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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]
  • […] 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]
  • Patient presentation A 73-year-old man presented to the emergency room with severe abdominal pain, fever, chills, intense perspiration, and obstipation.[mdct.net]
  • 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]
  • On admission, 102 (70%) patients presented as right upper quadrant pain, 39 (27%) as epigastric pain, 90 (62%) as fever, 108 (74%) patients had leukocytosis, and 33 (22.7%) patients were septic.[ncbi.nlm.nih.gov]
Rigor
  • 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]
  • While patients with a gallbladder empyema may experience symptoms similar to those with acute uncomplicated cholecystitis (fever, chills, rigors, and right upper quadrant pain), signs of sepsis may not always be present.[radiopaedia.org]
  • With the worsening of the disease, high fever, chills, rigors, and signs of systemic sepsis follows.[statpearls.com]
  • In severe cases, symptoms can include pain in the RUQ, jaundice and high swinging fevers with rigors and chills (Charcot's triad). Obstructive jaundice See the separate Jaundice article.[patient.info]
Malaise
  • Other symptoms were poor appetite, nausea, vomiting and general malaise for one week.[austinpublishinggroup.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]
Constitutional Symptom
  • We present a 79-year-old African American woman resident in New York City with a medical history of diabetes mellitus who presented at the ED with constitutional symptoms and right upper quadrant pain of a few days duration.[scopemed.org]
Acute Abdomen
  • Abdominal aortic aneurysm Abdominal examination Abdominal hernias About the USMLE Step 2 CS Achalasia Achilles tendon rupture Acid-base disorders Acne vulgaris Acoustic neuroma Acquired diaphragmatic hernias Acromegaly Actinomycosis Acute abdomen Acute[amboss.com]
Systolic Murmur
  • Systolic murmur in an asymptomatic child Altered bowel peristalsis Supported by an unrestricted educational grant from[mdct.net]
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]
  • 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]
  • 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]
Biliary Colic
  • 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]
  • 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]
  • Laparoscopic cholecystectomy for symptoms of biliary colic in the absence of gallstones. Am J Surg. 2003;186(1):1–3. 32. Henderson SO, Swadron S, Newton E. Comparison of intravenous ketorolac and meperidine in the treatment of biliary colic.[aafp.org]
  • 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]
Neck Mass
  • masses Congenital TORCH infections Congenital visceral malformations Congestive heart failure Conjunctivitis Connective tissue Connective tissue diseases Conservative treatment of fractures Constipation Coronary artery bypass grafting Cough Counseling[amboss.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].

Pseudomonas
  • The common pathogens were Escherichia coli (57%), Enterococcus (27%), Klebsiella pneumonia (18%), Morganella morganii (7.6%), Pseudomonas aeruginosa (4.1%) and Salmonella (0.7%).[ncbi.nlm.nih.gov]
  • Pelvic empyema in women is most often caused by Bacteroides strains or Pseudomonas aeruginosa. In elderly, chronically ill, or alcoholic patients, empyema is often caused by Klebsiella pneumoniae species of bacteria.[encyclopedia.com]

Treatment

  • The treatment can be surgical laparoscopic decompression and resection of the affected gallbladder is the criterion standard of therapy.[laparoscopyhospital.com]
  • BACKGROUND/AIMS: 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]
  • Treatment options include cholecystectomy or, in patients with comorbidities, drainage via percutaneous cholecystostomy, later followed by cholecystectomy.[ijri.org]
  • 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

  • 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 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]
  • Roncoroni Does laparoscopic cholecystectomy worsen the prognosis of unsuspected gallbladder cancer? Arch Surg, 135 (2000), pp. 1340-1344 [60.] T. Tsunoda, R. Tsuchiya, N.[elsevier.es]
  • 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

  • Alltogether the commonest etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis when confronted with contaminated bile.[laparoscopyhospital.com]
  • 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[statpearls.com]
  • . • Etiology : (recurrent trauma and chronic inflammation) – Gallstones are present in 60-90% of the cases – Parasitic disease of the biliary tree 38.[slideshare.net]

Epidemiology

  • 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]
  • CVD Epidemiology Newsletter, 36, 116, 1984 ISSN PT02271108, no IF, no Citation Index 2.[gomppublic.uniroma1.it]
  • Diehl Epidemiology of gallbladder cancer: a synthesis of recent data JNCI, 65 (1990), pp. 1209-1213 [10.] I. Roa, J.C. Araya, T.[elsevier.es]
  • 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]
  • […] intracranial pressure and brain herniation Elimination disorders Embryogenesis Emotional and behavioral disorders in children and adolescents Endarterectomy Endometrial cancer Endometriosis Endophthalmitis Environmental injuries Enzymes and biocatalysis Epidemiology[amboss.com]
Sex distribution
Age distribution

Pathophysiology

  • 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]

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]
  • 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]
  • Early and prompt surgical intervention in the form of cholecystectomy if not feasible, cholecystostomy prevents high morbidity and rare mortality.[statpearls.com]
  • Abstract Empyema of the gallbladder develops when the gallbladder neck is obstructed in the presence of infection, preventing pus from draining via the cystic duct.[ijri.org]
  • It only endorses products that yields therapeutic benefits or aids in the management or prevention of various foot ailments.[sporting-feet.com]

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