ORIGINAL ARTICLE

EMPYEMA GALL BLADDER – FORGOTTEN OR AN UNDER-REPORTED

HOW TO CITE THIS ARTICLE:

ABSTRACT: SUMMARY: Twelve patients with empyema of the gall bladder were diagnosed among
325 cases of gall-bladder disease presenting to our department of surgery in three years period
(March 2010 to March 2013). Abdominal pain was present for average of eight days in four cases
andin four cases, for between one and four months. In some cases, the disease was painless and was
found unexpectedly at operation for chromic cholecystitis disease. The severity of the problem was
subdued by the often scanty physical signs. Less than 50% the patients had pyrexia of more than
38.5C and the presence of sepsis was rarely suspected clinically. None of the patients died. This
considerable morbidity could be reduced by the wider use of blood culture in cases of cholecystitis
and by greater awareness that empyema of the gallbladder is sometimes chronic, painless, and
afebrile.

INTRODUCTION: Empyema of the gall bladder was described extensively in surgical texts of the
early years of this century1-3 but now rarely mentioned4. In addition, it appears to have been largely
forgotten that its course can be chronic2, 3. It could be due to the wider use of antibiotics, along with
the increasingly followed policy of early cholecystectomy for acute gall-bladder disease4-6. We have
recently treated several elderly patients in whom the disease was markedly milder event. As the
number of old people in the population is rising, it seemed important to determine whether this
neglected disease is still an important problem and to redefine its natural history. We decided,
therefore, to review all cases of empyema of the gall bladder which had presented to our hospital
over a period of three years.

METHODS: Empyema was defined as an inflamed gall bladder which contained pus (figure 1, 2,
3).The presence of inflammation and pus were established from the operation record, the gall-
bladder swab report, and the histology report on the resected gall bladder, cases of generalized
infection of the biliary tree were designated as cholangitis and excluded from the study. From the
325 sets of case notes, 12 patients (3.69%) were identified who fulfilled these criteria and, on
stringent review by all the authors, were agreed to be true examples of this disease. These cases
were analyzed to determine their age and sex distribution, and their clinical and pathological
features.

RESULTS: The 12 patients were mostly elderly, their average age being 60 years (range 40-80
years). There were nine women and three men, giving a female preponderance of three to one. Six
patients had no abdominal pain and the empyema were found unexpectedly, two at ultrasonography
and in a further four patients, empyema was found at routine cholecystectomy, after a long history of
apparently mild pain. The remaining six patients (50%) presented with abdominal pain of sufficient

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severity to merit emergency admission. The pain had been present, however, to some degree, for
average of four days and in four patients (33.33%), the pain had been present for between one and
four months. Most (83.33%) 10 out of 12 patients were tender in the right hypochondrium. Other
signs were less constant. Guarding was noted in only 6 of the 12 patients (50%) and a palpable mass
was present in only 5 (41.66%). There was clinically recognizable jaundice in 3 patients (25%).
Despite the presence of intra-abdominal pus, only 5 patients (41.66%) had pyrexia of more than
38.5°C at any time preoperatively. A white cell count of more than 11000 mm3, however, was found
in all cases. Liver function tests were performed in all the patients and showed one or more
abnormalities in 10/12 (83.33%) but there was no consistent pattern of derangement. The
preoperative, differential diagnosis as written in the case notes included empyema of the gall
bladder in only five cases (41.66%). In all 12 patients who were subjected to laparotomy, the
procedure performed was cholecystectomy. At laparotomy all the patients had a gall bladder
obstructed by stones. In three cases (25%) the gall bladder was perforated. A swab of the gall-
bladder contents, which was available in six of the patients, revealed the presence of white cells in
all. Aerobic culture of gall-bladder contents was positive in four of these cases: the remaining two
patients had all been treated with antibiotics preoperatively. The most common organisms isolated
were coliforms but the range of bacteria was wide, and in four cases there was a mixed growth of
two or three bacterial species. Blood cultures were taken preoperatively in only six patients (50%)
and were positive in two cases: yielding the same organism as grown from the gall bladder.

