비결석성 급성 담낭염에 대한 임상적 고찰

Abstract

[한글]

비결석성 급성 담낭염은 비교적 드문 질환으로써 조기진단이 어렵고, 병의 진행속도가 빠르므로 높은 사망율을 나타내는데 대부분 다발성 외상, 중증도의 화상후, 혹은 수술후에 발생하며 그외에 다양한 선행인자가 있지만 그 발생기전은 확실히 정립되지 않았다.

본 논문은 비결석성 급성 담낭염의 증상 및 이학적 소견, 선행인자, 진단 및 수술, 예후등에 대한 고찰로, 비결석성 급성 담낭염의 조기진단 및 예방을 위한 노력으로, 1976년 1월 1일부터 1986년 6월 30일까지 만 10년 6개월간 연세대학교 의과대학 외과학교실에서

비결석성 급성 담낭염으로 진단된 41예에 대한 임상적 관찰 및 분석을 통하여 다음과 같은 결론을 얻었다.

1) 담도계 질환으로 담낭절제술을 시행한 1,783명중 급성염은 463명이었으며, 그중 비결석성 급성 담낭염은 41예로, 급성 담낭염의 8.9%를 차지하였다.

2) 남녀의 비는 1:1.3이었으며 연령별 분포는 50대 이상이 58.1%를 차지하였다.

3) 가장 흔한 증상은 우상복부 동통으로 85.4%에서 나타났으며, 가장 흔한 이학적 소견은 우상복부 압통으로 90.2%에서 관찰되었다.

4) 백혈구 증다증은 68.3%에서 관찰되었으며, 간기능 검사상 53.7%가 비정상 소견이었는데 그중 alkaline phosphatase가 가장 현저한 증가를 나타내었다.

5) 진단방법중 복부 초음파 촬영이 23예 (56.1%)에서 시행되어 82.6%의 정확도를 나타냈으며, 그외에 시행된 경구적 담도촬영술, 경정맥 담도 촬영술, 내시경적 역행성 담취관 조영술은 진단에 도움이 되지 못하였다.

6) 시행되었던 주술식은 담낭절제술로 전체의 87.8%에서 시행되었으며, 담낭조루술은 12.2%에서 시행되었다.

7) 수술소견상 담낭괴사는 36.6%, 천공이 동반된 경우는 19.5%였으며, 담낭관의 이상은 7.3%에서 관찰되었다.

8) 선행요인은 53.2%에서 관찰되었는데, 그중 부정맥이 14.6%로 가장 많았으며, 수술후 상태 12.1%, 당뇨병 9.8%순, 고혈압 9.8%순으로 관찰되었다.

9) 수술후 발생한 5예는 각각 비담도계 복부수술후 2예, 정형외과 수술후 2예, 혈관수술후 1예씩 이었으며, 증상의 평균 발현시기는 수술후 19.4일 이었는데, 수술후 첫식이와 증상의 발현사이에 상관관계가 있는 경우는 2예였다.

10) 담즙배양을 시행했던 환자중 87%에서 배양되어 그중 E.coli가 가장 많았으며, 혈액배양을 시행했던 환자중 43.8%가 배양되어 그중 K.pneumonia가 가장 많았다.

담즙과 혈액배양을 같이 시행했던 환자중 41.7%에서 양자 모두 균 배양이 되었다.

11) 답즙배양 결과 Salmonella typhi가 4예에서 배양되었으며 Widal test에 양성이 2예로 장티푸스와 관련되었던 경우는 6예였다.

12) 수술후 합병증은 29.3%에서 발생하여 폐염이 가장 많았으며, 수술후 사망율은 12.2%로 주된 사망원인은 패혈증과 급성 호흡 부전증이었다.

13) 담낭수술후 합병증이 없던 경우의 평균 증상 발현기간은 8.7일인데 반해 합병증이 있던 경우는 13.4일, 사망한 경우는 16.8일로 수술전에 진단이 늦을수록 합병증과 사망률이 증가 하였다.

