Kwang Choon Lee

Mirizzi Syndrome Caused by Xanthogranulomatous Cholecystitis: Report of a case

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. In severe cases, inflammation extends to adjacent structures, and XGC is sometimes confused with a malignant neoplasm. We recently diagnosed XGC as the preoperative cause of Mirizzi syndrome in a patient based on the clinical course. The patient was admitted because of obstructive jaundice, with gallbladder carcinoma as the suspected cause. The gallbladder was swollen with gallstones and the serum level of carbohydrate antigen 19-9 (CA19-9) was 3070 U/ml at admission. A percutaneous transhepatic cholangiodrainage (PTCD) was done, and the common hepatic duct as well as the right and left hepatic ducts were found to be obstructed. Later, the CA19-9 level and swelling of the gallbladder decreased and the obstruction of the bile ducts disappeared. A cholecystectomy was performed and the intraoperative pathohistological diagnosis of chronic cholecystitis was made from frozen sections. The pathohistological diagnosis of XGC was made from paraffin-embedded sections. Mirizzi syndrome such as that seen in our patient is a rare complication of XGC. XGC occassionally causes extensive inflammation; thus, performing a conventional cholecystectomy can be unsafe. However, in our opinion, a total, not subtotal, cholecystectomy should be done whenever possible because the incidence of gallbladder carcinoma accompanied with XGC is higher than that with ordinary cholecystitis or gallstones.

ANALYSIS OF 69 PATIENTS WITH AMEBIC LIVER ABSCESS

All 69 patients with amebic liver abscess that we treated in 1981–1992 were studied retrospectively. Men predominated by a 10∶1 ratio. Of our 227 patients with amebiasis, some 30% yearly had liver involvement. The incidence peaked in 1988, decreasing later but increasing again in 1992. Most patients were 30–50 years old, the overall mean age being 45 years (range, 22–79), and decreasing with time. Patients with the related factors of travel abroad, positive results of a test forTreponema pallidum hemagglutination, and homosexuality have increased in number in recent years. Fever, abdominal pain, and hepatomegaly were the most frequent findings, and 39 patients had neither bloody stools nor diarrhea. Only 8 patients had had amebiasis previously. A solitary abscess in the right lobe of the liver was found in 40 patients.Eniamoeba histolytica was found in the stool of 31 patients and in the pus of 39 patients. Sixty-one patients had positive results for an amebic serological test(s). The abscesses ruptured into the peritoneal cavity in 4 patients. All patients received metronidazole. Percutaneous or surgical drainage (or both) was done in 62 patients. The outcome was good, with 1 exception, and only 2 patients had recurrences.

A Case of Intrahepatic Pure Cholesterol Stones Localized in the Caudate Lobe.

症例は胆嚢摘出術の既往を有する65歳の男性.肝膿瘍を繰り返すため胆道疾患の合併を疑い入院した.精査の結果, 総胆管結石症の他に早期胃癌を偶然発見し, 総胆管切開, 切石術と胃亜全摘術を施行した.その際尾状葉の肉眼所見, 術中胆道造影および超音波検査により尾状葉に限局する原発性肝内結石症を発見したため尾状葉切除術も追加した.結石成分は肝内・総胆管内ともコレステロール100%であった.尾状葉に限局する肝内結石症はまれな疾患であり, 術前診断は困難であったが, 尾状葉胆管の拡張と結石充満を反映する索状低吸収域を術前のCT像上看過していたことが判明した.一方, 術中超音波検査は簡便で結石の描出能に優れ, 部位診断にも有用であるため, 肝内病変の疑われる症例には励行されるべきである.

A case of hepatocellular carcinoma with a huge portal-systemic shunt via the inferior mesenteric vein and liver cirrhosis.

巨大な門脈下大静脈短絡路を有する肝硬変併存肝細胞癌の切除例を経験した.経皮経肝門脈造影像上,傍食道静脈への側副血行路は存在しなかったが,拡張蛇行した下腸間膜静脈から下大静脈への側副血行路が確認され,大部分の門脈血は遠肝性に逆流していた.門脈圧は26cmH2Oで,ICGR15値32.6%,血中アンモニア値141μg/dlと高値を示していたが,肝性脳症の既往はなかった.術中,電磁流量計を用いて門脈および下腸間膜静脈の血流を測定するとともに,S5亜区域切除を施行したが,側副血行路の遮断は行わなかった.術後,血中アンモニア値は上昇せず,肝性脳症の発症および食道静脈瘤の進展もみていない.以上より,巨大な側副血行路を有する肝硬変併存肝細胞癌症例の手術に際して,シャント遮断による門脈圧の亢進ひいては他の側副血行路の増悪も考慮し,肝性脳症や消化管出血の既往がなければ,肝切除のみでもよいと考えられる.

Hyperthyroidism associated with adenomatous goiter in an infant

We operated on a 5-year-old girl with adenomatous goiter and hyperthyroidism. Since the age of 6 months, the patient had had delayed growth and a large goiter; the serum level of thyroid iodine was high, and the diagnosis of hyperthyroidism was made. Treatment with propylthiouracil (PTU) was started. Circulating thyrotropin receptor antibody and long-acting thyroid stimulator were not detected. The patient continued to require PTU to remain euthyroid. When she was 5, the goiter was enlarged, and subtotal thyroidectomy was done. The diagnosis of adenomatous goiter was made. The postoperative course was uneventful. Two years after the operation, the patient remains euthyroid without medication.

Case of hepatocellular carcinoma with splenic and portal vein thrombosis treated by TAE.

症例は50歳,男性.発熱及び腹痛を主訴として当科受診.血清AFP値は62,100ng/mlと高値を呈し,各種画像診断法により脾転移および門脈本幹内腫瘍栓合併肝細胞癌と診断.oneshot動注療法を行ったが腫瘍の増大と脾静脈内腫瘍栓を認めたため,2回のTAEを施したところ著明な抗腫瘍効果が得られた.肝細胞癌の脾転移は稀であり,また脾静脈内腫瘍栓の報告例はない.原発巣のみならず転移巣においてもその輪出血管に腫瘍塞栓がみられたことは,腫瘍塞栓の形成機転を考える上で興味深い.またTAEが奏功したことより,脾転移巣および脾静脈内腫瘍栓は動脈により栄養されていると考えられた.進行肝癌に対するTAEの適応については論議のあるところであるが,本症例はその適応を考慮すれば,TAEが安全に且つ有効に行いうることを示唆するものと考えられる.