DISCUSSION: The literature shows that empyema mainly affects older patients and has a high
morbidity. While it usually presents with abdominal pain, the disease is sometimes painless. When
pain is present, it may be tolerated for a surprisingly long time before admission is sought. Our
patients had pain for average of eight days before hospital admission and, in four cases;pain was
present for between one and four months. This milder presentation was familiar to surgeons of the
earlier part of this century1, 3 but seems largely forgotten today. The serious nature of the disease is
often obscured by the scanty physical signs. In particular, less than half' the patients had a
temperature of more than 38.5°C. This subdued response to infection, which is perhaps related to
the often older age of the patients, makes it difficult for the physician to know whether to refer the
patient to hospital and for the surgeon to recognize the need for emergent operation. The great
majority of patients had abdominal tenderness, a raised white cell count and non-specific
derangement of the standard liver function tests. Unfortunately, these three abnormalities are also
common in cholecystitis without sepsis. Both of these conditions share the common initiating event
of gall-bladder obstruction by stones. Our data suggest that it is difficult or impossible to distinguish
empyema from 'chemical' cholecystitis or the transition from one to the other, either clinically or
biochemically. As empyema is such a dangerous condition this is, perhaps, an argument in favor of
'early' cholecystectomy in cases of acute gall-bladder disease5-7. When antibiotics had not been
administered preoperatively, culture of gall-bladder pus always grew one or more species of aerobic
organisms. This finding shows that empyema of the gall bladder is rarely caused by anaerobic
bacteria alone. The true frequency of septicemia complicating empyema is uncertain, as a blood
culture was taken in six patients only. This illustrates that the presence of infection was often
unsuspected. We suggest the wider use of blood culture in cases of apparent 'cholecystitis' so as to
detect possible complicating septicemia. This is of particular importance in the elderly in whom

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 ORIGINAL ARTICLE
septicemia is commonly occult, and who may be less able than younger patients to resist the
infection. Of the total group of 325 patients, only 3.69% developed an empyema. Why sepsis
supervened in these few cases remains uncertain. Of possible importance may be the age of the
patients (average: 60 years) and the length of time the gall bladder had probably been obstructed,
pain having been present for average of eight days. Some patients, however, were both relatively
young and had pain for only a day or two, so these cannot be the only predisposing factors.
Gall stones become more prevalent with increasing age and with the rising number of old
people in the population, empyema of the gall bladder is likely to become a more common problem.
None of our patients died but some mortality may be inevitable in this disease because of the
advanced age of the patients. Some deaths, however, might be avoided if blood cultures are taken in
more cases of apparent 'cholecystitis' and if doctors are more aware that empyema of the gall
bladder is sometimes chronic, painless, and afebrile.

REFERENCES:
1. Robson AWM, Dobson JF. Diseases of the gall-bladder and bile-ducts, including gall-stones.
London: Bailliere Tindall, 1904: 85.
2. Moynihan BGA. Gall-stones and their surgical treatment. Philadelphia: W B Saunders, 1905:
196.
3. Weiss S. Diseases of the liver, gall bladder, ducts and pancreas – their diagnosis and treatment.
New York: Hoeber, 1935: 668.
4. Harding Rains AJ, Ritchie HD. Bailey and Love's short practice of surgery. London: H K Lewis,
1981.
5. Jones PF. Acute cholecystitis: a case for early surgery? Br Med J 1982: 285: 1376-7.
6. Mitchell A, Morris PJ. Trends in management of acute cholecystitis. Br Med J 1982: 284: 27-30.
7. Espiner HJ. Emergency cholecystectomy: towards guaranteed safety. In: Wilson EH, Marsden
AK, eds. Care of the acutely ill and injured. New York: John Wiley, 1982: 385-7.

Fig. 1: Excised specimen of Fig. 2: Showing thick pus and calculus.

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Fig. 3: Showing gall bladder, large number of calculi and thick pus.

AUTHORS:
1. R.S. Hooda
2. Pawan Tiwari NAME ADDRESS EMAIL ID OF THE
3. Madhu Tiwari CORRESPONDING AUTHOR:
4. H.G. Vyas Dr.Pawan Tiwari,
A 104, Medical Campus,
PARTICULARS OF CONTRIBUTORS: SGT Medical College, Budhera,
Gurgaon, India.
1. Associate Professor, Department of Surgery,
[email protected]
SGT Medical College, Budhera, Gurgaon, India.
2. Assistant Professor, Department of Surgery,
SGT Medical College, Budhera, Gurgaon, India. Date of Submission: 12/12/2013.
3. Assistant Professor, Department of Date of Peer Review: 13/12/2013.
Anaesthiology, SGT Medical College, Budhera, Date of Acceptance: 17/12/2013.
Gurgaon, India. Date of Publishing: 27/12/2013.
4. Professor, Department of Surgery, SGT Medical
College, Budhera, Gurgaon, India.

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