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ORIGINAL ARTICLE 중증외상환자에서의급성무결석담낭염의발생 을지대학교의과대학 * 외과학교실, 을지대학교병원권역외상센터 김종범 * ㆍ문윤수 *, ㆍ권오상 *, ㆍ이민구 *, ㆍ박주승 * ㆍ장제호 * Acute Acalculous Cholecystitis in Severe Trauma Patients: A Single Center Experience

1 ORIGINAL ARTICLE 중증외상환자에서의급성무결석담낭염의발생 을지대학교의과대학 * 외과학교실, 을지대학교병원권역외상센터 김종범 * ㆍ문윤수 *, ㆍ권오상 *, ㆍ이민구 *, ㆍ박주승 * ㆍ장제호 * Acute Acalculous Cholecystitis in Severe Trauma Patients: A Single Center Experience Jong Beom Kim, M.D.*, Yun Su Mun, M.D.*,, Oh Sang Kwon, M.D.*,, Min Koo Lee, M.D.*,, Joo Seung Park, M.D.*, Je Ho Jang, M.D.* *Department of Surgery, Eulji University School of Medicine, Trauma Center, Eulji University Hospital, Daejeon, Korea Correspondence to: Yun Su Mun, M.D. Department of Surgery, Eulji University Hospital, 95 Dunsanseo-ro, Seo-gu, Daejeon 35233, Korea Tel: Fax: mdearnest@naver.com Purpose: Early diagnosis and prompt treatment of acute acalculous cholecystitis is important, because it is associated with high mortality. In major trauma patients, besides the direct damage the trauma itself causes, many complications can occur due to trauma. The purpose of this study was to evaluate the prevalence and risk factors for development of acute acalculous cholecystitis in patients with severe traumatic injuries. Methods: In this retrospective study, we reviewed the trauma registry data of 629 major trauma patients (injury severity score>15) of Eulji University Hospital seen between May 2012 and March Of the 629 patients, twelve were diagnosed with acute acalculous cholecystitis. Information collected from the medical record review included demographic data, clinical characteristics, laboratory findings, and diagnostic and therapeutic outcomes. Results: Twelve patients of 629 patients (1.9%) were diagnosed with acute acalculous cholecystitis, and while nine patients survived, three patients died. The clinical and laboratory findings at the initial emergency room visit and at diagnosis of acute acalculous cholecystitis were compared, and there were significant differences in the body temperature (p=0.002), C-reactive protein (CRP) (p=0.002), alkaline phosphatase (ALP) (p=0.008), total bilirubin (p=0.015), and lactate (p=0.046). Conclusion: Early diagnosis and proper treatment is important in acute acalculous cholecystitis after major trauma. If the patients after major trauma have elevated body temperature, lactate, CRP, ALP, and total bilirubin, one should keep in mind of the possibility of acute acalculous cholecystitis. (J Acute Care Surg 2015;5:52-58) Key Words: Acalculous cholecystitis, Wounds and injuries Received June 26, 2015, Revised September 18, 2015, Accepted September 19, 2015 Copyright 2015 by Korean Society of Acute Care Surgery cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN (Print), ISSN (Online) 서론 급성무결석담낭염은오래전부터알려져있으나다양한임상 적상황에서발생하며여러진단방법을평가하는전향적대조군임상시험 (prospective controlled trial) 이없고소수의임상적연구만이존재하기에명확하게질병을정의하기는어렵다. 급성무결 52 J Acute Care Surg Vol. 5 No. 2, October 2015

2 Jong Beom Kim, et al: Acute Acalculous Cholecystitis in Severe Trauma Patients 석담낭염은담석이없이발생하는담낭의급성괴사, 염증성질환이라고정의되며다양한원인에의해발생한다 [1,2]. 급성무결석담낭염은전체급성담낭염의약 10% 를차지하고있으며주로외상, 수술, 화상, 패혈증, 장기간금식, 비경구적영양섭취등중증의환자에서주로발생한다고알려져있다 [2,3]. 급성무결석담낭염은조기에적절한치료를받지않으면높은사망률을보이는질환이기에즉각적인진단과환자에맞춘적절한치료가환자의생명을보호하는데중요하다 [4]. 중증외상환자는외상으로인한높은이환율을보이고많은환자에게서수술적치료가필요하며장기간의금식등여러급성무결석담낭염의위험인자를가지고있는환자이다. 그렇기에이러한중중외상환자에서발생하는급성무결석담낭염의경우기존의심각한외상에더해져서더욱사망률이높아지기에조기에적극적이고적절한치료를해야한다. 이연구는중증외상환자에서발생하는급성무결석담낭염의발생빈도및위험인자, 진단방법, 치료와그에따른결과에대해알아보고자한다. 대상및방법 본연구는 2012년 5월부터 2015년 3월까지을지대학교병원권역외상센터로내원한환자중손상중증점수 (injury severity score, ISS) 가 15점이상인 629명의중증외상환자를대상으로급성무결석담낭염이발생한환자에대한데이터를후향적으로분석하였다. 본연구는을지대학교병원임상시험심사위원회의승인을획득하였다. 중증외상환자의기준은신체를해부학적으로나누어두경부, 안면부, 흉부, 복부, 사지및골반의약식상해등급 (abbreviated injury scale, AIS) 에서가장높은 3곳의제곱의합을구하여 ISS를산출하여 ISS가 15점이상인경우로정의하였다 [5]. 이연구에서의제외기준은수상당시혹은그이전에담낭의기저질환이있는경우로하였다. 중증외상환자의입원기간중우상복부통증또는발열등의증상, 혈액학적이상소견을보여급성무결석담낭염을의심한경우외과, 혹은소화기내과협진을통해복부초음파나복부컴퓨터단층촬영술을시행하여급성무결석담낭염을진단하였다. 진단기준은 Huffman과 Schenker [6] 가제시한두개의주기준을 Table 1. Imaging criteria of acute acalculous cholecystitis Modality Criteria Diagnosis Ultra-sonography Computed tomography Hepato-iminodia cetic acid scan Major 3.5- to 4-mm (or more) thick wall (if at least 5-cm distended longitudinally with no ascites or hypoalbuminemia) Pericholecystic fluid (halo)/subserosal edema Intramural gas Sloughed mucosal membrane Minor Echogenic bile (sludge) Hydrops distension greater than 8-cm longitudinally or 5-cm transversely (with clear fluid) Major 3- to 4-mm wall thickness Pericholecystic fluid Subserosal edema Intramural gas Sloughed mucosa Minor Hyperdense bile (sludge) Subjective distension (hydrops) Nonvisualization of the gallbladder 1 hour after injection of radiolabeledtechnetium (this is RC) Nonvisualization of the gallbladder 30 minutes after injection of morphine (after initial radiolabeled technetium) (this is MC) RC: radionuclide cholescintigraphy, MC: morphine cholescintigraphy. 2 major or 1 major and 2 minor (most studieshave favored the diagnostic triad-wall thickness, sludge, hydrops) 2 major or 1 major and 2 minor RC alone or RC and MC have been used. 53

