Introduction Gall stones disease is a common problem and its incidence is 5% to 15% in the west, 1,2 while in Asian countries is low. 3 In majority of these patients stones remain asymptomatic and only 10-20% develop symptoms. 1,2,4 The average risk of developing symptomatic disease is 2 to 2.6% per year. 4 Laparoscopic cholecystectomy is the standard procedure for the treatment of this condition and the demand of this procedure has exceeded the capacity of available resources in public hospitals and patients have to wait for definitive treatment. Waiting for laparoscopic cholecystectomy keeps patients at risk for development of complications of acute cholecystitis which may require re- admissions and emergency surgeries. 2 Empyema and gangrene of the gall bladder are serious consequences of acute inflammation of gall bladder and to prevent these complications early cholecystectomy should be performed for acute gall bladder diseases. 5,6 The incidence of empyema reported in the literature is in a range of 2.0 to 11% and of gangrenous gall bladder 15 to 18% in acute cholecystitis. 6,7 Early cholecystectomy is advisable for all forms of acute cholecystitis, but in large busy medical centres and in public hospitals where this disease is frequently dealt with, it is not possible for every case of acute cholecystitis to be operated early on admission because of the limited number of operating rooms and available resources. This delays the surgical treatment. 7 It is necessary to prioritise the patients for cholecystectomy, who are at more risk to develop empyema or gangrene of the gall bladder if the surgical treatment is delayed. Clinically, pre-operative diagnosis of acute inflammation and empyema or gangrene is often difficult because of the similarity of symptoms with biliary colic due to uncomplicated acute cholecystitis. 7-9 Biliary colic is a self- limiting transient obstruction of the gall bladder and its repeated attacks can lead to chronic cholecystitis, while acute calculus cholecystitis results from unrelieved obstruction and can lead to empyema or gangrene if not treated. 7,8 It is observed that these complications are more preponderant in males with acute cholecystitis compared to females, and ultrasound shows gall bladder wall more thickened in these patients. The current study was conducted to underline these observations of predictive risk factors for the incidence of acute cholecystitis Vol. 64, No. 2, February 2014 159 ORIGINAL ARTICLE Male gender and sonographic gall bladder wall thickness: important predictable factors for empyema and gangrene in acute cholecystitis Muhammad Laiq-uz-Zaman Khan, 1 Mujeeb Rehman Abbassi, 2 Muhammad Jawed, 3 Ubedullah Shaikh 4 Abstract Objective: To underline the status of male gender and gall bladder wall thickness as significant risk factors for acute cholecystitis complications. Methods: The retrospective study, with purposive sampling of the patients of acute cholecystits in age above 18 years, who were operated within 10 days of onset of symptoms, was conducted at the Department of Surgery, Dow University Hospital, Karachi, by reviewing the patients' medical record from March 2010 to August 2012. Correlation of incidence of acute cholecystitis complications (empyema and gangrene) to male gender and to the sonographic gall bladder wall thickness more than 4.5mm was analysed using SPSS 16. Result: Out of 62 patients, 8 (13%) patients had gangrene while 10 (16.12%) had empyema. Overall, there were 21 (33.87%) males in the study. Ten (47.6%) of the male patients developed empyema or gangrene of the gall bladder as a complication of acute cholecystitis. Of the 41 (66.12%) female patients, only 8 (19.5%) developed these complications. There were 22 (35.48%) cases of gall bladders with sonographic wall thickness more than 4.5mm who were operated for acute cholecystitis. Of them, 16 (72.7%) had empyema or gangrene. Conclusion: Male gender and sonographic gall bladder wall thickness more than 4.5mm were statistically significant risk factors for suspicion of complicated acute cholecystitis (empyema/gangrene) and by using these risk factors, we can prioritise patients for surgery in the emergency room. Keywords: Risk factors, Empyema gall bladder, Gangrene of gall bladder, Complicated acute cholecystitis, Male gender, Gall bladder wall thickness. (JPMA 64: 159; 2014) 1,3,4 Department of Surgery, Dow International Medical College, Dow University Hospital, Dow University of Health Sciences, Karachi, 2 Department of Laparoscopic Sugery, Liaquat University of Medical & Health Sciences, Karachi. Correspondence: Muhammad Laiq-uz-Zaman Khan. Email: dr.laiqkhan@hotmail.com