Gallbladder Empyema: Pus in the Gallbladder – Symptoms & Treatment

What is gallbladder empyema? (Suppurative cholecystitis)

Gallbladder empyema, also known as suppurative cholecystitis, is a severe form of acute cholecystitis where the gallbladder becomes filled with pus (purulent material). It occurs when the cystic duct is completely obstructed (usually by a stone) and secondary bacterial infection leads to accumulation of pus. Unlike simple acute cholecystitis, empyema carries a higher risk of gallbladder perforation, sepsis, and death. It is a surgical emergency requiring prompt source control.

Causes – progression of acute cholecystitis, cystic duct obstruction

Empyema develops when acute cholecystitis is not adequately treated or when the cystic duct obstruction is complete. Risk factors include:

• Delayed diagnosis or treatment of acute cholecystitis.
• Elderly age (>70 years).
• Diabetes mellitus (impairs immune response).
• Immunosuppression (steroids, chemotherapy, HIV).
• Large impacted gallstone at the cystic duct.
• Malignancy obstructing the cystic duct.

The most common infecting organisms are E. coli, Klebsiella, Enterococcus, and anaerobes (Bacteroides).

Symptoms – high fever, severe RUQ pain, septic appearance

Patients with gallbladder empyema are typically very ill. Symptoms include:

• High fever (often >39°C) with chills and rigors.
• Severe, constant right upper quadrant (RUQ) or epigastric pain.
• Tenderness and guarding in the RUQ – often with rebound tenderness.
• Nausea and vomiting.
• Jaundice (may occur if associated CBD stone or Mirizzi syndrome).
• Signs of sepsis: Hypotension, tachycardia, tachypnoea, confusion, oliguria.

Diagnosis – ultrasound, CT scan, laboratory findings

Diagnosis is based on clinical presentation and imaging:

• Blood tests: Marked leucocytosis (WBC >15,000‑20,000), elevated C‑reactive protein (CRP), elevated bilirubin and alkaline phosphatase (if associated obstruction). Blood cultures are often positive.
• Abdominal ultrasound: Findings include:
  • Distended gallbladder with internal echoes (pus).
  • Thickened gallbladder wall (>4‑5mm).
  • Pericholecystic fluid or abscess.
  • Lack of gallstones may be seen if the gallbladder is completely filled with pus (pseudo‑acalculous appearance).
• CT scan (preferred for surgical planning): Shows a distended gallbladder with fluid‑debris levels (pus), wall thickening, pericholecystic fat stranding, and possibly a stone at the cystic duct.

Treatment – emergency cholecystectomy, percutaneous drainage, antibiotics

Gallbladder empyema requires urgent source control. The approach depends on the patient’s condition:

• Emergency cholecystectomy (preferred): For stable patients, early laparoscopic or open cholecystectomy is performed. Open surgery is often preferred due to severe inflammation and risk of bile duct injury. Subtotal cholecystectomy may be needed.
• Percutaneous cholecystostomy (for unstable patients): A drainage tube is placed into the gallbladder under ultrasound/CT guidance to decompress the pus and control sepsis. The patient is stabilised, and interval cholecystectomy is performed 4‑6 weeks later.
• Antibiotics: Broad‑spectrum intravenous antibiotics (piperacillin‑tazobactam, meropenem, or ceftriaxone + metronidazole) are started immediately. Duration is typically 7‑14 days.
• Fluid resuscitation and vasopressors: For septic shock, intensive care management is essential.

Complications – perforation, peritonitis, sepsis, death

Without timely treatment, gallbladder empyema can lead to:

• Gallbladder perforation (10‑20% of empyema cases) – leads to biliary peritonitis or localised abscess.
• Sepsis and septic shock – multi‑organ failure.
• Pericholecystic or liver abscess.
• Bile duct injury during surgery due to obscured anatomy.
• Death: Mortality ranges from 5‑15% for empyema, higher in elderly and those with delayed treatment.

Prevention – early treatment of acute cholecystitis

The best prevention of gallbladder empyema is early recognition and treatment of acute cholecystitis. Patients with symptomatic gallstones should consider elective cholecystectomy to prevent acute attacks and complications. For those with acute cholecystitis, early cholecystectomy (within 72 hours) reduces the risk of progression to empyema.

Interactive FAQ – Gallbladder empyema

Disclaimer: This information is for educational purposes. Gallbladder empyema is a surgical emergency. If you have severe right upper quadrant pain with high fever, seek immediate medical attention at Vivekananda Hospital.