17. lieved by cholecystectomy. gradually, but usually fading gradually over many
hours. Thus although the pain was often very severe
Introduction for 2 to 3 hours, the mean total duration of the pain
was 16-0 hours (s.E.M.3-9). In 59% of patients the
107名の胆嚢炎患者の
ONES not causing symptoms are often
ted as the cause of symptoms originating 痛部位(%) there was some
pain was aggravated by Lancet. 197215% 5;2(7771):239-41.
food. In
Aug
relief of pain by alkalis, in a further 11 % by a white
e biliary system. Conversely, the symptoms
mixture which probably contained alkalis, and in 4%
by gallstones may be interpreted as being due
by a vagal paralysant such as propantheline. The pain
RUQの 痛よりも,
elsewhere. Usually the diagnosis of gall-
n be confidently made on the basis of a
実は心窩部の方が多い.
tic history, but symptoms and clinical
ay be atypical and occasionally bizarre and
It is それ以外にも様々な部位で
not easy to gain a comprehensive
the clinical features of gallstones. However,
erformed a痛の最強点を認める
prospective survey of patients
n for gallstones with a follow-up period of
and 2 years.
痛はVery severeが89%.
Methods
2-3hrで増悪し,
ts admitted to one surgical unit at Manchester
rmary between December, 1968, and April,
平均16hr(3.9)持続する.
t for some holiday periods), for the treatment
s were included in the survey. There were a
nd eleven80%に嘔気を伴い, four had
such patients, but since
coincidental pathological conditions such as a
44%は嘔吐後に腹痛が軽快
, they were excluded from the survey. All
re examined preoperatively and followed-up
ely for between 1 and 2 years by one of us
する.
wo patients did not attend follow-up, but one
ed by letter and the other through her daughter.
t had a full preoperative laboratory investiga-
nety-seven patients had an electrocardiogram.
tes were made on operative findings by one
uding operative cholangiographic findings on Fig. 1—Sitesof most severe7pain (%)A’in 107 patients with
gallstones.
18. 痛の放散部位(%) Lancet. 1972 Aug 5;2(7771):239-41.
240
有名なのは右肩甲骨下
部への放散痛.
正中部と合わせると
7割近くは同部位へ放散
Fig. 2-Sites of pain radiation ( % ) in 107 patients with gallstones.
19. BP 130/60, HR 110, RR 22, Sat 98%, BT 38.2
眼球結膜黄染無し.
腹部所見; 心窩部~RUQに圧痛あり. 肝叩打痛(+).
筋性防御無し. 反跳痛無し. Murphy Signは陰性.
特にMassは触れない.
血液検査; WBC 8000, Hg 12.4, PLT 200k,
AST 24, ALT 20, ALP 240, γ-GT 40, Bil 1.0,
Cre 1.0, BUN 22, Na 140, K 3.8, Cl 101. CRP 4.5
22. ERを受診した胆嚢炎疑い患者193名中,189名にエコーを施行.
最初にER residentが施行し, その内125名が技師によるエコーがオーダー.
最終的に26名が胆摘され, その内23名が病理的に胆嚢炎と診断.
ER residentは胆石, US murphy, 壁肥厚(>3mm), 周囲のFluidを評価し,
胆石 + 他どれか1つ陽性で胆嚢炎と診断
Ann Emerg Med 2010;56:114-22
Sn(%) Sp(%) LR(+) LR(-)
全体 bedside US 87[66-97] 82[74-88] 4.7[3.2-6.9] 0.16[0.06-0.46]
Radiology US 83[61-95] 86[77-92] 5.7[3.3-9.8] 0.20[0.08-0.5]
US murphy bedside US 65[43-84] 82[74-88] 3.5[2.2-5.6] 0.43[0.24-0.75]
Radiology US 48[26-70] 96[89-99] 10.5[3.6-30] 0.55[0.36-0.83]
壁肥厚 bedside US 65[43-84] 91[85-95] 7.2[3.9-13] 0.38[0.22-0.67]
Radiology US 59[36-79] 88[79-94] 5.0[2.5-10] 0.46[0.28-0.77]
周囲のFluid bedside US 26[10-48] 94[89-98] 4.6[1.8-12] 0.78[0.61-1]
Radiology US 39[20-62] 94[88-98] 7.0[2.6-19] 0.65[0.46-0.90]
US murphy, 壁肥厚はそれだけで診断に有用.
