肝右葉にガスで充満した膿瘍がある．図９〜図１１の↑は肝門部に集積した遊離ガスであるのでガス産生性肝膿瘍の破裂と診断するのが常識的である．しかし，肝膿瘍の肝門部側はかなりの厚さの肝組織で肝門部と隔てられており，膿瘍の外側は肝組織が薄く肝表面に近接しているので破裂を起こすとすれば外側へ起こす確率が高いと思われる．図２０の１から十二指腸を逆行性に追跡すると，十二指腸球部と胃幽門部の壁が浮腫性に壁肥厚を呈している．図１１〜図１３で十二指腸前方に液貯留を認め（▲），胃または十二指腸潰瘍の穿孔の可能性も考慮すべきである．図４〜図１０の低吸収域（白矢印）は，中肝静脈（M）が左（L）右（R）肝静脈と比較し細くなっているので，末梢での血栓による閉塞を意味し（次症例EE７０文献参照），図１０〜図１６の△部分は右肝静脈末梢の血栓によるものであろう．経皮経肝的ドレナージ後ショックに陥り，DICを合併し死亡した．オートプシーで十二指腸球部前壁潰瘍穿孔，幽門部非穿孔性胃潰瘍と肝膿瘍を認めた．

参考症例（ガス産生性肝膿瘍穿孔）：78歳女性．糖尿病と高血圧を加療中．前日に悪寒と発熱で発症し，近医受診後胆管炎の疑いで紹介来院した．肝左葉にガス産生性膿瘍があり，遊離ガスを認め（↑）膿瘍の破裂であるが腹水を認めない（画像省略）ので経皮経肝的にドレナージし（図Aと図B）治癒した．膿培養でE．Coliが，血培でBacteroides sp．が検出された．

文献考察１）：チューブを留置するドレナージ法より注射針で穿刺・吸引だけの方が有効である．
Hepatology. 2004 Apr;39(4):932-8.
Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration.
Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, Metreweli C.

This study aims to compare the therapeutic effectiveness of continuous catheter drainage versus intermittent needle aspiration in the percutaneous treatment of pyogenic liver abscesses. Over a 5-year period, 64 consecutive patients with pyogenic liver abscess were treated with intravenous antibiotics (ampicillin, cefuroxime, and metronidazole) and randomized into two percutaneous treatment groups: continuous catheter drainage (with an 8F multi-sidehole pigtail catheter); and intermittent needle aspiration (18G disposable trocar needle). There was no statistically significant difference between the two groups regarding patient demographics, underlying coexisting disease, abscess size, abscess number, number of loculation of abscess, the presenting clinical symptoms such as fever, abdominal pain, and pretreatment liver function test. Although not statistically significant, the duration of intravenous antibiotics treatment before percutaneous treatment was longer with the catheter group, and the change of antibiotics after the sensitivity test was more frequent with the needle group. The needle group was associated with a higher treatment success rate, a shorter duration of hospital stay, and a lower mortality rate, although this did not reach statistical significance. In conclusion, this study suggests that intermittent needle aspiration is probably as effective as continuous catheter drainage for the treatment of pyogenic liver abscess, although further proof with a large-scale study is necessary. Due to the additional advantages of procedure simplicity, patient comfort, and reduced price, needle aspiration deserves to be considered as a first-line drainage approach. PMID: 15057896

文献考察２）：6個のside holeを設けたドレナージ針（図）で膿を効果的に排液できる．
AJR Am J Roentgenol. 2005 Jul;185(1):58-63.
The utility of a drainage needle for percutaneous abscess drainage.
Yu SC.

OBJECTIVE: In this article, I describe a percutaneous drainage needle that consists of six side holes in its cannula. The needle is specially designed for effective evacuation of complex abscess collections consisting of internal solid components, including floating debris, that tend to block the needle aperture during aspiration. The characteristic features of the needle and its performance in both in vitro and in vivo environments are described. MATERIALS AND METHODS: An in vitro experiment was performed with the use of a model of a fluid collection containing floating sheets of gelatin sponge to mimic a complex body collection consisting of floating fibrinous strands. Five radiologists were asked to perform aspiration from two collections of normal saline and 5% methylcellulose of two different volumes using an ordinary aspiration needle and the drainage needle. The needle was evaluated in a prospective in vivo study of 30 postoperative abdominal collections in 29 consecutive patients that were drained by a single radiologist. Complete evacuation was attempted initially with a conventional aspiration needle. When there was sonographic evidence of residual fluid collection, a repeat aspiration using a drainage needle was performed during the same session. RESULTS: In the in vitro experiment, the median percentage of fluid aspirated with the conventional needle from the 10- and 15-mL collections of saline was 10% and 15% and from the 10 mL and 15 mL of methylcellulose solution was 20% and 26.67%, respectively, whereas the drainage needle was able to remove 100% of fluid in all attempts. In the in vivo study, the conventional needle was able to remove all drainable fluid from the 12 simple collections. For the 18 complex collections, the drainage needle was always able to remove some residual fluid from the collection after aspiration with the conventional needle. The median percentage of fluid volume aspirated with the conventional needle was 55.6%, whereas that aspirated with both the conventional and drainage needles was 95.5%, with a significant difference by Wilcoxon's signed rank test (p