Gallbladder Hydrops and Empyema

Published on 19/07/2015 by admin

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 Content usually sterile without GB inflammation

• GB empyema: Pus-filled, inflamed, and distended GB secondary to acute cholecystitis with suppurative intraluminal infection

IMAGING

• Hydrops

image CECT: Distended GB filled with low-density contents

– Usually no wall thickening, pericholecystic fluid, or adjacent fat stranding
image US: Distended GB with anechoic and simple contents

– GB wall appears thin or normal
– Negative sonographic Murphy sign
– Gallstones usually (but not always) present
• Empyema

image CECT: Distended GB with intraluminal contents > 15 HU

– Wall thickening with pericholecystic fat stranding and fluid (similar to conventional cholecystitis)
– Advanced cases may show gangrene or perforation
image US: Markedly distended GB with echogenic pus in lumen

– GB wall appears thickened
– Sonographic Murphy sign often positive
– Gallstones usually (but not always) present

PATHOLOGY

• GB hydrops caused by chronic GB outlet obstruction (most commonly due to impacted stone)
• Empyema caused by bacterial infection of bile within inflamed GB, usually in setting of acute cholecystitis

CLINICAL ISSUES

• Hydrops: RUQ pain without fever or signs of infection
• Fever or ↑ WBC with dilated GB concerning for empyema
• Cholecystectomy for GB hydrops if patient is symptomatic
• Urgent cholecystectomy for empyema
image
(Left) Oblique ultrasound shows an enlarged gallbladder in a 5 year old with fever and right upper quadrant pain. The hydropic gallbladder led to the diagnosis of Kawasaki disease, a known predisposing factor for hydrops in children. (Courtesy R.J. Fleck, Jr., MD.)

image
(Right) Axial CECT in a cirrhotic patient with RUQ pain demonstrates that the gallbladder is distended but thin-walled, and a stone is present within the cystic duct image, findings consistent with gallbladder hydrops.
image
(Left) Ultrasound in an elderly patient with sepsis shows a massively dilated and elongated gallbladder with a thick wall image and rounded but mobile internal echogenic sludge.

image
(Right) Coronal NECT in the same patient shows the dilated gallbladder with thickened wall image. Because the patient was considered a poor surgical candidate, she was treated with percutaneous cholecystostomy, which yielded thick bile with a heavy growth of bacteria, consistent with empyema of the gallbladder.

TERMINOLOGY

Synonyms

• Hydrops: Mucocele
• Empyema: Suppurative cholecystitis

Definitions

• Hydrops: Distended gallbladder (GB) secondary to chronic obstruction filled with watery mucoid material

image Content is usually sterile without GB inflammation
• Empyema: Pus-filled, inflamed, and distended GB secondary to acute cholecystitis with suppurative intraluminal infection

IMAGING

General Features

• Best diagnostic clue

image Rounded, distended GB filled with either anechoic watery mucoid content (hydrops) or echogenic pus (empyema)
• Location

image Markedly distended GB can extend downwards into pelvis in most severe cases
• Size

image GB distended > 5 cm transverse diameter
image Size can reach up to 1.5 liters
• Morphology

image Rounded distended GB

Imaging Recommendations

• Best imaging tool

image Ultrasound
• Protocol advice

image Grayscale and color Doppler ultrasound

CT Findings

• Hydrops

image Markedly distended GB filled with low-density contents
image Usually thin wall with minimal inflammatory change

– Typically no evidence of overt wall thickening, pericholecystic fluid, or adjacent fat stranding
• Empyema

image Markedly distended GB with high-density intraluminal contents > 15 HU
image GB wall thickened > 5 mm
image Gallstones usually present, but not always visible on CT
image Pericholecystic fluid and fat stranding
image Advanced cases may demonstrate evidence of wall gangrene or perforation, including areas of diminished wall enhancement, frank defect in GB wall, or pericholecystic fluid collection

