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.
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 . It is seen in approximately 2-11% of patients who suffer from cholecystitis  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)  . For this reason, the term suppurative cholecystitis is often used as a synonym in the medical literature  . 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  . 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)  . Symptoms may rapidly develop, and in the setting of sepsis (predominantly caused by gram-negative pathogens) or perforation, the condition might be life-threatening  . For this reason, early recognition is necessary in order to facilitate proper therapy  .
Entire Body System
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]
fever and right upper quadrant pain. [clinicalgate.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]
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]
Patient presentation A 73-year-old man presented to the emergency room with severe abdominal pain, fever, chills, intense perspiration, and obstipation. [mdct.net]
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]
Liver, Gall & Pancreas
- 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]
Patients with acute cholecystitis will be tender in the RUQ and will likely demonstrate a positive Murphy’s sign. Murphy’s Sign Whilst applying pressure in the RUQ, ask the patient to inspire. [teachmesurgery.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]
- Liver Mass
Clinical features • Liver mass • Non specific signs and symptoms : weight loss, pain, anorexia, ascites • If there is biliary obstruction : jaundice, acholic stool, nausea and vomiting, weight loss • Elevated alkaline phosphatase and aminotransferases [slideshare.net]
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  . Imaging studies, however, are the cornerstone in visualizing gallbladder empyema and establishing a firm diagnosis   . 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   . In addition to gallstones, thickening of the gallbladder wall, distension, and reactive hyperemia are other notable findings on the US and CT . 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  . Apart from significant leukocytosis, other laboratory findings are nonspecific  .
GB empyema is a life-threatening complication which should be kept as a possibility while evaluating patients with neutropaenia with pain abdomen localised to right hypochondrium as early diagnosis and treatment can lead to better outcomes. [ncbi.nlm.nih.gov]
The treatment can be surgical laparoscopic decompression and resection of the affected gallbladder is the criterion standard of therapy. [laparoscopyhospital.com]
Facial nerve paralysis can result in devastating consequences like deficiency of facial expression, impaired speech and ocular complications; therefore, its early detection has a critical impact in treatment. [posterng.netkey.at]
The patient was discharged 12 days after beginning intrapleural treatment, and no further drainage was needed. [journalpulmonology.org]
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 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]
Prognosis If treated early, otherwise healthy patients have a full recovery and return to normal activity. [emedicine.medscape.com]
Etiology The most frequent etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis in the face of contaminated bile. [emedicine.medscape.com]
Alltogether the commonest etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis when confronted with contaminated bile. [laparoscopyhospital.com]
Inclusion criteria Patients with EPE and/or pleural thickening of unknown etiology after repeated inconclusive thoracentesis were included in this study. [ejbronchology.eg.net]
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]
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]
Empyema can also occur in calculus cholecystitis.   Epidemiology Empyema of the gallbladder is estimated to occur in 5 % to 15% of cases diagnosed to have acute cholecystitis. [statpearls.com]
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]
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]
The incidence of postoperative complications regardless of the surgical approach is estimated to be 10% to 20%.  Pathophysiology The stagnant bile due to cystic duct obstruction in the background of gallstone disease can become infected. [statpearls.com]
Subjects with diabetes mellitus, chronic renal disease, and aplastic anemia have a predisposition for this infection.[ 4 ] To understand the pathophysiology of PPT, it is important to know the anatomy of diploic veins. [thieme-connect.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]
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]
It only endorses products that yields therapeutic benefits or aids in the management or prevention of various foot ailments. [sporting-feet.com]
Prevention Ursodeoxycholic acid is useful in preventing high-risk patients (eg, morbidly obese patients undergoing rapid weight loss following bariatric surgery) from developing gallstones [ 1 ]. [patient.info]
[…] 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]
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- 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.
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