Objective

Early detection of complicated cholecystitis, particularly gallbladder empyema, is important. Yet only a handful of patients are correctly diagnosed prior to intervention. The purpose of this study was to evaluate the sonographic and computed tomography features associated with gallbladder empyema compared with the intraoperative findings and histopathological examination.

Materials and methods

We retrospectively reviewed ultrasound and CT images for 146 patients with clinical suspicion of cholecystitis from January 2013 until December 2018. Ultrasound criteria reviewed included calculus, wall thickening, pericholecystic fluid, gallbladder distension and presence of echogenic material within the gallbladder. For CT, criteria reviewed were wall thickening, gallbladder distension, mucosal enhancement, pericholecystic fluid and hyperdense bile with an attenuation value of more than 20 HU. Association of these findings was made with intraoperative and pathological findings of 85 patients with proven gallbladder empyema.

Results

Sonographic signs that were statistically significantly associated with gallbladder empyema (p < 0.05) were thickened gallbladder wall (mean 5.4 versus 3.0 mm), distended gallbladder (mean 8.5 versus 6.4cm), pericholecystic fluid and echogenic material within the gallbladder. No significant association between gallstones and gallbladder empyema. Scores of two and more out of four significant sonographic findings were found to have an association with higher chances of developing gallbladder empyema (p < 0.05, odds ratio: 10). None of the CT features was found to be significant with gallbladder empyema (p > 0.05).

Conclusion

A combination of few ultrasound features has a high significant association with gallbladder empyema. Thus, in the proper clinical setting, these findings should alarm the sonographic operator on the possibility of gallbladder empyema.

