Uncommon Presentation of Severe Empyema of the Gallbladder: Case Report and Literature Review

Diagnostic complexity in the older patient: an unusual presentation of advanced biliary disease

Biliary disease is common in the older population, and gallbladder dysfunction and increased bile lithogenicity predispose to calculi formation. This case demonstrates an unusual presentation of gallbladder empyema. A 90-year-old male with metastatic prostate cancer presented with hypoactive delirium. With no localising features, normal liver function tests but persistently raised inflammatory markers, he was initially managed as a urinary tract infection. Chest wall discomfort and swelling over the right costal margin later developed. Abdominal imaging demonstrated a massive gallbladder empyema invaginating through the lower right rib cage, causing the superficial swelling. Pre-morbid status prevented cholecystectomy and he was managed conservatively with percutaneous cholecystostomy and antibiotics. He was discharged to 24-h care 2 weeks after diagnosis with a long-term drain.

Current grading of gall bladder cholecystitis and management guidelines: Is it sufficient?

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These two cases highlight the limitations in current grading systems, particularly in the context of gallbladder size.

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We propose modifications to the PGS to include not only abnormal anatomy but instances of distorted gallbladder anatomy due to inflammation and/or the large to giant size in order to account for the increased risk of complications.

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Both distorted gallbladder anatomy and giant gallbladder size can make laparoscopic cholecystectomy a challenge, and thus warrant contribution to overall clinical grade.

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While the PGS, Tokyo Guidelines, and AAST grading scales are validated grading scales for acute cholecystitis, additional modifications can further characterize different types of acute cholecystitis to better guide patient management.