急性氣腫性膽囊炎

690

ၡāāࢋ

X 80

Murphy's Sign

Clostridium perfringens X

ᙯᔣෟĈާّᓙᝃۆ ( Acute cholecystitis )

ঈཚّᓙᝃۆ ( Emphysematous cholecystitis ) ᓙඕϮ ( Gallstone )

݈֏

ঈཚّᓙᝃۆߏᓙᝃጨᗼѪޢצזயঈّ࡭

ঽෂ ( т E. coli, Clostridium welchii, C. perfringens,

׶ anaerobic streptococci ) Ѩ൴ّຏߖĂጱ࡭ᓙᝃ ට̚ѣঈវ۞хдĂᐌ඾়ঽ۞ซणĂঈវົ΍

னдᓙᝃጨĂࠤҌซˢᓙᝃ׹ᙝ௡ᖐ̚Ąιߏާ

ّᓙᝃۆ۞˘჌͌֍ͷᚑࢦ۞ԛёĂᓜԖাې૱

ᔳЄ҃д̙̙ۢᛇ̚ΐᆐĂ൒ޢซणԣిĂ૱ጱ

࡭ᓙᝃࡍ͋҃ᅮღާ͘ఙڼᒚĂᎤԌঽଈ͍׎т ѩ

Ąᔵ൒ཛొ෹ࢰگߏ෧ᕝᓙᝃ়ঽ۞ࢵᏴ̍

׍ĂҭЯࠎᓙᝃ̰ঈវ۞хдĂጱ࡭ᓙᝃᏰᙊ̙

ٽĂֹ଀ঈཚّᓙᝃۆྵᙱϤ෹ࢰگֽ෧ᕝĄӀ ϡཛొ X Ѝٕ࿪ཝᕝᆸֽᑭෛᓙᝃ̰ঈវ۞хд

݋ߏྵୂຏ۞෧ᕝ̍׍Ąԧࣇ೩΍˘࣎ಏ৷ͽ˯

ཛొණ൭ࠎাېܑன۞ާّঈཚّᓙᝃۆĂݒԣ

ిซणҌᓙᝃࡍ͋۞ঽּĄ

˘Ҝ 8 0 ໐շّঽˠ͹෦α͇݈؆୎ฟؕѣ

˯ཛණ൭ă⪰͕ယФ۞ଐԛĂ࿣͇അ࢒ώੰާ෧ ಶ෧Ą࿅Νѣঐّ̼ሚႹࡍ͋གྷࡤֲБ̷ੵ͘ఙ

۞ঽΫĂѩγ֭൑׎΁ր௚ّ۞়ঽĂ˵൑٩໬

ಅ੧۞௫ၚĄ༊ॡϠ׻ᇈ෪ᘦؠĂ֭൑൴፵ଐ ԛĄநጯᑭߤੵ˯ཛᅅ຋ᑅ൭γ֭൑׎΁ள૱Ą ҕ୵ᑭរ൴னϨҕ஧ᅅ຋̿੼ 11300 /uL Ăฺ݈

ҕᎤྵ੼Ĉ 151 mg/dL ( ϒ૱ࣃĈ 70-120 mg/dL ) γĂ׎ዶ۞ᑭរΒ߁քΑਕăඪΑਕăҕ୻፥

ৰ ă਌۹ ̈́Ԍ୵ᑭរ࠰ϒ૱Ąཛొ X Ѝᛷ ᇆ˵൑পঅ൴னĄ˯ঐ̼྽̰ෛᙡᑭߤ෧ᕝࠎࠃ Չᒧ̶ᙷ( Los Angeles classification ) B ৺ਗ਼߹ّ