Clinical analysis of acute acalculous cholecystitis

Jeong Hong, M.D.

Department of medical Science, The Graduate School, Yonsei University

(Directed by Professor Jin Sik Min, M.D.)

Acute acalculous cholecystitis is an acute inflammation of the gallbladder, in

the absence of stone, and it comprises 4 to 8% of all cases of acute cholecystitis,

and it has a tendency to occur after other disease, especially major trauma, burn,

or operation.

Typical findings of pain, tenderness, and a mass in RUQ are infrequent, and the

diagnosis rests on a high index of suspicion and ultrasonography.

It has the highest mertality and morbidity of all benign conditions affecting the

gallbladder, but its incidence is actually increasing due to increasing age of

patients, more extensive and invasive therapeutic procedures, prolonged survival of

gravely ill patients increasing the chances of initiation of the disease.

Awareness of this disease, knowledge of its clinical features, and early surgical

intervention are important facets of successful management.

This study was done to determine the features of acute acalculous cholecystitis

and to evaluate our experiences in its management at over the years 1976 to 1986

The results are summarized as follows:

1) Among 1783 patients who needed cholecystectomy due to biliary tract disease,

acute cholecystitis was found in 463 patients(26.3%), and acute acalculous

cholecystitis comprised 8.9%(41 cases) of all cases of acute cholecystitis.

2) The sex ratio of male to female was 1:1.3, and the age of patients varied from

6 to 81 years, the average age was 50 years.

3) The most common clinical symptoms were RUQ pain which were observed in 35

cases (85.4%), and the most common physical findings were RUQ tenderness which were

observed in 37 cases(90.2%).

4) On laboratory examination, leukocytosis was found in 28 cases (68.3%) of all

patients, and abnormalities in liver function test were observed in 22 cases

(53.7), among them alkaline phosphatase was most prominent.

5) Abdominal ultrasonography was used as important diagnostic method in 23 cases

(56.1%), and it revealed accuracy of 82.6%, and other procedures such as oral GB

cholangioglaphy, IV cholangiography and ERCP (Endoscopic retrograde

cholangiopan-creaticogram) were performed in 3 cases, but not dignostic.

6) Cholecystectomy was used as main procedure in 36 cases(87.8%), and

supplemental procedures such as operative cholangiogram, T-tube choledochostomy

were performed for passed stone in 31 cases in cholecystectomized patients.

Cholecystostomy was performed in 5 cases(12.2%).

7) Gangrenous changes in gallbladder were observed in 15 cases(36.6%), and 8

cases of perforation were found among them.

8) Possible predisposing factors were observed in 22 cases(53.2%), and arrhythmia

was most common among them (14.3%).

9) Acute acalculous cholecystitis developed in postoperative period were 5 cases;

2 cases after non-billary abdominal surgery, 2 cases after orthopedic surgery, 1

case after vascular surgery, and mean duration of symptoms were 19.4 days after

operation, possible relationship between first meal after operation and onset of

symptoms were observed in two cases.

10) Positive bile cultures were obtained in 20 cases, and E. coli was the most

common one (49%), and positive blood cultures were obtained in 7 cases (43.8%), and

K.pneumonia was the most common organism.

Positive culture fro both bile juice and blood were observed in 5 cases of 12

cases

11) Salmonella typhi were cultured from bile juice in 4 cases, in addition, two

cases of positive Widal test were observed.

12) Postoperative complications were observed in 12 cases (29.3%), and pneumonia

was the most common one (58.3%), and postoperative mortality was in 5 cases

(12.2%), and main cause of death was sepsis with ARDS.

13) Mean duration symptoms were 8.7 days in patients with uneventful

postoperative course, 13.4 days in patient with complicated postoperative course,

16.8 days in mortality cases.

