Gallbladder empyema: a rare and severe complication of acute cholecystitis (case report)

¹Radiology Department of National Institute of Oncology, CHU Ibn Sina, University Mohamed V Faculty of Medicine and Pharmacy, Rabat, Morocco

^&Corresponding author
Abdelkader Sqalli Houssaini, Radiology Department of National Institute of Oncology, CHU Ibn Sina, University Mohamed V Faculty of Medicine and Pharmacy, Rabat, Morocco

Introduction    

Acute cholecystitis is an inflammatory condition of the gallbladder, typically caused by cystic duct obstruction due to cholelithiasis, which leads to distension and inflammation [1,2]. While it usually manifests with fever, right upper quadrant pain, and nausea, complications such as gallbladder empyema are rare but pose significant risks, including severe sepsis and even mortality if not promptly managed [3]. Gallbladder empyema is characterized by the accumulation of purulent material within the gallbladder, which can complicate the clinical course and delay diagnosis, especially in elderly patients presenting with atypical symptoms. Radiological imaging, including ultrasonography and CT scans, is essential in identifying this rare condition and guiding management [4]. We report the case of an 84-year-old male with gallbladder empyema, presenting atypically with the absence of fever and delayed diagnosis, highlighting the importance of timely imaging and clinical vigilance.

Patient and observation     

Patient information: an 84-year-old male, non-smoker, non-alcoholic, hypertensive. He had no prior surgical interventions.

Clinical findings: the patient presented with severe pain in the epigastrium and right upper quadrant of the abdomen for one month. He did not present fever but reported chills, nausea, and unquantified weight loss. A palpable mass was detected in the right upper quadrant.

Timeline of the current episode: August 1, 2023: Onset of severe epigastric pain and chills. August 5, 2023: Consultation for nausea and weight loss; right upper quadrant mass detected on physical examination. August 10, 2023: ultrasound and CT scan were conducted August 12, 2023: biopsy of the gallbladder was performed. August 15, 2023: diagnosis of gallbladder empyema; initiation of triple antibiotic therapy. November 15, 2023: follow-up CT scan demonstrated complete abscess resolution with significant patient recovery.

Diagnostic assessment: laboratory tests were performed and returned normal results. Ultrasonography revealed irregular gallbladder wall thickness with color Doppler uptake showing microlithiasis. Computed tomography scan demonstrated a distended gallbladder with heterogeneous hypodense content and associated peri-vesicular edema (Figure 1). A biopsy of the gallbladder wall was realized, and the pathology result showed an abscess shell sampling, made of dense inflammatory infiltrate, lymphocytes, plasma cells, histiocytes, and neutrophils.

Diagnosis: the patient was diagnosed with gallbladder empyema secondary to acute cholecystitis. There were no significant challenges related to access to diagnosis; however, diagnosis was delayed due to atypical symptoms and the patient's age. Given the patient's age and the presence of empyema, the prognosis was cautiously optimistic with timely intervention.

Therapeutic interventions: the patient received triple antibiotic therapy, including Metronidazole (500 mg IV every 8 hours), B-lactamine (1 g IV every 6 hours), and Aminoside (1 mg/kg/day) for 7 days.

Follow-up and outcomes: the patient reported improved symptoms with the treatment received. A follow-up CT scan conducted after 3 months showed complete regression of the abscess and a sclero-atrophic gallbladder (Figure 2). The patient tolerated the medication well, with no significant side effects reported. There were no adverse events during treatment.

Patient perspective: the patient expressed satisfaction with the treatment received and reported an overall improvement in his condition.

Informed consent: the patient provided informed consent for the publication of this medical case in a medical article, understanding that details regarding his health condition, diagnosis, treatment, and relevant medical information may be included. He also authorized the use of radiological images to illustrate this case.