ࢴ྽ۆ̈́གྷࡤֲБ̷ੵ͘ఙ̈́ Billroth ௐ II ݭࡤ

۩བӚЪĄ ̝ޢঽˠҋᛇাېԼචĂٺ༊͇΍

ੰ֭ͷ૲ˬ͇ࡤᘽ̈́ܳࡤབᛅજ጗аछĂ࿰ࡗࡤ བքᓙࡊܝ෧Ą

ˬ͇ޢĂঽˠֽזܝ෧Ă͹෦ѣ൴፵ăཛ ණăΠ˯ཛ൭̈́ਮҒԌ۞ଐԛĂநጯᑭߤ൴னវ

໢ 3 7 . 2 ƨĂዮቯ຋ھเĂΠ˯ཛѣᅅ຋ᑅ൭̈́

ၬᑝ൭ĂၬᑝѣခࢰĂ൑ͅᇅ൭˵൑ Murphy's Sign ĄЯࠎѣเ৅ă൴፵̈́Π˯ཛ൭ĂᘃႷѣᓙ

྽൴ۆĂЯѩщଵҕ୵ᑭរ̈́ཛొ෹ࢰگᑭߤĂ ҕ୵ᑭរ൴னϨҕ஧ࢍᇴĈ 16300 /UL ( Band 1 %

; Neut 89% )Ă ᓁᓙࡓ৵Ĉ 3.7 mg/dL ( ϒ૱ࣃĈ 0 . 2 - 1 . 3 m g / d L ) Ăҕ୻ጊ῔ᅕਨዖᅕᖼ῔

ࣃĈ 5-40 U/L )Ăཛొ෹ࢰگᑭߤ൴னᓙᝃᔳ჏

ܢܕѣ̙ఢ݋ؾቢې੼аࢰ׀ൾऴ۞аᜩౚᇆ ( acoustic shadow with reverberation )Ăᓙᝃጨ൑ڱ ពனĂय़ѣ˘Ҳаࢰડા ( ဦ˘ )Ăពϯᓙᝃᔳ

჏ܢܕѣ˘Ԋొঈវჸะ۞ঽիĂ෹ࢰگଣᐝࢦ ᑅ՟ѣ΍னূ൭ΐᆐ۞ன෪ ( s o n o g r a p h i c Murphy's sign )ĂᅮᝥҾ෧ᕝ۞়ঽࠎঈཚّք ᓘႹ ( emphysematous liver abscess )ăާّঈཚّ

