Gallbladder Empyema

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Background

Acute cholecystitis in the presence of bacteria-containing bile may progress to suppurative infection in which the gallbladder fills with purulent material, a condition referred to as empyema of the gallbladder. (The underlying cause of cholecystitis involves obstruction of the cystic duct, which causes the buildup of infected fluid.) Systemic antibiotics and urgent drainage or resection are required to reduce the incidence of complications and to avoid or treat associated sepsis.

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. This process may be associated with calculous cholecystitis, acalculous cholecystitis, or carcinoma of the gallbladder. Left untreated, generalized sepsis ensues, with progression in the gallbladder to patchy gangrene, microperforation, macroperforation, or, rarely, cholecystoduodenal fistula. Patients at increased risk for cholecystitis include those with diabetes, immunosuppression, obesity, or hemoglobinopathies.

Epidemiology

Frequency

International

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%.

Mortality/Morbidity

The rate of laparoscopic cholecystectomy procedures converted to an open procedure is significantly higher in patients with empyema of the gallbladder. The postoperative complication rate (regardless of approach) for empyema of the gallbladder is 10-20% and includes wound infection, bleeding, subhepatic abscess, cystic stump leak, common bile duct injury, and systemic complications, including acute renal failure and/or respiratory insufficiency associated with sepsis.

Progression to death is unusual in otherwise healthy individuals but may occur in patients of advanced age, in patients with compromised immunity, or in individuals with significant comorbid conditions.

Race

American Indians and Central American Indians have an increased risk of cholelithiasis/cholecystitis, as do patients with hemoglobinopathies, such as sickle cell anemia (more likely in blacks).

History

The clinical history of a patient with empyema of the gallbladder is similar to that of a patient with acute cholecystitis (from which the empyema derives). 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.

Physical

Causes

The most frequent etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis in the face of contaminated bile. The most frequently isolated organisms include Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis, and anaerobes, including Bacteroides and Clostridia species. Suppurative inflammation ensues, tightly filling the gallbladder with purulent debris. Localized or free perforation occurs if drainage or resection is not performed at this juncture. Generalized sepsis frequently accompanies this progression.

A similar pattern is infrequently observed in association with acute acalculous cholecystitis. Rarely, obstruction of the distal common bile duct may result in pus formation within the extrahepatic biliary tree, which can then decompress into the gallbladder. This distends and infects that organ, with ensuing empyema.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Findings include a pus-filled gallbladder, with or without calculi, and an acute suppuration of the gallbladder wall, with or without areas of gangrene and perforation.

Medical Care

Intravenous antibiotic therapy is an adjunct to urgent decompression and/or resection of the gallbladder when empyema is likely. The choice of antibiotic is based on the organisms presumed to be involved (see Causes). Early in the course of the disease, good results are achieved with the adjuvant administration of ampicillin or a first- or second-generation cephalosporin. In more advanced cases associated with perforation and/or generalized sepsis, triple antibiotic therapy that includes an aminoglycoside (usually gentamicin), ampicillin or a cephalosporin, and metronidazole (anaerobic coverage) is advised.[1]

Antibiotic coverage is modified by culture results and the bacterial resistance encountered in the local hospital setting.

Urgent decompression is the goal of therapy for empyema of the gallbladder. In patients who are hemodynamically unstable or in individuals in whom surgery is contraindicated because of significant comorbid conditions, transhepatic drainage of the gallbladder under radiologic guidance may serve as a temporizing or final procedure. Though rapid and marked improvement in the patient's condition usually follows, complete resolution without further septic complication (mandating further intervention) is unpredictable.[2]

Surgical Care

Surgical decompression and resection of the affected gallbladder is the criterion standard of therapy. An advanced laparoscopic surgeon may treat empyema of the gallbladder (without significant gangrenous changes or perforation) with a laparoscopic procedure.[3] Initial decompression may be accomplished under radiographic guidance immediately before the procedure or via intraoperative, laparoscopically guided needle drainage, which allows for more facile manipulation of the gallbladder during the cholecystectomy portion of the procedure.

The conversion-to-open and complication rates reported in the literature for laparoscopic treatment of empyema vary widely. However, they are all significantly higher than the comparative rates reported in the same studies for laparoscopic treatment of uncomplicated acute cholecystitis. Laparoscopic subtotal cholecystectomy is acceptable only if the encountered pericholecystic inflammation is so severe as to preclude safe dissection via either a laparoscopic procedure or an open procedure.[4]

Importantly, the complications are related to the advanced disease process and not to the approach. In skilled hands, no increase is observed in the incidence of laparoscopic surgical misadventure with empyema of the gallbladder. Thus, despite the higher incidence of conversion to an open procedure (40-80%), it is quite reasonable to initially proceed with a laparoscopic procedure.

Consultations

When empyema of the gallbladder is considered, urgent consultation with gastroenterologists and surgeons is essential.

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Gentamicin (Garamycin)

Clinical Context:  Aminoglycoside antibiotic for gram-negative coverage bacteria, including Pseudomonas species. Synergistic with beta-lactamase against enterococci. Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.

Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least a trough level drawn on the third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.

Ampicillin (Omnipen, Polycillin)

Clinical Context:  Indicated as single-agent therapy in early empyema of the gallbladder. Bactericidal activity against susceptible organisms. Dosing depends on severity of infection.

Cefazolin (Ancef, Kefzol)

Clinical Context:  Indicated as single-agent therapy in early empyema of the gallbladder. First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, thus inhibiting bacterial growth. Dosing depends on severity of infection.

Metronidazole (Flagyl)

Clinical Context:  Indicated in severe infection in combination with aminoglycoside and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents.

Class Summary

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting. Base selection of antibiotics on blood culture sensitivity whenever feasible. Indicated as an adjunct to decompression/resection of the gallbladder with empyema.

Further Inpatient Care

Complications

Prognosis

Author

Benjamin Pace, MD, Director of Surgery, Chief of Breast Service, Queens Hospital Center

Disclosure: Nothing to disclose.

Coauthor(s)

Bruce Morel, MD, FACS, Clinical Assistant Professor, Department of Surgery, Mount Sinai School of Medicine

Disclosure: Nothing to disclose.

Sita Chokhavatia, MD, MBBS, Associate Fellowship Director, Associate Professor, Department of Internal Medicine, Division of Gastroenterology, Mount Sinai School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Maurice A Cerulli, MD, FACP, FACG, FASGE, AGAF, Associate Professor of Clinical Medicine, Albert Einstein College of Medicine of Yeshiva University; Associate Professor of Clinical Medicine, Hofstra Medical School

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Simmy Bank, MD, Chair, Professor, Department of Internal Medicine, Division of Gastroenterology, Long Island Jewish Hospital, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP, Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

References

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