Gallbladder Empyema

Gallbladder empyema is pus in the gallbladder lumen, a complication of acute calculous cholecystitis with cystic duct obstruction and bacterial suppuration.

• Occurs in 2 to 15% of acute cholecystitis, more in elderly, diabetics and immunosuppressed.
• Organisms: E. coli, Klebsiella, Enterococcus, anaerobes (Bacteroides, Clostridium), Pseudomonas.
• Emphysematous cholecystitis (gas forming Clostridium welchii) is a severe variant, especially in diabetic men.
• Complications: gangrene, perforation, sepsis, septic shock, biliary peritonitis, mortality 15 to 20%.

• Right upper quadrant pain and tenderness, high fever with rigors, vomiting, palpable mass.
• Toxic appearance, tachycardia, hypotension, jaundice if Mirizzi or cholangitis.
• Diabetics and elderly can be afebrile with subtle findings.
• Positive Murphy sign (may be absent in elderly).

• Leucocytosis, raised CRP, bilirubin and liver enzymes, lactate, blood cultures.
• Ultrasound: distended gallbladder with thick wall, echogenic debris or sludge layering, stones, pericholecystic fluid, sonographic Murphy sign.
• CT: wall thickening, mucosal enhancement defects (gangrene), gas in the wall or lumen, perforation.
• HIDA scan shows non filling of the gallbladder.
• Tokyo Guidelines severity grade III (organ dysfunction) is indicated by hypotension needing vasopressors, confusion, respiratory failure, renal failure, liver dysfunction, haematological dysfunction.

• Antibiotics: piperacillin tazobactam 4.5 g IV every 6 hours, or ceftriaxone 2 g daily plus metronidazole 500 mg every 8 hours; meropenem 1 g every 8 hours for severe or healthcare associated infection. Continue 4 to 7 days after source control (3 days if cholecystectomy is complete).
• Resuscitation and organ support.
• Source control: early laparoscopic cholecystectomy within 72 hours in fit patients, or open conversion when needed (subtotal cholecystectomy if Calot triangle is hostile).
• High risk patients: percutaneous cholecystostomy (transhepatic 8 to 10 Fr) or EUS guided gallbladder drainage as a bridge, then interval cholecystectomy after 6 to 8 weeks.
• Emphysematous cholecystitis: urgent cholecystectomy and antibiotics covering anaerobes.
• Control diabetes, correct coagulopathy.
• Cholecystostomy tube cholangiography before removal; remove after tract maturation (3 to 6 weeks).