ᓙᝃۆٕჃጡᇹᓙᝃ ( porcelain gallbladder )ĂЯ ѩޙᛉ֭щଵঽˠҝੰซ˘Վ۞ᑭߤĄ

༊͇˭̾ঽˠϤछᛳౖТՎҖˢঽٗĂҝੰ

ॡϠ׻ᇈ෪ᘦؠĂវ໢ 3 6 . 4 ƨĂҕᑅ 1 2 3 / 6 7 mmHg Ăਔຨ 100 ྯ/̶Ăײӛ 20 Ѩ/̶ĂА٩פ

׌इҕ୵ૈዳĂ൒ޢග̟Ꮾ୵̈́ԩϠ৵ڼᒚĄѨ

͟Ăঽˠ߿જҋтĂ̪ᛇ଀ᅅ຋ཛණ̈́Π˯ཛ൭

ဦ˘Ĉཛొ෹ࢰگពϯᓙᝃጨ൑ڱ୻຾ពனĂᓙᝃᔳ჏

ܢܕѣ˘̙ఢ݋ؾቢې੼аࢰᇆည׀ൾऴ۞аᜩ ౚᇆ ( ϨҒ቏ᐝ఍ )Ăय़ѣ˘ҲаࢰડાĄ

ဦ˟Ĉ਒ొ X Ѝពϯੵ˞Π˭۱ཧѣ۱Ꮆණ̙Б̈́҈ቯ

᎕ͪγĂдΠ˯ཛᓙᝃᔳ჏఍ѣ˘ӣঈ- ୵ࠧࢬ

( air-fluid level ) ۞ᓙᝃᇆည ( โҒ቏ᐝ఍ )Ą

ҭাې൑ೋ̼˵൑൴፵ଐԛĂநጯᑭߤ൴னΠ˯

ཛѣᅅ຋ᑅ൭Ă൑ͅᇅ൭˵൑ Murphy's Sign Ă ЯᘃႷѣঈཚّքᓘႹĂ߇щଵཛొ࿪ཝᕝᆸବ Ⴟֽүซ˘ՎቁᄮĄௐˬ͇Ăঽˠ̪߿જҋтĂ

াې൑ត̼˵൑൴፵ଐԛĂּҖّҕ୵ᑭរ൴ன ҕҒ৵ ( Hb )Ĉ 10.6 gm/dL ĂϨҕ஧ᇴ̿੼Ĉ 17900 /UL ( Band 1 % ; Neut 85% )Ăฺ݈ҕᎤĈ 115 mg/dL Ăᓁᓙࡓ৵Ĉ 2.3 mg/dL Ăมତᓙࡓ

৵Ĉ 1.4 mg/dL ( ϒ૱ࣃĈ 0.2-1.3 mg/dL )Ăҕ୻

ጊ῔ᅕਨዖᅕᖼ῔ ( SGOT )Ĉ 25 U/L Ăҕ୻ጊ

῔ᅕʹ⟮ᅕᖼ῔ ( SGPT )Ĉ 39 U/L Ăែّᒤ ᅕ Ĉ 152 U/L ( ϒ૱ࣃĈ 55-120 U/L )ĂϨకϨ ( albumin )Ĉ 2.9 gm/dL ( ϒ૱ࣃĈ 3.4-4.8 gm/dL )Ą

਒ొ X Ѝ൴னੵ˞Π˭۱ཧѣ۱Ꮆණ̙Б̈́҈ቯ

᎕ͪγĂдΠ˯ཛᓙᝃᔳ჏఍ѣ˘ӣঈ-୵ࠧࢬ ( air-fluid level ) ۞ᓙᝃᇆညĂᓙᝃጨ̰ѣঈវព ன ( ဦ˟ )ĂᘃႷࠎާّঈཚّᓙᝃۆĄཛొ࿪

ཝᕝᆸବႿՀ൴னᓙᝃඕϮăᓙᝃට̈́ᓙᝃጨ̚

ѣঈវ۞хдĂᓙᝃ׹ಛѣ൴ۆ୵វ̈́ഫᗓঈវ ჸ᎕ ( ဦˬ )Ăᙋ၁ࠎާّঈཚّᓙᝃۆ׀൴ᓙ ᝃࡍ͋Ąϲӈົ෧γࡊฟ˥ซҖᓙᝃ̷ੵ͘ఙĂ ఙ̚൴னᓙᝃልቯᆸᄃშቯᕆాĂԊొѣᓘႹய ϠĂᓙᝃ൴ۆ·ঈཚ̂ĂᓙᝃጨᆧݓĂᓙᝃ̰Ξ ᛈၤזᇴᔺ˘̶̳̂̈۞ඕϮಷ๫дᐚొĂఙޢ

ೇࣧଐڶ։рĂҝੰ̚۞׌इҕ୵ૈዳ̈́͘ఙ̚

ٙү۞ᓙϗૈዳ࠰ܜ΍ Clostridium perfringens ෂĄঽˠٺ׌ฉޢ૵ೇ΍ੰĂԼܝ෧੠ᖸĄ

੅ኢ

ঈཚّᓙᝃۆࢵАϤ We l c h ׶ F l e x n e r д 1896 ѐ೩΍׎ঽநপᇈĂд 1901 ѐ Stolz дގវ ྋ࣠ॡಶഅೡࢗ࿅ᓙᝃঈཚன෪ Ą׎ཛొ X Ѝ

۞পᇈ݋ࢵАϤ Hegner д 1931 ѐ೩΍

Ą̙Тٺ

ާّᓙᝃۆĂঈཚّᓙᝃۆྵ૱൴Ϡдҁѐˠ ( ̬ٺ 50 ז 70 ໐ ) ̈́ᎤԌঽଈ۰ ( ࡗҫ 50% )Ăշ

ّ൴Ϡதྵ੼Ăࡗࠎّ̃۞׌ࢺĂᓙඕϮТॡх д۞ͧதྵҲ ( 40% versus 90% )Ăࡗˬ̶̝˟۞

ঽଈົயϠᓙᝃᗼুĂ҃ᓙᝃࡍ͋൴ϠதՀ੼΍

̣ࢺĂѪ˸த˵ྵ੼ ( 15% versus 4 % )

