Background

A serious medical illness that affects the gallbladder, a small organ under the liver, is called gallbladder empyema. It causes when the gallbladder gets infected and fills with pus usually because of severe gallbladder inflammation or untreated gallstones. 

Hardened deposits that develop in the gallbladder are called gallstones. They may cause inflammation and infection by obstructing the bile ducts. 

Cholecystitis may occur by an infection, gallstones, or other medical disorders. Cholecystitis can develop into empyema if ignored.  

Gallbladder empyema is frequently connected with bacterial infection. The bile ducts can allow bacteria to enter the gallbladder, particularly in cases when gallstones are the cause of an obstruction. 

Epidemiology

he prevalence of gallbladder empyema is lower than that of gallbladder illnesses like cholecystitis. Different demographics and healthcare environments may have varying rates of gallbladder empyema.   

Some categories of people are more likely to experience gallbladder illnesses such as empyema. Gallbladder empyema is common in elderly persons, especially those over 50 but it can occur at any age. 

Anatomy

Pathophysiology

Gallstones frequently occur with the development of gallbladder empyema. Biliary stasis and reduced bile flow can result from gallstone blockages in the common or cystic ducts. Bacterial infection and overgrowth are made possible by stagnant bile. 

Bacteria can go up from the duodenum into the biliary system. Bacteroides species, Enterococcus, Klebsiella, and Escherichia coli are the most often involved bacteria in gallbladder empyema. 

The gallbladder wall becomes inflamed when bacteria cause an immunological reaction. Necrosis and tissue damage can result from the inflammatory process. 

Etiology

A combination of bile constituents such as mucus, calcium bilirubinate, and cholesterol crystals is known as biliary sludge. It may build up in the gallbladder and aid in the formation of gallstones. Biliary sludge can block the bile ducts which puts them at risk for acute cholecystitis and empyema.  

An important part of the pathophysiology of gallbladder empyema involves bacteria. A gallbladder infection frequently results from an ascending infection from the biliary tract or bacterial translocation from the colon. 

Genetics

Prognostic Factors

The degree and gravity of the gallbladder’s bacterial infection are important factors in predicting the outcome. Unfavorable results are more likely in patients with extensive infection, a significant bacterial burden, or septic sequelae. 

The prognosis is greatly affected by complications such gallbladder perforation, abscess formation, bile duct obstruction, or peritonitis. In addition to requiring more intensive treatment, complicated patients carry a higher risk of morbidity and fatality. 

The degree of ischemia, necrosis, and inflammation in the gallbladder can affect the prognosis. A more advanced stage of the disease and a worse prognosis could be indicated by severe inflammation combined with gangrenous alterations. 

Clinical History

Age Group:  

Gallbladder empyema can affect individuals across a wide age range, but it is more commonly observed in older adults, particularly those over the age of 50.  

Associated Comorbidity or Activity:   

Gallstones are a significant risk factor for gallbladder empyema. The presence of gallstones increases the likelihood of bile duct obstruction, leading to stasis of bile and predisposing the gallbladder to infection. 

Obesity is closely linked to the development of gallbladder diseases, including cholelithiasis and acute cholecystitis. Excess body weight is a known risk factor for gallstone formation and can contribute to the progression to gallbladder empyema. 

Diabetes mellitus is associated with an increased risk of gallstone formation and gallbladder disease. Poorly controlled diabetes can impair gallbladder function and bile composition, promoting the development of gallbladder empyema. 

Acuity of Presentation:  

Patients with gallbladder empyema often experience a sudden onset of symptoms, which may include severe abdominal pain, fever, and chills. The pain is typically located in the upper right quadrant of the abdomen and may radiate to the back or shoulder. 

The abdominal pain associated with gallbladder empyema is often severe and persistent, lasting for several hours or days. The pain may be described as sharp, stabbing, or colicky and is usually exacerbated by movement or deep breathing. 

Patients with gallbladder empyema often present with fever, which may be accompanied by chills or rigors. The fever is typically high-grade and may indicate systemic infection and inflammation. 

