図５〜図１０の▲はガスを含む肝膿瘍である．図７〜図１５で遊離ガスを認め（↑），図９〜図１２で右側に腹水があり（※），ガス産生性肝膿瘍の破裂である．腹腔鏡下膿瘍開窓術を施行し治癒した．膿培養でKlebsiella pneumoniae が検出された．

参考症例（肝膿瘍破裂）：62歳男性．4日前からの右上腹部痛と発熱のため来院．体温：38.1℃，右上腹部に圧痛がある．図１〜図５が来院時のCT．低吸収値の肝病変は腹部エコー所見でも肝膿瘍を示唆し，膿瘍と思われる．抗生剤CEZとCLDMで保存的治療を開始した．図６〜図１５は3日後のCT．膿瘍は巨大となり，周囲に腹水を伴い（※）破裂を強く疑う．腹腔鏡下にS6下部での膿瘍穿孔を確認し，ドレナージを施行した．膿培養：陰性．血清アメーバ抗体が100倍以上で，1年前中国への旅行歴がありアメーバ膿瘍の可能性が極めて高い．3週間で治癒した．

文献考察１）：肝膿瘍破裂例の本邦集計24例中20例はKlebsiella pneumoniaeが起炎菌であった．
肝膿瘍破裂による汎発性腹膜炎の1例
　 Author：奥田勝裕(刈谷総合病院 外科), 榊原堅式, 辻秀樹, 斉藤雄史, 三井章, 西脇忠
　 Source：日本臨床外科学会雑誌(1345-2843)65巻8号 Page2251-2254(2004.08)
　 Abstract：症例は73歳,男性.腹痛を主訴に来院し,汎発性腹膜炎の診断で入院となった.入院時腹部全体に腹膜刺激症状を認め,白血球2,100/μl,CRP 38mg/dl.CT検査にて,肝臓のS8領域に直径6cm大で不均一に造影される低吸収領域,および小腸イレウス像を認めた.腹腔内遊離ガス像や絞扼所見はなく,肝の低吸収領域にもガス像は認めなかった.入院当日,開腹手術を施行.肝膿瘍破裂による腹膜炎と診断し,腹腔内洗浄・ドレナージ術を施行した.起炎菌はKlebsiella pneumoniaeであった.術後膿瘍腔は漸次縮小し,術後32日目に退院となった.細菌性肝膿瘍の腹腔内穿孔は稀であり,過去5年間本邦の報告例は10例をみるに過ぎなかった(著者抄録)

文献考察２）：肝膿瘍424例中穿孔例は23例．60.9%に糖尿病が基礎にあり，65.2%が特発性，起炎菌はKlebsiella pneumoniaeが最も多く43.5％．手術が唯一の治療法である．
Am J Gastroenterol. 1995 May;90(5):767-70.
Rupture of pyogenic liver abscess.
Chou FF, Sheen-Chen SM, Lee TY.

OBJECTIVE: Our objective was to study the clinical manifestations, course, treatment, and results obtained in 23 patients with ruptured pyogenic liver abscess and compare these findings with those of nonruptured cases. METHODS: Four hundred twenty-four patients with clinical diagnoses of pyogenic liver abscess were enrolled in the study. Among these, 23 patients had ruptured pyogenic liver abscess. The clinical manifestations, incidence of septic shock, laboratory findings, concurrent diabetes mellitus, etiology of abscess, and results of the treatment were recorded. Qualitative data were analyzed by chi 2 test, and quantitative data were analyzed by Student's t test. RESULTS: Except for abdominal pain and septic shock, other symptoms, such as fever, chills, and jaundice, were similar in ruptured and nonruptured groups. Laboratory findings indicated that the group with ruptured liver abscess had higher levels of bilirubin, blood glucose, and aspartate aminotransferase than the non-ruptured group. Of the patients with ruptured abscess, 14 (60.9%) had diabetes mellitus and 15 (65.2%) were cryptogenic. Klebsiella pneumoniae was the bacteria most often isolated in both blood cultures and liver aspirates. Surgical intervention--draining the abscess and cleaning the abdominal cavity--was the only means of saving the patients' lives. The overall mortality rate was higher in this group (43.5%) than in the nonruptured group (15.5%). CONCLUSIONS: Ruptured pyogenic liver abscess should be suspected if septic shock and diffuse abdominal pain are found in a patient with pyogenic liver abscess, concurrent with high levels of bilirubin, aspartate aminotransferase, and blood glucose. Surgery is the only treatment for this condition.PMID: 7733086

文献考察３）：Klebsiella pneumoniaeによる肝膿瘍140例中，8例（5.7%）が穿孔で来院した．破裂例は非破裂例と比べて基礎に糖尿病があり（100％），膿瘍のサイズが大きく，ガス産生性で（87.5％），左葉に多い．
Diagn Microbiol Infect Dis. 2005 Jun;52(2):79-84.
Risk factors for spontaneous rupture of liver abscess caused by Klebsiella pneumoniae.
Lee CH, Leu HS, Wu TS, Su LH, Liu JW.

To identify risk factors for spontaneous rupture of liver abscess (SRLA), a retrospective study on patients with liver abscess caused by Klebsiella pneumoniae was performed. Of the 140 enrolled patients with liver abscess caused by K. pneumoniae, 8 (5.7%) experienced SRLA. In comparison to those with nonruptured liver abscess (NRLA), patients with SRLA were found to have significantly higher proportions of diabetic mellitus (100% versus 62.1%, P = 0.003), larger abscess size (mean of maximal diameter 7.8 versus 6.1 cm, P = 0.043), gas formation in abscess (87.5% versus 23.5%, P