Ą ঈཚّᓙᝃۆ۞ܐؕᓜԖাېܑனᄃާّᓙ ᝃۆ࠹ҬĂͽΠ˯ཛ൭ă൴፵ă⪰͕ယФࠎ͹Ą ᐌޢᓜԖাې૱д̙̙ۢᛇ̚ΐᆐĂ൒ޢซणԣ

ిĂ૱ጱ࡭ᓙᝃࡍ͋

Ąঽந፟ᖼ˵̙ТĂᓙᝃ જਔ̈́׎̶͚۞ҕგܡ๫ጱ࡭ᓙᝃ৿ҕᗼѪĂ͔

੓யঈّ࡭ঽෂ ( т E. coli, Clostridium welchii, C.

perfringens, ׶ anaerobic streptococci )Ѩ൴ّຏߖĂ யϠঈវдᓙᝃጨăᓙᝃටĂࠤҌซˢᓙᝃ׹ᙝ

௡ᖐ̚Ăజᄮࠎߏঈཚّᓙᝃۆ۞࡭ঽ፟ᖼ

Ą ϒΞͽྋᛖࠎңঈཚّᓙᝃۆ૱൴Ϡдҁѐշّ

̈́ᎤԌঽଈ۰Ą

ώঽּߏ˘Ҝ੼᛬ଈ۰Ă֭൑ᎤԌঽΫĂҝ

ੰ۞࿅඀̚Ăؕ௣Ϊͽᅅ຋Π˯ཛණ൭۞াېܑ

னĂநጯᑭߤ˵ΪѣΠ˯ཛᅅ຋ᑅ൭̈́ၬᑝ൭Ă

҃՟ѣ൴፵ă⪰͕ယФ˵՟ѣ Murphy's Sign ඈާ

ّᓙᝃۆ۞׏ݭাܑ࣏னĄள૱۞ҕ୵ᑭរᇴ ፂĂΒ߁Ϩҕ஧࿅੼ăքΑਕ̈́เ৅޽ᇴள૱Ă ពϯѣᓙ྽൴ۆ۞ΞਕĄҭߏཛొ෹ࢰگᑭߤ൑

ڱдௐ˘ॡมү΍ϒቁ෧ᕝ҃Ϥ࿪ཝᕝᆸବႿቁ ෧Ąࡁտ൴னާّᓙᝃۆ۞ҁѐˠଈ۰ ( ѐ᛬̂

ٺ 65 ໐ )Ăགྷ૱Ϊͽ˯ཛٕΠ˯ཛ൭׶Π˯ཛᓙ ડᑅ൭۞াېֽܑனĂ҃৿ͻ׎΁া࣏Ąᄃѐᅅ ଈ۰̙Т۞ߏĂ෹࿅Ηᇴ۞ާّᓙᝃۆ۞ҁѐˠ ଈ۰՟ѣ⪰͕ယФͽ̈́൴፵ĂࠤҌซणזᓙᝃᄊ ᓘăᗼুăࡍ͋ॡĂ̪ѣˬ̶̝˘۞ଈ۰՟ѣ൴

