SUMMARY: Twelve patients with empyema of the gall bladder were diagnosed among 325 cases of gall-bladder disease presenting to our department of surgery in three years period (March 2010 to March 2013). Abdominal pain was present for average of eight days in four cases andin four cases, for between one and four months. In some cases, the disease was painless and was found unexpectedly at operation for chromic cholecystitis disease. The severity of the problem was subdued by the often scanty physical signs. Less than 50% the patients had pyrexia of more than 38.5C and the presence of sepsis was rarely suspected clinically. None of the patients died. This considerable morbidity could be reduced by the wider use of blood culture in cases of cholecystitis and by greater awareness that empyema of the gallbladder is sometimes chronic, painless, and afebrile. INTRODUCTION: Empyema of the gall bladder was described extensively in surgical texts of the early years of this century1-3 but now rarely mentioned4. In addition, it appears to have been largely forgotten that its course can be chronic2, 3. It could be due to the wider use of antibiotics, along with the increasingly followed policy of early cholecystectomy for acute gall-bladder disease4-6. We have recently treated several elderly patients in whom the disease was markedly milder event. As the number of old people in the population is rising, it seemed important to determine whether this neglected disease is still an important problem and to redefine its natural history. We decided, therefore, to review all cases of empyema of the gall bladder which had presented to our hospital over a period of three years. METHODS: Empyema was defined as an inflamed gall bladder which contained pus (figure 1, 2, 3).The presence of inflammation and pus were established from the operation record, the gallbladder swab report, and the histology report on the resected gall bladder, cases of generalized infection of the biliary tree were designated as cholangitis and excluded from the study. From the 325 sets of case notes, 12 patients (3.69%) were identified who fulfilled these criteria and, on stringent review by all the authors, were agreed to be true examples of this disease. These cases were analyzed to determine their age and sex distribution, and their clinical and pathological features. RESULTS: The 12 patients were mostly elderly, their average age being 60 years (range 40-80 years). There were nine women and three men, giving a female preponderance of three to one. Six patients had no abdominal pain and the empyema were found unexpectedly, two at ultrasonography and in a further four patients, empyema was found at routine cholecystectomy, after a long history of apparently mild pain. The remaining six patients (50%) presented with abdominal pain of sufficient