瀑状胃
Showing posts with label Gastroenterology. Show all posts
Showing posts with label Gastroenterology. Show all posts
Apr 27, 2009
Sep 7, 2008
Sep 3, 2008
PTGBA : percutaneous transhepatic gallbladder aspiration
経皮経肝胆嚢吸引穿刺法（PTGBA : percutaneous transhepatic gallbladder aspiration）
超音波映像下に胆嚢に細径針を穿刺し胆嚢内胆汁を吸引する方法である（図2）。ベッドサイドで簡便に行えレントゲン透視も必要としないためコストもかからず合併症も少ない胆嚢ドレナージ法である。PTGBDに比べてドレナージチューブの管理の必要がないため逸脱などの合併症がなく3)，患者のADLも損なわれないなどの利点を持つが，RCT8) によればドレナージ効果に劣るとされる（表2）。ただし，PTGBAは2回以上行うことによりドレナージ効果がより高くなることが知られており5,7)，PTGBDとの単純なドレナージ効果の比較だけでなく患者ADLなどもアウトカムに含めたRCTによる検証が必要である。
腹腔内への胆汁の漏れを考慮し肝臓を介した穿刺ルートを選択し，超音波映像下に穿刺針の先端を確認しながら胆嚢内容液が十分に吸引され胆嚢が虚脱するまで行う（図2）。18Gの太い穿刺針では炎症性産物や胆砂で粘稠な胆汁を吸引するのに好都合であるが穿刺針抜去後の胆汁の漏れを考慮する必要がある。一方，細径の21G針では抜去後の漏れの恐れは少ないが，粘稠な胆汁では吸引が難しいため抗生物質を混じた生理食塩水で洗浄しながら吸引する必要がある。本邦での報告では21G針が用いられることが多い5,7,8)。
表2 PTGBAとPTGBDの成績の比較
超音波映像下に胆嚢に細径針を穿刺し胆嚢内胆汁を吸引する方法である（図2）。ベッドサイドで簡便に行えレントゲン透視も必要としないためコストもかからず合併症も少ない胆嚢ドレナージ法である。PTGBDに比べてドレナージチューブの管理の必要がないため逸脱などの合併症がなく3)，患者のADLも損なわれないなどの利点を持つが，RCT8) によればドレナージ効果に劣るとされる（表2）。ただし，PTGBAは2回以上行うことによりドレナージ効果がより高くなることが知られており5,7)，PTGBDとの単純なドレナージ効果の比較だけでなく患者ADLなどもアウトカムに含めたRCTによる検証が必要である。
腹腔内への胆汁の漏れを考慮し肝臓を介した穿刺ルートを選択し，超音波映像下に穿刺針の先端を確認しながら胆嚢内容液が十分に吸引され胆嚢が虚脱するまで行う（図2）。18Gの太い穿刺針では炎症性産物や胆砂で粘稠な胆汁を吸引するのに好都合であるが穿刺針抜去後の胆汁の漏れを考慮する必要がある。一方，細径の21G針では抜去後の漏れの恐れは少ないが，粘稠な胆汁では吸引が難しいため抗生物質を混じた生理食塩水で洗浄しながら吸引する必要がある。本邦での報告では21G針が用いられることが多い5,7,8)。
表2 PTGBAとPTGBDの成績の比較
Jul 31, 2008
Xanthogranulomatous cholecystitis
黄色肉芽腫性胆嚢炎
INTRODUCTION — Xanthogranulomatous cholecystitis is a rare inflammatory disease of the gallbladder characterized by a focal or diffuse destructive inflammatory process, with accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic inflammatory cells [1] . In 1970 it was first known by the descriptive term fibroxanthogranulomatous cholecystitis [2] but in 1981 the name xanthogranulomatous cholecystitis was proposed in a review of 40 cases from the Armed Forces Institute of Pathology [3] . Its importance lies in the fact that it is a benign condition that may be confused with carcinoma of the gallbladder, which is associated with a poor prognosis.
Xanthogranulomatous cholecystitis was initially described as a variant of chronic cholecystitis. However, while the latter is usually regarded as a benign condition with questionable clinical significance, xanthogranulomatous cholecystitis is an active and destructive process that can lead to significant morbidity as the inflammatory process usually extends into the gallbladder wall and adjacent structures. Thus, it should be considered a distinct clinical entity.