፵۞ଐԛĂҕ୵ᑭរ˵ϏυΞያĂ 30% Ҍ 40% ۞ ҁѐˠଈ۰՟ѣϨҕ஧࿅੼۞ଐԛĂࠤҌѣֱք Αਕ޽ᇴ˵൑ள૱

Ąضрཛొ෹ࢰگᑭߤᄃଣ ᐝૻᑅົ΍னূ൭۞ன෪ ( sonographic Murphy's ဦˬĈཛొ࿪ཝᕝᆸពϯᓙᝃඕϮăᓙᝃට̈́̚ᓙᝃጨ

̰ѣঈវ۞хдĂᓙᝃ׹ಛѣ൴ۆ୵វ̈́ഫᗓঈ

វჸ᎕ ( ϨҒ቏ᐝ఍ )Ą

ᝃ়ঽ۞ࢵᏴ̍׍Ăҭߏ၆ٺঈཚّᓙᝃۆĂཛ

ొ෹ࢰگ૱൑ڱдௐ˘ॡมү΍ϒቁ෧ᕝĂჹЯ ٺᓙᝃ̰ঈវ̒ᕘĂጱ࡭ᓙᝃ൑ڱ୻຾ពனĄ

Gill ඈˠ൴னާّঈཚّᓙᝃۆଈ۰Ăଂҝ

ੰҌϒቁ෧ᕝॡมπӮࠎ 2 ͇ĂࡶϤௐ˘ቢཛొ

෹ࢰگϒቁ෧ᕝĂ෧ᕝॡมᒺൺҌ 1 ͇Ąࡶཛొ

෹ࢰگ൑ڱϒቁ෧ᕝ҃Ϥ࿪ཝᕝᆸϒቁ෧ᕝĂ෧ ᕝॡมؼܜࠎ 4 ͇

ĄЯѩ˞ྋঈཚّᓙᝃۆ۞

ᇆညܑன֭ͷѝഇ෧ᕝѝഇڼᒚĂ૟ΞࢫҲ׎П ᐍّ̈́Ѫ˸தĄ

ঈཚّᓙᝃۆ۞ཛొ෹ࢰگᇆညົ൴னѣঈ វ᎕ჸдᓙᝃᔳ჏఍ĂЯঈវณ۞кဿͽ̈́ٙд Ҝཉ̙Т҃Ӕன΍˘࣎Ϥᓙᝃጨٕ̰ටঈវٙய Ϡ۞̙ఢ݋ؾቢې੼аࢰᇆည׀ൾऴ̈́৴ใ۞а ᜩౚᇆ ( acoustic shadow with reverberations )дᓙ ᝃડ

Ąઊ҃༊ঽˠ઎዁ॡΞ൴னధк̈۞੼а ࢰᕇଂᓙᝃටغొ႓ঙ҃˯ĂᙷҬ˘ړ݂ڽڽ۞

ࢶᕠ੧ĂჍࠎ champagne sign

Ąᓙᝃፋវͽ̈́ᓙ ඕϮົЯঈវ̒ᕘ҃൑ڱពனĄ

Blaquieve ׶ Dewbury ૻአ༊ཛొ෹ࢰگ൴ னѣႷҬঈវ᎕ჸдք၁ኳĂপҾߏдᓙᝃᔳ჏

఍Ăυืщଵཛొ X Ѝͽડ̶ߏঈវٕߏჃጡᇹ ᓙᝃ ( porcelain gallbladder ) ۞ถ̼ᇆည

Ąঈཚ

ّᓙᝃۆ۞ཛొ X ЍΞ൴னдΠ˭҈ቡડѣ˘ဥ ঈវჸ᎕Ăࡶࠎᓙᝃጨ̰ঈវ ( intramural gas ) ົ Ӕன˘າ͡ԛ౅Ѝડ ( crescentic lucency ) дᓙᝃ α׹Ąࡶࠎᓙᝃ̰ටঈវ ( intraluminal gas )Ăд ঽˠЈۻॡĂдΠ˯ཛົӔன˘࣎Ҍᇴ࣎ঈڽᇹ

ٕ˘࣎୨ԛ౅Ѝડ ( pear-shaped lucency )Ăдঽ ˠۡϲٕ઎ۻॡĂӔன΍ӣѣ˘ঈ-୵ࠧࢬ ( air- fluid level ) ۞ᓙᝃᇆည

Ą

ੵ˞Ⴣጡᇹᓙᝃ ( porcelain gallbladder ) ۞ถ

̼ᇆညγĂ׎΁ညᓙᝃܢܕ۞བঈă˩˟޽བ֯

ࡎ̷ฟఙޢᓙ྽ঈཚăᓙඕϮབܡ๫ ( gallstone ileus )ăޢཛටഫᗓঈវ ( retroperitoneal air ) ăབ ք გ ( enterohepatic fistula ) ٕঈཚّքᓘႹ˵