So, if a patient with predisposing factors such as postoperative state or major

trauma shows high fever and abdominal signs, acute acalculous chelecystitis must be

considered as a possible cause, and in that case, early diagnosis with

ultrasonography will reduce postoperative complication and mortality.

[영문]

Acute acalculous cholecystitis is an acute inflammation of the gallbladder, in the absence of stone, and it comprises 4 to 8% of all cases of acute cholecystitis, and it has a tendency to occur after other disease, especially major trauma, burn, or operation.

Typical findings of pain, tenderness, and a mass in RUQ are infrequent, and the diagnosis rests on a high index of suspicion and ultrasonography.

It has the highest mertality and morbidity of all benign conditions affecting the gallbladder, but its incidence is actually increasing due to increasing age of patients, more extensive and invasive therapeutic procedures, prolonged survival of gravely ill patients increasing the chances of initiation of the disease.

Awareness of this disease, knowledge of its clinical features, and early surgical intervention are important facets of successful management.

This study was done to determine the features of acute acalculous cholecystitis and to evaluate our experiences in its management at over the years 1976 to 1986

The results are summarized as follows:

1) Among 1783 patients who needed cholecystectomy due to biliary tract disease,acute cholecystitis was found in 463 patients(26.3%), and acute acalculous cholecystitis comprised 8.9%(41 cases) of all cases of acute cholecystitis.

2) The sex ratio of male to female was 1:1.3, and the age of patients varied from 6 to 81 years, the average age was 50 years.

3) The most common clinical symptoms were RUQ pain which were observed in 35 cases (85.4%), and the most common physical findings were RUQ tenderness which were observed in 37 cases(90.2%).

4) On laboratory examination, leukocytosis was found in 28 cases (68.3%) of all patients, and abnormalities in liver function test were observed in 22 cases (53.7), among them alkaline phosphatase was most prominent.

5) Abdominal ultrasonography was used as important diagnostic method in 23 cases (56.1%), and it revealed accuracy of 82.6%, and other procedures such as oral GB cholangioglaphy, IV cholangiography and ERCP (Endoscopic retrograde cholangiopan-creaticogram) were performed in 3 cases, but not dignostic.

6) Cholecystectomy was used as main procedure in 36 cases(87.8%), and supplemental procedures such as operative cholangiogram, T-tube choledochostomy were performed for passed stone in 31 cases in cholecystectomized patients.

Cholecystostomy was performed in 5 cases(12.2%).

7) Gangrenous changes in gallbladder were observed in 15 cases(36.6%), and 8 cases of perforation were found among them.

8) Possible predisposing factors were observed in 22 cases(53.2%), and arrhythmia was most common among them (14.3%).

9) Acute acalculous cholecystitis developed in postoperative period were 5 cases; 2 cases after non-billary abdominal surgery, 2 cases after orthopedic surgery, 1 case after vascular surgery, and mean duration of symptoms were 19.4 days after operation, possible relationship between first meal after operation and onset of symptoms were observed in two cases.

10) Positive bile cultures were obtained in 20 cases, and E. coli was the most common one (49%), and positive blood cultures were obtained in 7 cases (43.8%), and K.pneumonia was the most common organism.

Positive culture fro both bile juice and blood were observed in 5 cases of 12 cases

11) Salmonella typhi were cultured from bile juice in 4 cases, in addition, two cases of positive Widal test were observed.

12) Postoperative complications were observed in 12 cases (29.3%), and pneumonia was the most common one (58.3%), and postoperative mortality was in 5 cases (12.2%), and main cause of death was sepsis with ARDS.

13) Mean duration symptoms were 8.7 days in patients with uneventful postoperative course, 13.4 days in patient with complicated postoperative course, 16.8 days in mortality cases.

So, if a patient with predisposing factors such as postoperative state or major trauma shows high fever and abdominal signs, acute acalculous chelecystitis must be

considered as a possible cause, and in that case, early diagnosis with ultrasonography will reduce postoperative complication and mortality.