What Is Gallbladder Empyema?
Empyema is a term used to describe pockets of pus that have collected inside a body cavity. Empyema of the gallbladder occurs when acute cholecystitis in the presence of bacteria-containing bile leads to suppurative infection in which the gallbladder is filled with purulent material. Empyema of the gallbladder is the most severe complication of acute cholecystitis or inflammation of the gallbladder. The cause of acute cholecystitis involves obstruction of the cystic duct leading to the buildup of infected fluid. Gallbladder empyema is a surgical emergency that requires immediate treatment with antibiotics and urgent aspiration or removal of the gallbladder to decrease the risk of developing septic shock.
Empyema of the gallbladder occurs in around 5 % to 15 % of the cases diagnosed with acute cholecystitis. Men are more likely to develop gallbladder empyema than women. Aged people with comorbid conditions are also at high risk of developing the condition. People suffering from diabetes, immunosuppressant therapy, or hemoglobinopathies have a high chance of suffering from gallbladder empyema. Death of a patient with gallbladder empyema is rare except in aged patients, patients with compromised immunity, or with comorbidities.
What Is the Cause of Gallbladder Empyema?
The empyema of the gallbladder is seen in association with acute calculus cholecystitis, where there is stasis of bile and an obstructed cystic duct. The organisms that are most frequently isolated are Clostridia species, Klebsiella pneumoniae, Bacteroides, Streptococcus faecalis, and Escherichia coli. The stagnant bile in the gallbladder is contaminated with microorganisms leading to pus formation in an actively inflamed gallbladder, and thus the gallbladder lumen is filled with pus and exudative material. Free or localized perforation occurs if resection or drainage is not performed at this point. This also frequently leads to generalized sepsis.
What Are the Signs and Symptoms of Gallbladder Empyema?
The sign and symptoms of empyema of the gallbladder are similar to acute cholecystitis, such as:
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Sudden, sharp, and persistent pain in the upper right side of the belly.
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Increased body temperature (fever).
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Associated pain in the right shoulder.
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Sweating.
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Loss of appetite.
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Yellow coloration of the skin and sclera.
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Clay-colored stools.
As the disease progresses, the symptoms that are seen are:
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Severe pain in the abdomen.
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Associated fever.
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Chills and rigors.
Patients who suffer from diabetes or immunosuppression may show few signs and symptoms.
What Are the Complications of Gallbladder Empyema?
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Wound Infections: The signs of wound infection include spreading redness, pus, increased pain or swelling, and fever.
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Sepsis: It is the body’s response to an infection. It occurs when the chemicals that are injected into the bloodstream to fight an infection trigger inflammation in the whole body. It is a life-threatening complication.
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Cystic Duct Stump Leak: Cystic duct is a common site of bile leakage after surgery called a cholecystectomy.
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Subphrenic Abscess: It is the accumulation of pus in the space between the diaphragm, spleen, liver, and intestines.
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Acute Renal Failure: It is a condition in which the kidneys suddenly stop filtering waste from the blood.
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Bile Duct Injury: It is the damage to the bile duct that happens during gallbladder surgery. The bile duct can get burned, cut, or pinched and lead to leakage of the bile into the abdomen.
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Bleeding: Major bleeding after laparoscopic surgery is rare, but it is a life-threatening complication.
How to Diagnose Gallbladder Empyema?
The diagnosis of gallbladder empyema starts with taking the medical history of the patient and doing a physical examination. A combination of laboratory, clinical and radiological findings is crucial for arriving at the final diagnosis of empyema of the gallbladder.
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Physical Examination - In the early stage of the disease, the findings are similar to acute cholecystitis, such as abdominal tenderness and positive murphy’s sign (the patient is told to breathe deeply with the doctor’s hand pressed on the tummy below the rib cage, gallbladder moves downwards as the patient breathes and if the patient feels sudden pain it indicates cholecystitis).
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Blood Tests - Blood tests prescribed by the doctor are complete blood count (CBC), liver function test, kidney function test, and coagulation profile.
