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Gallbladder empyema

Gallbladder empyema (suppurative cholecystitis1) is an uncommon complication of cholecystitis and refers to a situation where the gallbladder lumen is filled and distended by purulent material (pus).

Epidemiology

Associations

There is an increased incidence in those with diabetes 2 and/or advanced atherosclerotic disease 7.

Clinical presentation

While patients with a gallbladder empyema may experience symptoms similar to those with acute uncomplicated cholecystitis (fever, chills, rigors, and right upper quadrant pain), signs of sepsis may not always be present.

Pathology

The gallbladder neck is usually obstructed by a calculus (or rarely from a malignant mass such as an underlying cholangiocarcinoma) which prevents pus from draining through the cystic duct 5

Radiographic features

Ultrasound

May show the the usual sonographic features of cholecystitis with added echogenic content within the gallbladder lumen (this feature is however not specific for an empyema)

CT

May show general imaging features of cholecystitis with added high-attenuating material (representing pus) within the distended gallbladder lumen. Again this feature is non specific and is often difficult to differentiate from sludge within the gallbladder. 

MRI

MRI sometimes may be helpful in distinguishing pus from sludge by using heavily T2 weighted sequences, which may show fluid-fluid levels with dependent layering of purulent bile. On other MR seqences images, pus or purulent bile may be difficult to demonstrate 2.  The purulent component is usually of lower signal on T2 weighted images 7-8.

Treatment and prognosis

Management options for suppurative cholecystitis include both emergent cholecystectomy and percutaneous catheter drainage, also termed percutaneous cholecystostomy (which can later be followed by a cholecystectomy) 1,5-6. The latter option is usually reserved those with additional co-morbidities 6. The rate of conversion of a laparoscopic cholecystectomy to an open procedure is considered greater than that with cases of uncomplicated acute cholecystitis. Gallbladder empyema is associated with a significant morbidity and mortality 9.

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