ただし, どれかが陰性でも除外できない. 全て陰性が大事
23. mal control population included 17
CT Diagnosis Reviewer 1 Reviewer 2 Reviewer 3 Reviewer 4 Combined
n with ages ranging from 19 to 72
2 years). Acute cholecystitis
胆嚢炎のCT所見
Sensitivity 91.7 89.6 91.7
AJR 2002;178:275–281
93.8 91.7
Specificity 100.0 100.0 96.3 100.0 99.1
obtained using helical technique
eed or CTI scanner (General Elec- Accuracy 94.7 93.3 93.3 96.0 94.3
75名(壊疽性胆嚢炎23名, 非壊疽性胆嚢炎25名, 胆嚢炎(-)27名)
ms, Milwaukee, WI). All patients Gangrenous cholecystitis
udy received IV contrast material,
Sensitivity 21.7 39.1 17.4 39.1 29.3
の造影CT所見を4名のReviewerが評価したRetrospective trial.
s of 2 or 3 mL/sec. Slice thickness
Specificity 100.0 100.0 92.0 92.0 96.0
10 mm. In the gangrenous chole-
ce thickness in 16 patients was Accuracy 62.5 70.8 56.3 66.7 64.1
急性胆嚢炎に対する感度91.7%, 特異度99.1%と高いが,
tients was 3 mm, and in two pa-
and 10 mm. In the nongangrenous
壊疽性胆嚢炎に対する感度29.3%, 特異度96.0%程度.
group, slice thickness in 11 pa-
n seven patients was 7 mm, in four Specificity, Sensitivity, and Frequency of CT Findings In Patients with
TABLE 2 Gangrenous Cholecystitis, Nongangrenous Cholecystitis, and Normal
各所見の感度, 特異度.
, and in three patients was 10 mm.
Controls
hout cholecystitis, slice thickness
atients, 5 mm in two patients, and Specificitya Sensitivitya Frequencyb Frequency b Frequencyb
Finding
nt. 壁肥厚, (%) (%) Gangrenous LR(-)
LR(+) Nongangr. Normal
Gas in wall or lumen 100.0 7.6 ∞1 0.9 0 0
胆嚢拡張所見(-)
tation
Intraluminal membranes 99.5 9.8 19.6
3 0.9 0 0
re randomized and retrospectively
Irregular or absent wall 97.6 28.3 11.8
11 0.7 1 1
は除外に有用.
ally by four experienced abdomi-
aware of the pathologic diagnosis. Pericholecystic abscess 96.6 15.2 4.5
4 0.9 0 0
e informed that the cases included Mural striation 89.9 37.0 3.7
5 0.7 4 0
with normal gallbladders, acute un-
Adjacent hepatic enhancement 89.3 27.2 2.5
11 0.8 6 0
壁の2重化,
cystitis, and gangrenous cholecys-
Pericholecystic fluid 87.0 53.3 4.1
8 0.5 2 1
ers were asked to identify the
Gallstones 83.2 47.8 2.8
12 0.6 7 0
不整, 欠損は
ollowing 11 findings: gallbladder
tive assessment), gallbladder wall Pericholecystic Inflammation 72.1 78.3 2.8
21 0.318 0
診断に有用
mm), gallstones, pericholecystic
stic fat stranding (increased soft-
Distention 59.1 88.0 2.2
23 0.221 2
Wall thickening 57.7 88.0 20
2.1 0.223 2
e pericholecystic fat), striated wall