EPIDEMIOLOGY — The prevalence of xanthogranulomatous cholecystitis among patients with symptomatic gallbladder disease ranges from 0.7 percent in the United States to up to 10 percent in India and Japan [4-8] . The mean age at presentation varies in different studies from 44 to 63 years [4,9] . A study from India reported a 1:9 male to female ratio [4] while in other reports the male to female ratio ranged from 2:1 to 1:2 [3,7,9] .
PATHOGENESIS — The pathogenesis of xanthogranulomatous cholecystitis is thought to be related to extravasation of bile into the gallbladder wall from rupture of Rokitansky-Aschoff sinuses or by mucosal ulceration [3,10] . This event incites an inflammatory reaction in the interstitial tissue whereby fibroblasts and macrophages phagocytose the biliary lipids in bile, such as cholesterol and phospholipids leading to the formation of xanthoma cells.
Gallstones may have an important role in the pathogenesis, since they appear to be present in all patients [4,9,11] . It has been suggested that xanthogranulomatous cholecystitis is analogous to xanthogranulomatous pyelonephritis, which results from obstruction and stasis due to renal calculi [12] .
INTRODUCTION — Xanthogranulomatous cholecystitis is a rare inflammatory disease of the gallbladder characterized by a focal or diffuse destructive inflammatory process, with accumulation of lipid laden macrophages, fibrous tissue, and acute and chronic inflammatory cells [1] . In 1970 it was first known by the descriptive term fibroxanthogranulomatous cholecystitis [2] but in 1981 the name xanthogranulomatous cholecystitis was proposed in a review of 40 cases from the Armed Forces Institute of Pathology [3] . Its importance lies in the fact that it is a benign condition that may be confused with carcinoma of the gallbladder, which is associated with a poor prognosis.
Xanthogranulomatous cholecystitis was initially described as a variant of chronic cholecystitis. However, while the latter is usually regarded as a benign condition with questionable clinical significance, xanthogranulomatous cholecystitis is an active and destructive process that can lead to significant morbidity as the inflammatory process usually extends into the gallbladder wall and adjacent structures. Thus, it should be considered a distinct clinical entity.
EPIDEMIOLOGY — The prevalence of xanthogranulomatous cholecystitis among patients with symptomatic gallbladder disease ranges from 0.7 percent in the United States to up to 10 percent in India and Japan [4-8] . The mean age at presentation varies in different studies from 44 to 63 years [4,9] . A study from India reported a 1:9 male to female ratio [4] while in other reports the male to female ratio ranged from 2:1 to 1:2 [3,7,9] .
PATHOGENESIS — The pathogenesis of xanthogranulomatous cholecystitis is thought to be related to extravasation of bile into the gallbladder wall from rupture of Rokitansky-Aschoff sinuses or by mucosal ulceration [3,10] . This event incites an inflammatory reaction in the interstitial tissue whereby fibroblasts and macrophages phagocytose the biliary lipids in bile, such as cholesterol and phospholipids leading to the formation of xanthoma cells.
Gallstones may have an important role in the pathogenesis, since they appear to be present in all patients [4,9,11] . It has been suggested that xanthogranulomatous cholecystitis is analogous to xanthogranulomatous pyelonephritis, which results from obstruction and stasis due to renal calculi [12] .
Jul 6, 2008
Ogilvie's syndrome
Ogilvie's syndrome
Associated persons:
Sir William Heneage Ogilvie
Intestinal pseudo-obstruction was first described in 1938 by the German surgeon W. Weiss. Weiss reported megaduodenum in 6 persons in 3 generations of a German family. His observation pointed to an inherited subset of intestinal pseudo-obstruction.
Ogilvie in 1948 reported the syndrome in two patients with metastatic cancer and retroperitoneal spread to the celiac plexus. Report of a third case was made by J. Dunlop in 1949. The condition was seen in men aged 56, 58, and 66 years. Large bowel colic was the predominant symptom and was accompanied by constipation, abdominal distension, and progressive loss of weight, but with no evidence of organic obstruction to the intestinal flow. Rupture of the cecum and peritonitis are the most frequent complications. In 1958, Dudley et al used the term pseudo-obstruction to describe the clinical appearance of a mechanical obstruction with no evidence of organic disease during laparotomy.
基礎疾患
Saunders, MD, Kimmey, MB. Systematic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther 2005; 22:917.
Feb 3, 2008
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