文献考察:胆道出血(hemobilia,biliary tract hemorrhage)
1)胆道出血
Author:松川雅也(国立国際医療センター), 林茂樹, 梅田典嗣
Source:日本臨床(0047-1852)別冊肝・胆道系症候群 肝外胆道編 Page187-189(1996.02) 要旨:胆道出血とは”何らかの原因で血管と胆管,または膵管との間に交通が生じ,血液が十二指腸乳頭部に達した状態”をいう.原因疾患は表.
2)D'Angelica M,Fong Y. The Liver:In Townsend's Sabiston Textbook of Surgery.17th ed.2004,page:1561-1562.Elsevier Saunders.Philadelphia. 要旨:1980年以前はhemobiliaの原因は外傷性が最も多く,医原性(肝生検,経皮経肝胆道ドレナージ,その他のIVR)の2倍であったが,最近では医原性が40〜60%を占め最も多い.肝生検後は1%に,経肝胆道ドレナージ後は2〜10%に胆道出血を合併する.次いで多い肝外傷では,0.2〜3%に胆道出血が発生すると言われる.門脈や肝静脈からの胆道内出血はまれで,起こっても少量で自然治癒する場合が多いが,動脈からの出血は輸血を要するほどのmajor hemobiliaとなることもある.初発症状は上腹部痛(胆道疝痛),黄疸と消化管出血(吐下血)が典型的な3徴である.下血は90%,吐血:60%,胆道疝痛:70%,黄疸は60%に出現する.肝外の原因としては外傷,胆石または無石胆嚢炎による胆嚢出血もまれではない.診断は内視鏡検査で乳頭部からの出血を確認すること,または造影CTで胆道内へのextravasationを認めることである.治療は,major hemobiliaは動脈からの出血が多いので血管造影を行い,extravasationを認める部位,動脈瘤の塞栓術(TAE:TransArterial Embolization)を行うが,成功率は80〜100%と高い.
3)222例の考察.最も多い原因は医原性.典型的な3徴を呈するのは22%だけ(図).
Br J Surg. 2001 Jun;88(6):773-86. Haemobilia.
Green MH, Duell RM, Johnson CD, Jamieson NV.
BACKGROUND: This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia. METHOD: A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed. RESULTS: Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent. CONCLUSIONS: Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia. PMID: 11412246
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