Physical Examination

• General Appearance: Assess the patient’s general appearance for signs of distress or discomfort. Patients with gallbladder empyema may appear unwell, with symptoms such as fever, diaphoresis, and agitation. 
• Abdominal Inspection: Inspect the abdomen for any visible abnormalities, such as distension, asymmetry, or surgical scars.  
• Abdominal Palpation: Palpate the abdomen gently to assess for tenderness, particularly in the right upper quadrant where the gallbladder is located. Deep palpation may exacerbate pain, indicating inflammation or infection of the gallbladder. 
• Jaundice: Evaluate for signs of jaundice, including yellowing of the skin and sclerae. Jaundice may occur in cases of biliary obstruction secondary to gallbladder empyema or associated complications. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Acute Cholecystitis: Gallbladder empyema is a severe form of acute cholecystitis characterized by pus accumulation within the gallbladder. In less severe cases of acute cholecystitis, the gallbladder may be inflamed without evidence of pus formation. 
• Gallstone Pancreatitis: Pancreatitis can result from gallstone obstruction of the common bile duct, leading to pancreatic enzyme activation and inflammation. Patients may present with severe abdominal pain, nausea, vomiting, and elevated serum amylase and lipase levels. 
• Choledocholithiasis: Bile duct stones can cause biliary obstruction, leading to symptoms like gallbladder empyema, including right upper quadrant pain, jaundice, and fever.  
• Ascending Cholangitis: Ascending cholangitis is a bacterial infection of the biliary tree caused by obstruction and bacterial overgrowth. It presents with fever, jaundice, right upper quadrant pain, and signs of systemic inflammation. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Initial Stabilization: Patients with suspected or confirmed gallbladder empyema should be promptly assessed and stabilized. 
• Laboratory tests, including complete blood count, liver function tests, serum amylase and lipase levels, and inflammatory markers are obtained to assess the severity of infection and evaluate for complications. 

• Percutaneous Drainage: In patients with severe symptoms or evidence of complications such as gallbladder perforation or abscess formation, percutaneous drainage of the gallbladder may be performed under imaging guidance. 
• Postoperative Care: Following cholecystectomy, patients are monitored closely in the postoperative period for signs of recovery and potential complications such as bleeding, bile leakage, or surgical site infection. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-gallbladder-empyema

• Antibiotic Therapy: Antibiotics play a crucial role in controlling bacterial infection within the gallbladder. Empirical broad-spectrum antibiotics are typically initiated promptly upon suspicion of gallbladder empyema and adjusted based on culture and sensitivity results. 
• Biliary Decompression: In cases of biliary obstruction or choledocholithiasis contributing to gallbladder empyema, biliary decompression may be necessary to restore bile flow and reduce bacterial overgrowth.  

Role of Antibiotics

• Ceftriaxone: It is a third-generation cephalosporin antibiotic with excellent activity against gram-positive and gram-negative bacteria, including many pathogens involved in gallbladder infections.
• Its bactericidal activity results from inhibition of bacterial cell wall synthesis, leading to cell lysis and death. 

• Ciprofloxacin: It is a fluoroquinolone antibiotic with broad-spectrum activity against gram-negative and some gram-positive bacteria, as well as atypical pathogens.
• Its mechanism of action involves inhibition of bacterial DNA gyrase and topoisomerase IV, leading to inhibition of DNA replication, transcription, and repair. 

Role of Second-generation cephalosporin

• Cefuroxime: It exhibits broad-spectrum activity against both gram-positive and gram-negative bacteria. It is effective against many of the common pathogens implicated in gallbladder infections.
• It works by inhibiting bacterial cell wall synthesis, leading to bacterial cell death. It binds to penicillin-binding proteins (PBPs) on the bacterial cell wall. 

use-of-intervention-with-a-procedure-in-treating-gallbladder-empyema

• Cholecystectomy: It may be performed using either a laparoscopic or open surgical approach, depending on the patient’s clinical condition, surgeon expertise, and intraoperative findings.
• Laparoscopic cholecystectomy is the preferred approach when feasible, as it is associated with less postoperative pain, shorter hospital stays, and faster recovery compared to open surgery.
• In cases of severe inflammation, dense adhesions, or suspected complications such as gallbladder perforation, conversion to open cholecystectomy may be necessary to ensure safe and complete removal of the gallbladder. 

use-of-phases-in-managing-gallbladder-empyema

• Initial Assessment and Stabilization: The initial phase begins with the assessment and stabilization of the patient presenting with symptoms suggestive of gallbladder empyema. This includes a comprehensive medical history, physical examination, and initial diagnostic tests to confirm the diagnosis and assess the severity of infection. 
• Diagnostic Evaluation: Following initial assessment, diagnostic tests are performed to confirm the diagnosis of gallbladder empyema and evaluate for complications. 
• Medical Management: Medical management is initiated concurrently with diagnostic evaluation and includes empirical antibiotic therapy to cover likely bacterial pathogens involved in gallbladder empyema.  
• Postoperative Care and Monitoring: Following surgical intervention, patients require close postoperative monitoring and supportive care to ensure optimal recovery.  

Medication

Future Trends

Media Gallary

References

Gallbladder Empyema – StatPearls – NCBI Bookshelf (nih.gov)