Gallbladder empyema
Gallbladder empyema is a severe suppurative complication of acute cholecystitis in which persistent cystic duct obstruction lets the gallbladder fill with frank pus under pressure. Patients present with high fever, marked right upper quadrant pain, and a positive Murphy sign, often with systemic toxicity. Diagnosis is confirmed by aspiration of pus at drainage or surgery, and treatment pairs broad-spectrum antibiotics with urgent source control, cholecystectomy when feasible or percutaneous cholecystostomy in unstable patients.
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What this article covers
- Overview
Gallbladder empyema, also called suppurative cholecystitis, is frank pus filling a gallbladder whose cystic duct remains obstructed, usually by an impacted gallstone.
- Epidemiology
Gallbladder empyema develops in a minority of patients admitted with acute calculous cholecystitis, most often when diagnosis or source control is delayed.
- Risk factors
Diabetes mellitus: microvascular disease and impaired neutrophil function favor gangrenous and suppurative progression.
- Pathophysiology
Empyema begins as ordinary acute calculous cholecystitis: a gallstone impacts the cystic duct, bile stasis follows, and the gallbladder wall becomes inflamed.
- Clinical features
Persistent right upper quadrant or epigastric pain: steady, present for more than 6 hours, often radiating to the right shoulder or back, distinguishing it from the brief colic of simple biliary colic.
- Differential diagnosis
Uncomplicated acute calculous cholecystitis: similar pain and a positive Murphy sign, but the wall is thickened without a tensely distended, pus-filled lumen, and symptoms resolve on antibiotics without emergent drainage.
- Diagnosis
Diagnosis is established by aspiration of frank, thick pus from the gallbladder lumen, obtained at percutaneous cholecystostomy or at cholecystectomy; a strong pre-procedural suspicion never substitutes for direct sampling of pus.
- Management
First, resuscitate and start piperacillin-tazobactam 3.375 g IV every 6 hours, infused over 30 minutes, along with intravenous fluids, supplemental oxygen as needed, and analgesia, ideally within the…
- Complications
Gallbladder gangrene: full-thickness wall necrosis from sustained intraluminal pressure and ischemia, often coexisting with or preceding empyema.
- Prognosis
Outcomes are generally favorable when source control and antibiotics start promptly, with most patients recovering fully after cholecystectomy or cholecystostomy drainage.
- Prevention
Prompt cholecystectomy for symptomatic gallstone disease: definitive surgery for biliary colic or uncomplicated acute cholecystitis before complicated disease develops.
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Related articles
- Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
- Acute cholangitis
Acute cholangitis is a bacterial infection of an obstructed biliary tree, classically presenting as Charcot triad of fever, right upper quadrant pain, and jaundice and progressing to septic shock when drainage is delayed. Diagnosis follows the Tokyo Guidelines and severity grade, and treatment combines prompt broad-spectrum antibiotics with biliary drainage, most often by ERCP.
- Acalculous cholecystitis
Acalculous cholecystitis is acute gallbladder inflammation without gallstones, driven by ischemia and biliary stasis in critically ill, fasting, or TPN-dependent patients. Ultrasound showing gallbladder wall thickening or pericholecystic fluid without stones supports the diagnosis. Untreated mortality reaches 75 percent, so treatment starts with intravenous antibiotics plus percutaneous cholecystostomy, followed by cholecystectomy once the patient stabilizes.
- Sepsis
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 points or more in a patient with known or suspected infection. Survival depends on recognizing the pattern early and completing the hour-1 bundle: lactate, blood cultures before antibiotics, broad-spectrum antibiotics such as cefepime 2 g IV every 8 hours, and 30 mL/kg crystalloid for hypotension or a lactate of 4 mmol/L or higher.
- Pyogenic liver abscess
Pyogenic liver abscess is a polymicrobial hepatic infection that most often seeds from the biliary tract or the portal circulation, presenting with fever, right upper quadrant pain, and a cholestatic liver profile. Diagnosis rests on contrast imaging plus culture, and treatment combines empiric broad-spectrum antibiotics with image-guided drainage for abscesses at or above 3 to 5 cm.
- Acute pancreatitis
Acute pancreatitis is acinar-cell autodigestion and inflammation of the pancreas, most often from gallstones or alcohol, diagnosed by the revised Atlanta criteria and graded mild, moderately severe, or severe by organ failure. Management centers on early goal-directed lactated Ringer's resuscitation, analgesia, early enteral feeding, and timed ERCP for gallstone pancreatitis with cholangitis, reserving antibiotics for confirmed infected necrosis.