早期腹腔鏡下胆囊摘出術が有効であった急性壊疽性無石胆囊炎の1例

Acute gangrenous acalculous cholecystitis treated by early laparoscopic cholecystectomy

症例は56歳，男性．腹痛，嘔吐を主訴に来院した．エコーでは胆囊結石の所見を認めなかったが，sonographic Murphy徴候陽性であった．CTで胆囊壁周囲と肝表面に液体貯留を認めた．絶食，抗生剤投与など，初期治療においても臨床症状の改善がみられなかったため，発症より17時間後，腹腔鏡下胆囊摘出術を施行した．胆囊壁の壊死と，肝下面，胆囊周囲に胆汁性腹水を認めた．カローの三角，肝床に炎症性変化を認め易出血性であったが，剝離操作は容易であった．本症例のように耐術症例で，腹水貯留をきたしPTGBD（percutaneous transhepatic gallbladder drainage）が禁忌である無石胆囊炎に対しても，早期LC（laparoscopic cholecystectomy）が有効である可能性が示唆された．

　A 56-year-old man was admitted for abdominal pain, nausea, and right hypochondrial pain. A stone-free gallbladder was detected by abdominal ultrasonography and abdominal computed tomography showed fluid retention surrounding the gallbladder and at the surface of the liver. Initial treatments. included fasting administration of antibiotics but, his fever and abdominal pain did not improve. Therefore, he underwent laparoscopic cholecystectomy（LC）, 17 hours after the onset of the symptoms. Necrotic change of the gallbladder wall and peri-cholecystic biliary fluid were observed through laparoscope. Inflammatory and hemorrhagic adhesion in Calot's triangle and liver bed were ablated easily. Recently early LC is recommended for the treatment of acute calculous cholecystitis because of its effectiveness. It is also recommended as an alternative treatment for acute acalculous cholecystitis especially when the percutaneous transhepatic gallbladder drainage can not be performed due to ascites retention like this case.