Discussion     

Gallbladder empyema is a severe and rare complication of acute cholecystitis, occurring in approximately 5-15% of cases [3]. Acute cholecystitis typically results from cystic duct obstruction, most commonly due to gallstones, leading to inflammation and distension of the gallbladder [1]. If untreated, it may progress to life-threatening complications, including gangrenous cholecystitis, gallbladder perforation, emphysematous cholecystitis, and empyema. Empyema is characterized by the accumulation of purulent material within the gallbladder, and it primarily affects elderly patients and individuals with comorbidities such as diabetes or immunosuppression [3,5]. Early recognition of this condition is essential, as delays in diagnosis can lead to septic complications and increased mortality.

Clinically, gallbladder empyema often presents with right upper quadrant pain, anorexia, nausea, vomiting, and fever, similar to uncomplicated cholecystitis [2]. However, atypical presentations, particularly in elderly patients, can delay diagnosis, as seen in our case where the patient did not exhibit fever. Imaging remains pivotal for diagnosis. Ultrasonography typically demonstrates gallbladder wall thickening, luminal distension, pericholecystic fluid, and echogenic material resembling sludge, indicative of pus accumulation [4]. Computed tomography imaging adds diagnostic precision by showing intraluminal hypodense content (>15 HU), irregular wall thickening (>5 mm), and peri-vesicular edema, which are suggestive of empyema [6]. These imaging findings are critical for differentiating empyema from other complications, such as gangrenous or emphysematous cholecystitis, which may present similarly but require distinct management approaches [4,6].

Management of gallbladder empyema traditionally involves urgent cholecystectomy, which remains the gold standard, especially in uncomplicated acute cholecystitis [2]. However, in elderly or high-risk patients, conservative management with antibiotics and percutaneous drainage may be considered as alternatives. In our case, the patient was successfully treated with triple intravenous antibiotic therapy consisting of Metronidazole, Amoxicillin-Clavulanate, and Aminoside. This approach was guided by the patient´s advanced age, clinical stability, and comorbidities. While surgery is often preferred, non-surgical management can achieve favorable outcomes in carefully selected patients, provided close monitoring and follow-up imaging are performed [3].

Outcomes of gallbladder empyema depend on early diagnosis and appropriate intervention. In our case, timely imaging and antibiotic therapy led to a complete abscess resolution within three months, as confirmed by follow-up CT scans. The patient reported significant clinical improvement and tolerated the treatment without adverse effects. This highlights the importance of individualized treatment strategies and thorough radiological evaluation to guide management, particularly in patients with atypical presentations. Prompt diagnosis and intervention are critical to prevent severe complications, including sepsis and gallbladder perforation, which are associated with high morbidity and mortality [5].

Conclusion     

This case demonstrates that gallbladder empyema can present atypically in elderly patients, delaying diagnosis due to the absence of classic symptoms such as fever. Thus, early imaging with ultrasound and CT scans is necessary to confirm the diagnosis, showing the classical aspects of gallbladder wall thickening, intraluminal hypodense contents, and perivesicular edema, enabling prompt and targeted management. Antibiotic therapy with Metronidazole, amoxicillin-clavulanate, and aminoside allowed, as in our case, the avoidance of surgery considering the patient's advanced age and comorbidities.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Abdelkader Sqalli Houssaini and Hatim Essaber. Data collection: Ikram Sarsar, Ali Haidar, Sara Loubaris, Youssef Omor, and Rachida Latib. Manuscript drafting: Abdelkader Sqalli Houssaini. Manuscript revision: Hatim Essaber, Ikram Sarsar, Ali Haidar, Sara Loubaris, Youssef Omor, Rachida Latib, and Sanae Amalik. All authors have read and approved the final version of the manuscript.

Figures     

Figure 1: CT findings of gallbladder empyema: CT scan in portal phase, axial (A) and oblique coronal (B) images showing an enlarged gallbladder (white arrow) with hypodense heterogeneous content associated with peri-vesicular edema (black arrow); the gallbladder empyema is communicating (red arrow) with a parietal abscess of the external duodenal wall (yellow arrow) we note the presence of biliary cysts (green arrows)

Figure 2: follow-up CT showing resolution of the abscess: CT scan in portal phase, coronal image (A) demonstrating a complete regression of the abscess with sclera-atrophic gallbladder (white arrow) sagittal image (B) showing a contracted gallbladder (white arrow) containing multiple lithiasis (blue arrow)

References