1. Kimura, Y., Takada, T., Kawarada, Y., Nimura, Y., Hirata, K., Sekimoto, M., Yoshida, M., Mayumi, T., Strasberg, S., Pitt, H. A., Gadacz, T. R., Belli, G., Linehan, J., Laksmana, I. R., & Tokyo Guidelines Revision Committee. (2007). Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. Journal of Hepato-Biliary-Pancreatic Surgery, 14(1), 15–26. https://doi.org/10.1007/s00534-006-1150-y
2. Charalel, R. A., Jeffrey, R. B., & Shin, L. K. (2011). Complicated cholecystitis: The complementary roles of sonography and computed tomography. Ultrasound Quarterly, 27(3), 161–170. https://doi.org/10.1097/RUQ.0b013e318229a8a7
3. Fry, D., Cox, R., & Harbrecht, P. (1981). Empyema of the gallbladder: A complication in the natural history of acute cholecystitis. The American Journal of Surgery, 141(3), 366–369. https://doi.org/10.1016/0002-9610(81)90199-5
4. Khan, M. L., Abbassi, M. R., Jawed, M., & Shaikh, U. (2015). Male gender and sonographic gallbladder wall thickness: Important predictable factors for empyema and gangrene in acute cholecystitis. Journal of the Pakistan Medical Association, 64(2), 159–162.
5. Abraham, S., Rivero, H. G., Erlikh, I. V., Griffith, L. F., & Kondamudi, V. K. (2014). Surgical and nonsurgical management of gallstones. American Family Physician, 89(10), 795–802.
6. Shakespear, J. S., Shaaban, A. M., & Rezvani, M. (2010). CT findings of acute cholecystitis and its complications. American Journal of Roentgenology, 194(6), 1523–1529. https://doi.org/10.2214/AJR.09.3640
7. van Breda Vriesman, A. C., Engelbrecht, M. R., Smithuis, R. H. M., & Puylaert, J. B. C. M. (2007). Diffuse gallbladder wall thickening: Differential diagnosis. American Journal of Roentgenology, 188(2), 495–501. https://doi.org/10.2214/AJR.05.1720
8. Peterson, C. M., McNamara, M. M., Kamel, I. R., Al-Refaie, W. B., Belcher, T. L., Chang, K. J., Do, R. K., Grajo, J. R., Hindman, N. M., Horowitz, J. M., Leyendecker, J. R., Linehan, J., Marin, D., Shaffer, K., Shogan, P. J., Small, W. C., Soloff, E. V., Zaheer, A., & Carucci, L. R. (2019). ACR Appropriateness Criteria right upper quadrant pain. Journal of the American College of Radiology, 16(5), S235–S243. https://doi.org/10.1016/j.jacr.2019.02.013
9. Lamki, N., Raval, B., & St. Ville, A. (1986). Computed tomography of complicated cholecystitis. Journal of Computer Tomography, 10(4), 319–324. https://doi.org/10.1016/0149-936X(86)90059-8
10. Raghavendra, B. N., Helen, D. F., Subramanyam, B. R., Ranson, J. H. C., Toder, S. P., Horii, S. C., & Madamba, M. R. (1981). Acute cholecystitis: Sonographic-pathologic analysis. AJR. American Journal of Roentgenology, 137(2), 327–332. https://doi.org/10.2214/ajr.137.2.327
11. Shapira-Rootman, M., Mahamid, A., Reindorp, N., Nachtigal, A., & Zeina, A. R. (2015). Sonographic diagnosis of complicated cholecystitis. Journal of Ultrasound in Medicine, 34(12), 2231–2236. https://doi.org/10.7863/ultra.15.01016
12. Barak, O., Elazary, R., Appelbaum, L., Rivkind, A., & Almogy, G. (2009). Conservative treatment for acute cholecystitis: Clinical and radiographic predictors of failure. The Israel Medical Association Journal, 11(12), 739–743.
13. Brook, O. R., Kane, R. A., Tyagi, G., Siewert, B., & Kruskal, J. B. (2011). Lessons learned from quality assurance: Errors in the diagnosis of acute cholecystitis on ultrasound and CT. AJR. American Journal of Roentgenology, 196(3), 597–604. https://doi.org/10.2214/AJR.10.5135
14. Smith, E. A., Dillman, J. R., Elsayes, K. M., Menias, C. Complicated cholecystitis: The complementary roles of sonography and computed tomography., & Bude, R. O. (2009). Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. American Journal of Roentgenology, 192(1), 188–196. https://doi.org/10.2214/AJR.07.3803
15. Chawla, A., Lim, T. C., Srinivasan, S., Teh, H. S., & Shenoy, J. N. (2015). Imaging of acute cholecystitis and cholecystitis-associated complications in the emergency setting. Singapore Medical Journal, 56(8), 438–444. https://doi.org/10.11622/smedj.2015121
16. O’Connor, O. J., & Maher, M. M. (2011). Imaging of cholecystitis. AJR. American Journal of Roentgenology, 196(4), 367–374. https://doi.org/10.2214/AJR.10.4340
17. De Vargas, M. M., Lanciotti, S., De Cicco, M. L., Coniglio, M., & Gualdi, G. F. (2006). Ultrasonographic and spiral CT evaluation of simple and complicated acute cholecystitis: Diagnostic protocol assessment based on personal experience and review of the literature. La Radiologia Medica, 111(2), 167–180. https://doi.org/10.1007/s11547-006-0018-8
18. Fidler, J., Paulson, E. K., & Layfield, L. (1996). CT evaluation of acute cholecystitis: Findings and usefulness in diagnosis. AJR. American Journal of Roentgenology, 166(5), 1085–1088. https://doi.org/10.2214/ajr.166.5.8615248
19. Gore, R. M., Thakrar, K. H., Newmark, G. M., Mehta, U. K., & Berlin, J. W. (2010). Gallbladder imaging. Gastroenterology Clinics of North America, 39(2), 265–287. https://doi.org/10.1016/j.gtc.2010.02.008
20. Thornton, J. R., Heaton, K. W., Espiner, H. J., & Eltringham, W. K. (1983). Empyema of the gallbladder – Reappraisal of a neglected disease. Gut, 24(12), 1183–1185. https://doi.org/10.1136/gut.24.12.1183
21. Wu, B., Buddensick, T. J., Ferdosi, H., Narducci, D. M., Sautter, A., Setiawan, L., Shariati, A., Shariati, A., & Tseng, J. F. (2014). Predicting gangrenous cholecystitis. HPB, 16(9), 801–806. https://doi.org/10.1111/hpb.12214
22. Ong, C. L., Wong, T. H., & Rauff, A. (1991). Acute gallbladder perforation: A dilemma in early diagnosis. Gut, 32(8), 956–958. https://doi.org/10.1136/gut.32.8.956
23. Ambe, P., Weber, S. A., Christ, H., & Wassenberg, D. (2014). Cholecystectomy for acute cholecystitis: How time-critical are the so-called “golden 72 hours”? Or better “golden 24 hours” and “silver 25–72 hours”? A case control study. World Journal of Emergency Surgery, 9, Article 60. https://doi.org/10.1186/1749-7922-9-60
24. Gurusamy, K. S., Davidson, C., Gluud, C., & Davidson, B. R. (2013). Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database of Systematic Reviews, 2013(6), Article CD005440. https://doi.org/10.1002/14651858.CD005440.pub2
25. Samad, A. M. A., Ibrahim, A. A., & Ibrahim, Y. A. (2018). Percutaneous cholecystostomy as a nonsurgical option for treatment of acute cholecystitis in elderly patients. The Egyptian Journal of Radiology and Nuclear Medicine, 49(4), 1155–1158. https://doi.org/10.1016/j.ejrnm.2018.07.005