What are the causes and management options for a contracted gallbladder?

Causes of Contracted Gallbladder

A contracted gallbladder on imaging represents severe acute cholecystitis with high risk of empyema, perforation, or gangrenous changes, requiring urgent surgical intervention rather than being a benign finding. 1

Pathologic Causes (Requiring Urgent Intervention)

Acute Cholecystitis with Complications

• Gangrenous cholecystitis with impending or actual perforation causes gallbladder wall necrosis and contraction, representing a surgical emergency 1
• Gallbladder empyema (pus-filled gallbladder) presents with a contracted, thick-walled gallbladder on ultrasound and requires urgent laparoscopic or open cholecystectomy 1
• Gallbladder perforation occurs in 2-11% of acute cholecystitis cases with mortality rates of 12-16%, causing wall discontinuity and contraction 2, 1

Chronic Inflammatory Changes

• Scleroatrophic cholecystitis from recurrent inflammation causes chronic fibrosis and gallbladder wall thickening with contraction 2
• Chronic cholecystitis with repeated inflammatory episodes leads to fibrotic wall thickening and reduced gallbladder capacity 3
• Mirizzi syndrome (impacted stone in cystic duct/infundibulum) causes chronic inflammation and contracted appearance 2

Critical Diagnostic Distinctions

Pathologic vs. Physiologic Contraction

Do not mistake a contracted gallbladder for normal post-prandial contraction—the clinical context (fever, right upper quadrant pain, elevated inflammatory markers) distinguishes pathologic from physiologic states. 1

Imaging Findings Indicating Pathology

• Ultrasound shows pericholecystic fluid, distended or contracted gallbladder with edematous wall (>3mm), gallstones, and positive sonographic Murphy's sign 2, 1
• CT with IV contrast better demonstrates gallbladder wall defects, pericholecystic collections, intramural gas (emphysematous cholecystitis), and free intraperitoneal fluid indicating perforation 2, 1
• The sonographic "hole sign" suggests gallbladder perforation 2

Risk Factors for Severe Disease Leading to Contraction

Patient Factors

• Age >65 years, male gender, and diabetes mellitus increase risk of complicated cholecystitis requiring conversion to open surgery 2
• Critically ill patients and those with multiple comorbidities develop more severe gallbladder pathology 2

Disease Factors

• Thickened gallbladder wall on preoperative imaging predicts severe inflammation 2
• Duration of symptoms >48 hours before presentation increases complication risk 2
• Impacted stones in the infundibulum or cystic duct cause more severe inflammation 2

Management Algorithm

Immediate Assessment

1. Obtain inflammatory markers (WBC, CRP) and liver function tests to assess severity 1
2. Perform ultrasound as first-line imaging to evaluate for cholecystitis, empyema, or perforation 2, 1
3. Consider CT with IV contrast if ultrasound is equivocal or complications are suspected, as CT better demonstrates wall defects and collections 2, 1

Definitive Treatment

Urgent laparoscopic or open cholecystectomy is the definitive treatment for contracted gallbladder due to acute cholecystitis, empyema, or perforation. 1 Early operative intervention (within 7-10 days of symptom onset when possible) reduces infectious morbidity and mortality compared to delayed surgery 1

Antibiotic Therapy

• For immunocompetent, non-critically ill patients: Amoxicillin/clavulanate 2g/0.2g every 8 hours with adequate source control 2, 1
• For critically ill or immunocompromised patients: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g every 6 hours (or 16g/2g continuous infusion) 2, 1
• For beta-lactam allergy: Eravacycline 1 mg/kg every 12 hours OR Tigecycline 100 mg loading dose then 50 mg every 12 hours 2, 1

Alternative for High-Risk Surgical Candidates

Percutaneous cholecystostomy may be considered as a temporizing measure for elderly or critically ill patients unfit for surgery, though laparoscopic cholecystectomy is superior even in high-risk patients. 2, 1 However, cholecystostomy carries higher major complication rates in critically ill populations compared to cholecystectomy 2

Critical Pitfalls to Avoid

• Do not delay surgical intervention beyond initial antibiotic stabilization in surgical candidates, as delayed operative intervention increases infectious morbidity and mortality 1
• Do not overlook gallbladder perforation, which requires immediate surgical intervention to decrease morbidity and mortality 1
• Do not rely solely on percutaneous drainage in critically ill patients when cholecystectomy is feasible, as outcomes are worse with drainage alone 2, 1