ົѣᙷҬ۞ཛొ෹ࢰگᇆညĂυืщଵཛొ࿪ཝ ᕝᆸବႿ̖ਕүՀซ˘Վቁᄮ Ą࿪ཝᕝᆸବႿ ၆ٺঈវઍീՀࠎୂຏĂΞͽពϯ΍ঈវϒቁٙ

ּтᓙᝃฉᙝ۞൴ۆត̼ăᓘႹăٕࡍ͋

Ą

ާّঈཚّᓙᝃۆ۞ڼᒚĂᅮАග̟Ꮾ୵̈́

உᄏཀྵᜋͩౚّ̈́နউෂ۞ᇃड़ّԩϠ৵âό ቁϲ෧ᕝĂυื໰ົγࡊүღާᓙᝃ̷ੵ͔̈́߹

͘ఙڼᒚͽࢫҲѪ˸۞ПᐍّĄ

ާّঈཚّᓙᝃۆ۞ҁѐଈ۰Ăགྷ૱ΪͽΠ

˯ཛණ൭ܑன҃৿ͻ׏ݭ۞া࣏Ăఙ݈෧ᕝ̙ट ٽĂ༊෹ࢰگᑭߤ൴னᓙᝃ൑ڱ୻຾ពன҃ᘃႷ ᓙᝃ̰ѣঈវхдॡĂυืщଵཛొ X Ѝ̈́࿪ཝ ᕝᆸүՀซ˘Վቁᄮâόቁϲ෧ᕝĂυืүღ

ާ͘ఙڼᒚͽࢫҲѪ˸۞ПᐍّĄ

ણ҂͛ᚥ

1.Mentzer Jr RM, Golden GT, Chandler JG, Horsley III JS. A com- parative appraisal of emphysematous cholecystitis. Am J Surg 1975; 129: 10-5.

2.Hegner CF. Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg 1931; 22: 993-1000.

3.Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, Garcia-Sancho Martin L. Acute emphysematous chole- cystitis: report of twenty cases. Hepatogastroenterology 1999;

46: 2144-8.

4.Sherlock S, Dooley J. Gallstones and inflammatory gallbladder diseases. In: Sherlock S, Dooley J, eds. Diseases of the liver and biliary system. London: Blackwell Scientific, 1997; 593-624.

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Acute Emphysematous Cholecystitis Ĉ A Case Report

Ching-Fu Chen, Tsang-En Wang

, Shee-Chan Lin

, Wen-Hsiung Chang

, and Shou-Chuan Shih

Emphysematous cholecystitis is a relatively rare variant but rapidly progressive and life threatening form of acute cholecystitis caused by gas-producing organisms. In contrast to acute cholecystitis, emphysematous cholecystitis occurs more commonly in elderly and diabetic patients, and is frequently associated with perfora- tion and death, requiring emergent surgical intervention. Because poor visualization of the gallbladder in ab- dominal sonogram, emphysematous cholecystitis is very difficult to diagnose in most of cases. Plain film or com- puted tomography, are more sensitive in detecting and characterizing the gas in the gallbladder. We present a 80-year-old man with no diabetes presented with right upper abdominal pain, but without typical symptoms of acute cholecystitis as fever, nausea, vomiting and Murphy's sign after admission. Emphysematous cholecystitis with gallbladder perforation was confirmed by computed tomography. Emergent cholecystectomy was performed immediately and Clostridium perfringens was isolated from the bile and blood culture. He had an uneventful post- operative recovery. Elderly patients who have emphysematous cholecystitis may present with only right upper abdominal pain. Other signs may be absent. Preoperative diagnosis can be difficult. When the gallbladder is poor- ly visualized and gas is suspected on ultrasonography, it should be defined by plain film and computed tomog- raphy and emergent cholecystectomy is needed to minimize the risk of mortality. ( J Intern Med Taiwan 2008; 19:

360-364 )

Division of Gastroenterology, Department of internal Medicine,

Mackay Memorial Hospital, Hsin-chu and

Taipei, Taiwan