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Liver Abscess Draining into Biliary System

대한외과학회지 1967년 9권 4호 p.223 ~ 229
김무신,
소속 상세정보
김무신 (  ) - 전주예수병원 외과

Abstract


The liver abscess draining into biliary tree was reported as early as in 1928 by Ude Walter " in American Journal of Roetgenology and the other articles were reported by 2´ McDonald, Ian, 11 Berkman J. M., J. A. Bayer and 11 Bower-s R. F. et Barnes Z. B. Jr.
Recently we have encountered 3 consecutive cases of Liver Abscess which was confirmed by operation, and operative cholangiography.
The first case was 51 year old women who came in our P. M. C. Hospital, Chonju, Chulla Puk Do, Korea with right upper quadrant pain and fever for one day´s duration. Pain was colicky but intermittent and not responded by analgesics and chloromycetine which was treated elsewhere.
Past history revealed previous admission 1960 May 31 under the impression of pancreatitis. Physical -examination was not remakable except marked tenderness but no rebound tenderness. Otherwise no abnormalities were noted on physical examination. Surgical exploration revealed moderate distension of gallbladder and common duct, more than 1 cm in diameter. After cholecystectomy, common ,duct was opend and then thick yellow pus came out about 200 cc.
The operative cholangiography (Fig. 1) revealed that cystic cavity on left hepatic duct, about 5X7 ,cm in diameter. Cheledochostomy was carried out and pus was drained satisfactorily, so T-tube was removed at postoperative 14th day. The culture was reported no growth and no organism on smear of gram stain, especially no cyst or trophozoid of E, Histolitica. Postoperative course was uneventful and discharged on 15th postoperative day.
The second case was 57 year old man who came to P. M. C. Hospital with c. c. of right upper -quadrant pain for 5 month duration.
He had experienced R. U. Q. pain for 5 month which was progressively worse for 15 days but afterward symptom was stationary. Past history was not remarkable, especially no history of amebiasis. Physical examination revealed no jaundice but tenderness on R.U.Q., otherwise no abnormalities were noted.
Gallbladder series and Upper G. I. series were not remarkable. So he was treated as gastritis. 6 months after onset of symptom, he returned with marked pain and tenderness on right upper abdomen, without rebound tenderness. Surgical exploration revealed that gall bladder was not enlarged and other abdominal visceras were within normal limits. Common duct was explored but nothing was found. However, operative cholangiogram revealed small cystic dilatation of terminal right hepatic duct 2 X 1 cm in diameter which was connected to common duct (Fig. 2).
Postoperatively fever was running and upper abdominal pain was persisted at postoperative 12th
day, chest X-ray was taken which revealed marked elevation of right diaphragm especially anterior side. Right subphrenic space was explored which revealed nothing in subphrenic space but marked enlargement of right liver and distension of Glisson´s capsule. Peritoneum was opened and fixed to liver surface for marsupialization. Glisson´s capsule opened and then large pus cavity was reached. About 800 c.c. of thick chocolate colored pus came out. 1 inch sized pen-rose drain inserted and procedure terminated. Afterward, pus was continuously drained out via drain. Chloroquine 0.25 gm t. i. d. and tetracycline 1 gm per day were started. Total amount of chloroquine was 15 gm. Pus was ceased and T-tube and drain removed. Culture revealed no growth and no organism on gram stained smear.
The third case was 54 year old man who came in P.M. C. Hospital with chief complaint of right upper quadrant pain for 3 months. Past history was not remarkable.
Physical examination revealed marked tenderness but no rebound tendernss on right upper abdomen. One and three days gall bladder series revealed no dye concentration in gallbladder. After combat anemia and general status, exploration was done which revealed marked distenssion of gall-bladder and common duct and thickening of gallbladder.
Cholecystectomy was carried our and common duct was opened and then profuse amount of thick pus came out. Also mass in the right lobe of liver 10 X 8 cm in diameter was noted, where 800 c. c. of thick chocolate colored pus was aspirated. Operative cholangiography was take which revealed that 6 X 6 cm diametered cystic dilatation in right lobe of liver which was drained to right hepatic duct. (Fig. 3) Postoperative chloroquine and tetracycline started and amounted totally 15 gm of chloroquine. T-tube cholangiography showed interval shrinkage of pus pocket so T-tube was remained in place and discharged. Culture revealed no organism.

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