MR Findings

• Hydrops

image Distended GB with internal contents demonstrating simple fluid signal (high T2WI and low T1WI)
image No evidence of wall edema or adjacent inflammation
image Gallstones usually present (usually visible as signal voids on all sequences)
• Empyema

image Distended GB with internal contents demonstrating variable signal depending on proportion of bile, pus, and blood
image High signal edema in thickened GB wall on T2WI
image Pericholecystic fluid and fat stranding

Ultrasonographic Findings

• Markedly distended GB in both hydrops and empyema

image GB wall appears thin or normal in hydrops
image GB wall appears thickened (often asymmetric) in empyema
• Sonographic Murphy sign negative in hydrops, but often positive in empyema
• GB contents appear anechoic and simple in hydrops
• Echogenic pus in lumen, similar in echogenicity to sludge, in empyema
• Gallstones often present in both hydrops and empyema, but may also be acalculous
• Look for imaging signs of GB gangrene

image Intraluminal membranes from sloughed mucosa
image Discrete defects in GB wall with pericholecystic fluid collections
image Asymmetric wall thickening with irregularity and ulcerations

DIFFERENTIAL DIAGNOSIS

Gangrenous Cholecystitis

• GB wall necrosis and gangrene occurs in 1/4 of patients with acute cholecystitis (usually elderly, diabetic, or immunocompromised patients)
• May result from progression of GB hydrops and places patient at risk for perforation
• Ultrasound findings: Asymmetric GB wall thickening with ulceration and irregularity of wall

image Intraluminal membranes secondary to sloughed mucosa
image Flow to involved portions of GB wall may be absent on color Doppler US
• CECT: Patchy or diminished enhancement of portions of GB wall

image Discrete defect in GB wall may be present ± pericholecystic fluid collection/abscess

Emphysematous Cholecystitis

• Secondary infection of GB with gas-forming organism (such as Clostridium  welchii)
• Ultrasound demonstrates gas in GB wall with “dirty” posterior acoustic shadowing, ring-down artifact from gas bubbles, and champagne sign (effervescent gas bubbles rising within GB)
• CT demonstrates GB wall thickening with gas within GB lumen or wall

Courvoisier Gallbladder

• Simultaneous chronic obstruction of GB and CBD due to obstructing pancreatic head or ampullary mass
• GB may be massively distended, but usually in conjunction with severe intrahepatic and extrahepatic biliary dilatation
• Usually discrete mass present at ampulla or pancreatic head with abrupt obstruction of CBD ± pancreatic ductal obstruction

Liver Abscess

• Ultrasound

image May be hypo-, iso-, or echogenic “mass”
image Avascular on color Doppler
image Often associated with right pleural effusion and RLL atelectasis
image May have unilocular or multiseptate appearance
• CECT

image “Cluster” sign of multiple low-density interconnecting locules of pus
image Adjacent transient hepatic attenuation difference (THAD) secondary to hepatic hyperemia on arterial-phase imaging

Perforated Duodenal Ulcer

• Pneumoperitoneum
• Fluid &/or gas in right anterior pararenal space, subhepatic space, or Morison pouch

Pancreatitis

• Pancreatic enlargement
• Fluid stranding in anterior pararenal space, lesser sac, or mesentery
• Nonenhancing areas of pancreas due to necrosis

Choledochal Cyst

• May superficially mimic hydropic GB, particularly on US
• Distinction made readily on CT or MR, as GB is visualized as separate structure from choledochal cyst

PATHOLOGY

General Features

• Etiology

image Hydrops: Chronic GB outlet obstruction

– Impacted stone in neck/cystic duct   (most common)
– GB tumors or polyps (usually near GB neck or cystic duct)
– Extrinsic compression of GB outlet by tumor, lymph node, or fibrosis
– Prolonged TPN
– Ceftriaxone
– Congenital narrowing of cystic duct
– Parasites (rare): Ascariasis
image Empyema: Bacterially contaminated bile within inflamed GB

