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
[…] 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]
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]
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]
- Wound Infection
The total postoperative complication rate was 17%, which included wound infection, bleeding, subhepatic abscess, cystic duct stump leak, common bile duct injury and pneumonia. Postoperative mortality was 2.6%. [ncbi.nlm.nih.gov]
For patients with complications (eg, intra-abdominal infections, wound infections, sepsis), therapy and follow-up care are patient specific and, therefore, individualized. [emedicine.medscape.com]
The postoperative complication rate regardless of approach either open of laparoscopic surgery for empyema from the gallbladder is 10-20% and includes wound infection, bleeding, subhepatic abscess, cystic stump leak, common bile duct injury, and systemic [laparoscopyhospital.com]
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]
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]
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]
Early in the disease process, abdominal examination findings are similar to those of patients with acute cholecystitis, with mild-to-moderate tenderness in the right upper abdomen and a positive Murphy sign (ie, arrest of inspiration as the gallbladder [emedicine.medscape.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  .
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