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Ultrasound - It is the most common test done for the diagnosis of gallbladder disease. It is not very helpful in case of empyema cases but can raise doubts about an empyema when there is a very edematous gallbladder or when there are echogenic contents in the gallbladder along with gallstones.
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CT (Computed Tomography) Scan - This scan is useful when the ultrasound is not helpful in making the diagnosis. The findings of the CT scan may show distended or enlarged edematous walls and pericholecystic collection.
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MRI (Magnetic Resonance Imaging) Scan - This scan is helpful when the diagnosis becomes difficult. The MRI scan shows the level of fluid with a layering of purulent bile. It also helps in differentiating between pus and sludge.
What Is the Differential Diagnosis of Gallbladder Empyema?
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Cholecystitis - It is the infection and inflammation of the gallbladder. It is caused by the stones that block the tube that connects the gallbladder and the intestines.
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Gallstones - It is the hard deposits of bile that forms in the gallbladder.
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Biliary Colic - It is a pain in the abdomen due to obstruction due to the presence of a stone in the common bile duct of the biliary tree.
What Are the Treatment Options for Gallbladder Empyema?
In the treatment of empyema of the gallbladder, gastroenterologists and surgeons have an important role to play.
1. Medication
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IV (intravenous) antibiotic therapy is given to supplement urgent decompression and/or resection of the gallbladder. Which antibiotic is to be given is decided based on the microorganism involved. Good results are seen early in the treatment course with adjuvant administration of second-generation Cephalosporin. In serious cases that are associated with perforation or generalized sepsis, broader spectrum coverage with Piperacillin and Tazobactam is recommended. Antibiotic therapy is given until the fever subsides.
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The main aim of the therapy is urgent decompression for empyema of the gallbladder. Transhepatic drainage of the gallbladder under radiologic guidance is a temporary or final procedure for patients who are hemodynamically unstable or patients in whom surgery is contraindicated because of comorbid conditions. Even though significant improvement in the patient's condition is seen after the procedure, complete resolution without further septic complications is unpredictable.
2. Surgery
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Surgical decompression and resection of the affected gallbladder is the standard surgical procedure for the treatment of empyema of the gallbladder.
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Laparoscopic procedures are done for the empyema of the gallbladder without significant gangrenous changes or perforation. The laparoscopic removal of the gallbladder is done by an experienced surgeon, even though the conventional practice is to perform open cholecystectomy.
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The surgeon should have a low threshold to convert a laparoscopic procedure into an open procedure due to encounters with technical difficulties. This conversation rate is higher in cases of empyema of the gallbladder than in cases of uncomplicated acute cholecystitis. This higher rate of conversion is because of decreased visualization or distortion of the anatomical structures in the Calot triangle and heavy bleeding due to inflamed friable tissue.
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A Calot triangle or hepatocystic triangle is an anatomical space at the porta hepatis of special value in cholecystectomy, as it is dissected during the surgery and contains a cystic artery and cystic duct. When the surgeon comes across pericholecystic inflammation that makes a safe dissection of the Calot triangle impossible, then subtotal cholecystectomy is performed, though rarely.
3. Post-operative Care
Post-operative complications are seen irrespective of the method of surgery, be it laparoscopic or open surgery. The incidence of such complications is 10 % to 20 %. These complications are higher for empyema of the gallbladder than for cholecystitis. The postoperative complications include wound infection, bleeding, common bile duct injury, cystic duct stump leak, and subhepatic abscess. After the surgery and removal of the gallbladder, IV antibiotics are given until the fever subsides, and the count of white blood cells returns to normal. Most of the patients are discharged with prescribed antibiotics for one week.
Conclusion:
Gallbladder empyema is associated with acute cholecystitis, so patients with the condition need to be very careful with their health. They should go for regular check-ups so that timely diagnosis can be made and proper and prompt treatment can be given. People with a high risk of developing gallbladder empyema should be monitored. The prognosis is excellent when it is diagnosed and treated promptly.
