腹部超音波検査で術前診断し緊急腹腔鏡下胆囊摘出術により救命しえた胆囊仮性動脈瘤破裂の1例

A rare case of ruptured pseudoaneurysm of the cystic artery diagnosed by ultrasonography and followed by a successful urgent laparoscopic cholecystectomy

◆要旨：患者は87歳，女性．大量下血による出血性ショックにて，前医より輸血を行いながら当院に搬送された．腹部超音波検査（カラードップラー）で肝床側から胆囊内腔に向けて拍動性の出血を認め，胆囊仮性動脈瘤破裂による胆囊出血と診断した．輸血により全身状態を改善した後，緊急腹腔鏡下胆囊摘出術を施行した．胆囊は高度緊満を伴うものの炎症所見は軽微で，手術は定型的に可能であった．術後経過は良好で，リハビリテーション継続のため術後19日目に転院となった．胆囊仮性動脈瘤破裂は，臨床症状と各種血液検査所見，カラードップラー超音波検査などの画像診断により術前診断が可能で，確定診断後の適切かつ速やかな治療が重要と思われた．

An 87-year-old woman was referred to our hospital for the management of hemorrhagic shock related to hemobilia. Physical examination demonstrated a slight tenderness in the right hypochondrium. Abdominal ultrasonography showed a distended gallbladder filled with echogenic debris. In addition, color Doppler ultrasound depicted pulsatile blood-flow signals in the gallbladder at the bed of the gallbladder, suggesting the diagnosis of ruptured pseudoaneurysm of the cystic artery. After a blood transfusion, the patient underwent an urgent laparoscopic cholecystectomy. The operation went smoothly as planned. Macroscopically, an aneurysm-like structure, 4mm in size, was identified in the mucosa of the bed of the gallbladder. Any stones or tumors were not observed. The diagnosis of chronic cholecystitis was made histologically. The postoperative course was uneventful and the patient left our hospital on postoperative day 19. An abdominal Doppler ultrasound may allow us to detect a ruptured pseudoaneurysm of the cystic artery and urgent laparoscopic cholecystectomy could be the treatment of choice for such an acute abdomen requiring immediate surgery.