Gallbladder empyema

Case contribution: Dr. Radhiana Hassan


  • A 62 years old lady
  • Underlying DM, HPT and hyperlipidaemia
  • Also had gallstone, refused operation due to financial constraint
  • Presented with right hypochondriac pain, fever and reduced oral intake

Ultrasound findings:

  • Gallbladder is distended with multiple echogenic foci casting acoustic shadowing is seen within it in keeping with calculi (white arrows).
  • The largest calculus measures about 1.1 cm in length.
  • No sludge or sediment is seen within the gallbladder.
  • The gallbladder wall appears thickened measuring up to 1.2 cm in maximum thickness.
  • Presence of pericholecystic fluid is also observed.
  • Sonographic Murphy’s sign is positive.
  • The biliary tree is not dilated with CBD measures 3.9 mm in diameter.
CT scan abdomen in axial plane soft tissue window post contrast

CT scan findings:

  • The gallbladder is grossly distended and filled with homogenous fluid, which is slightly denser at the dependant part (HU average: 20-30).
  • The gallbladder wall is thickened and oedematous measuring up to 1.0 cm in thickness.
  • No luminal or intra-mural air pocket is detected.
  • There is adjacent fluid collection which is seen tracking superiorly under the liver and anteriorly to the abdominal wall.
  • Pericholecystic fluid and the surrounding fat streakiness is also observed.
  • Minimal interloop fluid is also seen inferior to the liver and below the spleen.
  • Significant free fluid is also noted at the pelvic region.

Progress of patient:

  • Patient conditioned worsened due to sepsis.
  • Patient also developed respiratory distress requiring intubation and admission into ICU after one day admitted.
  • Percutaneous cholecystostomy done by IR and about 10 cc of pus aspirated.
  • Pus C&S from cholecystostomy: Klebsiella pneumonia
  • Completed antibiotic 10 days
  • Complicated by Pulmonary embolism
  • Discharged well later and planned for elective cholecystectomy.

Diagnosis: Gallbladder empyema


  • Gallbladder empyema is an unusual complication of cholecystitis.
  • Gallbladder lumen is distended and filled with purulent material (pus).
  • Increased incidence in those with DM and/or advanced atherosclerotic disease.
  • Ultrasound may show the usual sonographic features of cholecystitis with added echogenic content within the gallbladder lumen (not specific for an empyema).
  • CT may show general imaging features of cholecystitis with added high-attenuating material (representing pus) within the distended gallbladder lumen. Again this feature is nonspecific and is often difficult to differentiate from sludge within the gallbladder.
Author: radhianahassan