronted with contaminated bile.[laparoscopyhospital.com]
  • Etiology Cholelithiasis Imbalance of bile salts, lecithin (stabilizer), diluted substances ( cholesterol , calcium carbonate , bilirubin ) and gallbladder stasis Risk factors Obesity Female sex , especially among those receiving estrogen therapy Multiparity[amboss.com]

Epidemiology

  • Epidemiology International The true incidence of empyema of the gallbladder associated with acute cholecystitis is difficult to assess, although findings from limited series indicate a range of 5-15%.[emedicine.medscape.com]
  • 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.[statpearls.com]
  • : similar to cholelithiasis Cholecystitis Sex : Prevalence : 33% of patients with cholelithiasis Peak incidence : 40–50 years References: [1] [2] [3] Epidemiological data refers to the US, unless otherwise specified.[amboss.com]
  • Epidemiology [ 1 ] 1-4% of asymptomatic patients in the adult Western world develop symptoms annually. The most common presentations are biliary colic (56%) and acute cholecystitis (36%) [ 1 ] .[patient.info]
  • Over the past two decades, much has been learned about the epidemiology of this condition and its risk factors 2 ( Table 1 3 ) .[aafp.org]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology In the bacterially contaminated gallbladder, the stagnation and marked inflammation associated with acute cholecystitis fills the gallbladder lumen with exudative material principally comprised of frank pus.[emedicine.medscape.com]
  • 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.[statpearls.com]
  • Pathophysiology Figure 1 – The biliary system, which transports bile from the gallbladder to the duodenum. Bile is formed from cholesterol , phospholipids , and bile pigments (products of haemoglobin metabolism).[teachmesurgery.com]
  • […] postcholecystectomy Cholecystitis Due to obstructing cholelithiasis : 90% of cases, with secondary bacterial infection ( E. coli , Klebsiella , Enterobacter ) References: [2] [4] [5] [1] Classification Cholecystitis Edematous Necrotizing Suppurative Chronic Pathophysiology[amboss.com]

Prevention

  • The gallbladder neck is usually obstructed by a calculus (or rarely from a malignant mass such as an underlying cholangiocarcinoma ) which prevents pus from draining through the cystic duct 5 .[radiopaedia.org]
  • Prevention 1. pay attention to diet. Food to light is appropriate, Eat greasy and fried, baked food. 2. Keep the stool open. 3. To change the meditation lifestyle, more walking, more exercise. 4. To support the sex.[healthfrom.com]
  • […] keeps patients at risk for development of complications of acute cholecystitis which may require re-admissions and emergency surgeries. 2 Empyema and gangrene of the gall bladder are serious consequences of acute inflammation of gall bladder and to prevent[jpma.org.pk]
  • Early and prompt surgical intervention in the form of cholecystectomy if not feasible, cholecystostomy prevents high morbidity and rare mortality.[statpearls.com]
  • Seite 290 - Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: A meta-analysis. Hepatology 1999; 29: 1655-61 6. ‎[books.google.de]

References

Article

  1. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J; 2011.
  2. 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. J Pak Med Assoc. 2014;64(2):159-162.
  3. Smith EA, Dillman JR, Elsayes KM, Menias CO, Bude RO. Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J Roentgenol. 2009;192(1):188-196.
  4. Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2016.
  5. Watanabe Y, Nagayama M, Okumura A, et al. MR imaging of acute biliary disorders. Radiographics. 2007;27(2):477-495.
  6. Shakespear JS, Shaaban AM, Rezvani M. CT findings of acute cholecystitis and its complications. AJR Am J Roentgenol. 2010;194(6):1523-1529.

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Last updated: 2018-06-22 04:52