Prof. Dr. R. K. Mishra. MRCS,M.MAS (U.K).

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Empyema Gallbladder is often found in case of acute cholecystitis. Empyema develops in the presence of bacteria-containing bile may progress to suppurative infection in which the gallbladder fills with purulent material, an ailment referred to as empyema of the gallbladder. The main 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 lessen the incidence of complications and also to avoid or treat associated sepsis. Many times it is found during routine laparoscopic cholecystectomy.

Within the bacterially contaminated gallbladder, sometime the stagnation and marked inflammation related to acute cholecystitis fills the gallbladder lumen with exudative material principally comprised of frank pus. This method of formation of empyema may be associated with calculous cholecystitis, acalculous cholecystitis, or carcinoma from the gallbladder. If the case of empyema left untreated, generalized sepsis ensues, with progression in the gallbladder to patchy gangrene, microperforation, macroperforation, or, rarely, cholecystoduodenal fistula. Empyema gallbladder oftem found if patients at increased risk for cholecystitis include individuals with diabetes, immunosuppression, obesity, or hemoglobinopathies.

All over world the true incidence of empyema of the gallbladder related to acute cholecystitis is difficult to assess, although findings from limited series indicate a variety of approximately 5-15%. The rate of laparoscopic cholecystectomy procedures converted to a wide open procedure is really a lot higher in patients with empyema from the gallbladder. The postoperative complication rate regardless of approach either open of laparoscopic surgery for empyema from 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 respiratory insufficiency related to sepsis.

In cases of empyema gallbladder progression to death is unusual in otherwise healthy individuals but may exist in patients of advanced age, in patients with compromised immunity, or perhaps in individuals with significant comorbid conditions.

Empyema gallbladder is more found in Indians and they come with an increased chance of cholelithiasis and cholecystitis, as do patients with hemoglobinopathies, such as sickle cell anemia much more likely in blacks.

The clinical good reputation for a patient with empyema from the gallbladder is comparable to that of a patient with acute cholecystitis from which the empyema derives. Because the disease in gallbladder progresses, severe pain and associated high fever, chills, and even rigors may be reported. Patients with diabetes or immunosuppression may exhibit few signs or symptoms due to empyema gallbladder.

It is very interesting to learn that patients with an early empyema of the gallbladder often present with no differently than any patient with acute cholecystitis, with symptoms that only sometime include fever temperature, >101°F, stable blood pressure, and mild tachycardia. However, if localized reely perforation has occurred and the patient has generalized sepsis, fevers, temperature, 103°F, chills and rigors, and confusion may be observed in association with hypotension and severe tachycardia.

In early stages of empyema gallbladder, abdominal examination findings are similar to those of patients with acute cholecystitis, with mild-to-moderate tenderness within the right upper abdomen and a positive Murphy sign ie, arrest of inspiration as the gallbladder descends to the touch a hand previously placed deep within the mid right abdomen. As the condition of empyema gallbladder progresses, empyema from the gallbladder might be associated with a palpable distended gallbladder that is markedly tender on even superficial palpation.

Alltogether the commonest etiology of empyema of the gallbladder is unresolved acute calculous cholecystitis when confronted with contaminated bile. Probably 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 isn't performed only at that juncture. Generalized sepsis frequently accompanies this progression.

In many patient a similar pattern is infrequently noticed in connection to acute acalculous cholecystitis. Rarely, obstruction of the distal common bile duct may lead to pus formation within the extrahepatic biliary tree, which can then decompress into the gallbladder. This distends and infects that organ, with ensuing empyema. The treatment can be surgical laparoscopic 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. Initial decompression may be accomplished under radiographic guidance immediately prior to the procedure or via intraoperative, laparoscopically guided needle drainage, that allows for additional facile manipulation of the gallbladder throughout the cholecystectomy area of the procedure.

It should be kept in mind that the conversion-to-open whole performing laparoscopic cholecystectomy in a case of empyema gallbladder 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 within the same studies for laparoscopic treatment of uncomplicated acute cholecystitis. Laparoscopic subtotal cholecystectomy is suitable only when the encountered pericholecystic inflammation is so severe as to preclude safe dissection via whether laparoscopic procedure or an open procedure.

One of the most important point is that, the complications are based on the advanced disease process and not to the approach. In skilled hands, no increase is noticed in the incidence of laparoscopic surgical misadventure with empyema of the gallbladder. Thus, regardless of the higher incidence of conversion for an open procedure (40-80%), it is extremely reasonable to initially proceed with a laparoscopic procedure.