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Recent advances in gastroenterology 5

Empyema of the gall bladder Sir, The excellent article written by Dr Thornton and colleagues about empyema of the gall bladder (Gut 1983; 24: 1183-5) raises the problem of distinguishing cholecystitis from gall bladder empyema. The whitish, purulent-like fluid often found in a gall bladder with cholecystitis, composed of calcium and bilirubin precipitates, debris, and a few white blood cells, often with bacteria, is not very different from pus collected from a gall bladder with empyema, which often contains remarkably few white blood cells.' Studies in Japan suggest that cholecystitis is sometimes an infectious disease from the beginning, namely when associated with bile pigment and calcium, or mixed stones, in whose origin infection with (-glucoronidase producing E coli, Klebsiella, Bacteroides, or Clostridium could play an important role.2 3 In western countries infection seems to be generally secondary to cholecystitis.1 3 Cholecystitis can be initiated by phospholipase for example, released by trauma from a stone which converts lecithin into lysolecithicin and activates prostaglandin.4 Acalculous cholecystitis in debilitated patients is initiated by necrosis of the gall bladder blood vessels, probably related to factor XII activation.5 Whatever the cause of the inflammation, intestinal bacteria can reach the gall bladder by the portal circulation, and then directly from the liver through the bile, or through the lymphatics between the liver and the gall bladder. Occasionally infection may reach it by the cystic artery, or through the common duct.' The frequency of bactobilia increases during the first week of acute cholecystitis, reaching up to 75%, and then decreases slowly.6 The final outcome of empyema, or cholecystitis, depends on the complications, including bacteraemia and sepsis and these are related to the age of the patient and the length of obstruction.6 But the clinical, as well as the laboratory differences between these two entities remain to be sharply defined and a question has to be asked: is there a real frontier between cholecystitis and gall bladder empyema?