– Most common organisms are  Escherichia  coli and Klebsiella
– Most commonly develops due to acute calculous or acalculous cholecystitis, but can also result from super-infection in setting of malignant obstruction of GB
• Associated abnormalities

image Hydrops can be seen in association with Kawasaki syndrome in children

– Most cases in children unrelated to gallstones and are attributable to infections or Kawasaki syndrome
– Less common associations

image Streptococcal pharyngitis
image Mesenteric adenitis
image Typhoid fever
image Hepatitis
image Nephrotic syndrome
image Familial Mediterranean fever
• Pathophysiology

image Hydrops

– GB outlet obstruction → GB distention
– Continued resorption of bile and bile pigment and continued secretion from mucosa → clear and watery mucoid content
– Increased GB volume is also associated with GB dyskinesia: Advanced age, diabetes, obesity

Gross Pathologic & Surgical Features

• Hydrops

image Thin-walled, distended GB with minimal inflammatory changes
• Empyema

image Acute cholecystitis with intraluminal pus, ± gallstones

Microscopic Features

• Hydrops

image Flattened mucosa lined by columnar or cuboidal cells
image ↑ number of Rokitansky-Aschoff sinuses
• Empyema

image Acute inflammation within GB wall with submucosal edema and hemorrhage
image Pus and WBC debris in GB lumen

CLINICAL ISSUES

Presentation

• Most common signs/symptoms

image Hydrops often presents with RUQ pain or palpable GB 

– Usually no systemic signs of infection or focal tenderness in RUQ
image Presence of fever, chills, or ↑ WBC with distended GB raises concern for acute cholecystitis and empyema

– Symptoms of GB empyema similar to conventional acute cholecystitis
– Tender to palpation in RUQ (positive Murphy sign)
• Other signs/symptoms

image Rigors (empyema)
image Empyema: Generalized sepsis if untreated

Demographics

• Age

image Usually > 65 years
image Can rarely occur in children (17 months to 7 years)
• Gender

image M < F
• Epidemiology

image Hydrops: 3% of all GB pathologies
image Empyema occurs in 5-15% of all cases of acute cholecystitis

Natural History & Prognosis

• Empyema

image Progressive inflammation and sepsis
image Risk of gangrene and perforation if not promptly treated

Treatment

• Hydrops

image Cholecystectomy if symptomatic, but asymptomatic patients can be treated conservatively
• Empyema

image Antibiotic therapy
image Urgent cholecystectomy is preferred, although cholecystostomy often performed if patient is unstable and not immediate surgical candidate

– Laparoscopic approach possible, although risk of conversion to open procedure and surgical complication rate higher compared to uncomplicated acute cholecystitis (without empyema)

DIAGNOSTIC CHECKLIST

Consider

• Consider GB empyema in a patient with a distended GB filled with echogenic material and symptoms of cholecystitis

Image Interpretation Pearls

•  
image
(Left) Surveillance ultrasound of an elderly woman with primary sclerosing cholangitis shows a hydropic GB. Low-level echoes within the inferior aspect of the GB are due to side lobe artifact image.

image
(Right) Hepatobiliary phase T1WI C+ FS MR with gadoxetate (Eovist) in the same patient shows an unopacified, hydropic GB and a dilated cystic duct image. Lack of contrast within the GB in the hepatobiliary phase suggests that this chronic asymptomatic hydrops is due to a cystic duct obstruction.
image
(Left) Ultrasound image in a septic patient after renal transplant demonstrates a distended GB with wall thickening and layering echogenic material image. The patient had a positive Murphy sign and underwent cholecystectomy, which demonstrated cholecystitis and empyema.

image
(Right) Ultrasound image in an elderly man with RUQ pain and fever demonstrates a markedly distended GB with internal layering echogenic material image. Sonographic Murphy sign was positive, compatible with GB empyema.
image
(Left) Ultrasound in an elderly woman presenting with fever and RUQ pain shows distension of the GB, which is filled with echogenic pus image. The poor definition of the GB wall image was suspicious for gangrene, confirmed at surgery.

