上腹部痛(Epigastric Pain)シリーズ15 RESIDENT COURSE 解答 【症例 ER 71】

肝嚢胞内出血.Hemorrhage in hepatic cyst




肝嚢胞内にdensityの高い不整な構造物があり(△) ,血腫を形成した嚢胞内出血を強く疑う.図Aの腹部エコー検査では嚢胞内に高輝度の内容物が認められ(▲),翌日の腹部エコー検査で嚢胞の大きさが95×72cmから97×90cmcmに増大し, Hbは入院時14.7g/dl から12.6g/dlに低下し,さらに3日目の腹部エコー検査で高輝度の内容物は消失したので嚢胞内出血の可能性は極めて高い.5日間で腹痛は次第に軽快し消失した.図3〜図5で肝左葉外側区域が萎縮し肝内胆管が拡張している(↑)のは,3回のエコー検査で肝内結石は指摘されていないので,嚢胞による慢性的な圧迫による閉塞または狭窄が原因と解釈する.




参考症例 1(Plain CT.肝嚢胞内出血):56歳女性.多発性嚢胞腎による腎不全がある.血液透析中に急に上腹部痛と背部痛を訴えた.体温:36.0℃,腹部に圧痛や反跳痛はなく軟.↑の嚢胞は他の嚢胞と比較して内容液が高吸収値を示し,嚢胞内出血の可能性が高い.安静のみで症状は消失した.





参考症例 2(肝包虫症(肝エキノコックス症).Intrahepatic hydatid cyst):北海道在住の68歳女性.心窩部に腫瘤(肝臓)を触れ腫大してきたので来院した.手術で肝エキノコックス症と診断された.





文献考察:肝嚢胞性疾患.57例の単純性嚢胞中嚢胞内出血例は2例(3.5%),感染例は1例であった.
J Am Coll Surg. 2001 Jul;193(1):36-45.
Large cystic lesions of the liver in adults: a 15-year experience in a tertiary center.
Regev A, Reddy KR, Berho M, Sleeman D, Levi JU, Livingstone AS, Levi D, Ali U, Molina EG, Schiff ER.

BACKGROUND: Cystic lesions of the liver consist of a heterogeneous group of disorders and may present a diagnostic and therapeutic challenge. Large hepatic cysts tend to be symptomatic and can cause complications more often than smaller ones. STUDY DESIGN: We performed a retrospective review of adults diagnosed with large (> or = 4 cm) hepatic cystic lesions at our center, over a period of 15 years. Polycystic disease and abscesses were not included. RESULTS: Seventy-eight patients were identified. In 57 the lesions were simple cysts, in 8 echinococcal cysts, in 8 hepatobiliary cystadenomas, and in 1 hepatobiliary cystadenocarcinoma. In four patients, the precise diagnosis could not be ascertained. Mean size was 12.1 cm (range, 4 to 30 cm). Most simple cysts were found in women (F:M, 49:8). Bleeding into a cyst (two patients) and infection (one patient) were rare manifestations. Percutaneous aspiration of 28 simple cysts resulted in recurrence in 100% of the cases within 3 weeks to 9 months (mean 4(1/2) months). Forty-eight patients were treated surgically by wide unroofing or resection (laparoscopically in 18), which resulted in low recurrence rates (11% for laparoscopy and 13% for open unroofing). Four of the eight patients with echinococcal cysts were symptomatic. All were treated by open resection after irrigation of the cavity with hypertonic saline. There was no recurrence during a followup period of 2 to 14 years. Hepatobiliary cystadenomas occurred more commonly in women (F:M, 7:1) and in the left hepatic lobe (left:right, 8:0). Seven were multiloculated. All were treated by open resection, with no recurrence, and none had malignant changes. Cystadenocarcinoma was diagnosed in a 77-year-old man, and was treated by left hepatic lobectomy. CONCLUSIONS: Large symptomatic simple cysts invariably recur after percutaneous aspiration. Laparoscopic unroofing can be successfully undertaken, with a low recurrence rate. Open resection after irrigation with hypertonic saline is a safe and effective treatment for echinococcal cysts. Hepatobiliary cystadenomas have predilection for women and for the left hepatic lobe. Malignant transformation is an uncommon but real risk. Open resection is a safe and effective treatment for hepatobiliary cystadenoma, and is associated with a low recurrence rate.PMID: 11442252

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