image
(Right) Axial CECT in a patient presenting with gram-negative sepsis and RUQ pain shows marked distension of the GB, a focal perforation along the lateral wall image, and a large gallstone image, compatible with GB empyema and associated contained perforation.
image
Transverse grayscale ultrasound in a 67-year-old woman presenting with RUQ pain and fever demonstrates intraluminal membranes image within the gallbladder due to gangrenous cholecystitis, as well as echogenic pus image within the gallbladder due to gallbladder empyema.

image
Ultrasound image in a patient with sepsis after renal transplant demonstrates a distended GB with internal echogenic material. The patient was tender over the GB, compatible with GB empyema.
image
Ultrasound of a 79-year-old man with generalized abdominal pain, sepsis, and GB empyema shows layering echoes within the GB lumen image and a poorly defined pericholecystic fluid collection along adjacent liver image.
image
Axial CECT in the same patient shows GB wall thickening image and a pericholecystic fluid collection image. A perforated, pus-filled GB and an adjacent abscess were identified at laparotomy and cholecystectomy.
image
Ultrasound of a 66-year-old woman with jaundice shows a distended, Courvoisier GB, sludge image, and cystic duct dilatation image. GB distension was the most obvious manifestation of duct obstruction at ultrasound and prompted additional imaging.
image
Axial CECT in the same patient shows a distended GB and intrahepatic biliary ductal dilatation image. GB distension was due to obstruction of the distal common bile duct by a pancreatic head carcinoma (not shown).

SELECTED REFERENCES

1. Mathai, SS, et al. Gall bladder hydrops – a rare initial presentation of Kawasaki disease. Indian J Pediatr. 2013; 80(7):616–617.

2. Brook, OR, et al. Lessons learned from quality assurance: errors in the diagnosis of acute cholecystitis on ultrasound and CT. AJR Am J Roentgenol. 2011; 196(3):597–604.

3. Panico, MR, et al. Massive hydrops of the gallbladder mimicking a choledochal cyst. J Pediatr Surg. 2011; 46(5):1015–1018.

4. Queiroz, AB, et al. Images in clinical medicine. Hydropic gallbladder. N Engl J Med. 2011; 364(20):e43.

 

Tongdee, R, et al. The value of MDCT scans in differentiation between benign and malignant gallbladder wall thickening. J Med Assoc Thai. 2011; 94(5):592–600.

Kawasaki, F, et al. Gallbladder edema in type 1 diabetic patient due to delayed-type insulin allergy. Intern Med. 2009; 48(17):1545–1549.

Mahid, SS, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009; 144(2):180–187.

Gurusamy, KS, et al. Early versus delayed laparoscopic cholecystectomy for biliary colic. Cochrane Database Syst Rev. (4):2008. [CD007196].

Misiakos, EP, et al. Laparoscopic cholecystectomy after open cholecystostomy for gallbladder empyema: a case report. J Laparoendosc Adv Surg Tech A. 2007; 17(5):655–658.

Nguyen, DQ, et al. A fatal case of MRSA septicaemia and gallbladder empyema. Int J Surg. 2004; 2(2):120–121.

Agrawal, S, et al. Gallstones, from gallbladder to gut. Management options for diverse complications. Postgrad Med. 2000; 108(3):143–146. [149-53].

Tseng, LJ, et al. Palliative percutaneous transhepatic gallbladder drainage of gallbladder empyema before laparoscopic cholecystectomy. Hepatogastroenterology. 2000; 47(34):932–936.

Feretis, CB, et al. Endoscopic transpapillary drainage of gallbladder empyema. Gastrointest Endosc. 1990; 36(5):523–525.

Krogh, J. Empyema of the gallbladder: a case with unusual presentation. Acta Chir Belg. 1989; 89(4):204–205.

Radder, RW. Ultrasonically guided percutaneous catheter drainage for gallbladder empyema. Diagn Imaging. 1980; 49(6):330–333.

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