3 J Acute Care Surg Vol. 5, No. 2, Oct 만족하거나한개의주기준과두개의소기준을만족할경우급성무결석담낭염으로진단하였다 (Table 1). 중증외상환자에서발생한급성무결석담낭염환자들의나이, 성별, 글래스고혼수척도 (Glasgow coma scale, GCS), 동반손상, ISS, 수혈양, 금식기간, 외상으로인한수술시행횟수및종류, 처음응급실에내원한시점과담낭염진단된시점의활력징후및혈액검사를비교분석하였다. 외상발생시점에서부터급성무결석담낭염이진단되기까지의기간, 중환자실및총입원기간, 증상, 진단방법, 치료방법, 치료결과에대해분석하였다. 통계적분석은 PASW Statistics ver (IBM Co., Armonk, NY, USA) 을이용하여분석하였다. 연속형변수의비교는 Wilcoxon signed rank test로분석하였고, p값은 0.05 미만인경우에통계적유의성이있는것으로판단하였다. 결과 2012년 5월부터 2015년 3월까지본원외상센터로내원한 ISS 15 이상의중증외상환자는총 629명이었으며이중 12명 (1.9%) 의환자에서급성무결석담낭염의발생하였다. 이환자들의평균연령은 60.8±16.5세였고, 남성이 8명 (66.7%) 을차지하였다. 외상의원인으로는모두둔상에의한손상이었으며보행자교통사고가 4명, 운전자교통사고 3명, 경운기교통사고 2명, 추락 2명, 오토바이교통사고가 1명순으로손상이발생하였다. 외상초기응급실에서 GCS는평균 11.2±4.2점이었으며 ISS는평균 29.0± 11.7점이고각부위별 AIS를살펴보았을때흉부의 AIS가평균 3.2±0.7점으로가장높게나타났다. 모든환자에서수혈을시행하였으며그중 4명 (33.3%) 의환자에서대량수혈을시행하였고평균수혈양은농축적혈구 24.3±31.7단위였다. 병원에내원하여급성무결석담낭염이진단될때까지기간동안 6명 (50.0%) 의환자에서쇼크상태를경험하였거나쇼크로인하여카테콜아민을사용하였으며 6명 (50.0%) 의환자에서파종혈관내응고소견을보였다. 총 10명 (83.3%) 의환자에서기계적환기를사용하였으며평균금식기간은 12.4±8.2일이었다. 모든환자에서한차례이상의수술을시행하였으며각환자당평균 1.9±0.9회의타장기수술을시행하였다. 동반되어시행한수술중사지수술이 10예 (43.5%) 로가장많이차지하였고흉부와복부수술이각각 4예 (17.4%) 를차지하였다 (Table 2). 중증외상환자가응급실에처음내원하였을당시와급성무결석담낭염이진단되었을당시의혈역학적지표및혈액학적소견을비교하였다. 체온은응급실내원할당시에는 35.9±0.6 o C였으 나급성무결석담낭염진단당시에는 38.2±0.8 o C로통계적으로유의한차이를보였으며 (p=0.002), C-reactive protein (CRP) 은응급실내원할당시에는 0.47±0.92 mg/dl였으나급성무결석담낭염진단당시에는 7.38±3.97 mg/dl로통계적으로유의한차이를보였다 (p=0.002). 간기능검사상 alkaline phosphatase (ALP), total bilirubin은응급실내원할당시에는각각 66.0±24.4 IU/L, 0.59±0.28 mg/dl로급성무결석담낭염진단당시에는각각 187.1±117.4 IU/L, 3.5±6.1 mg/dl로모두통계적으로유의하게차이를보였다 (p=0.008, p=0.015; Table 3). Table 2. Clinical and demographic information of patients (n=12) Characteristic Value Age (y) 60.8±16.5 Sex Male 8 (66.7) Female 4 (33.3) Trauma cause Pedestrian traffic accident Driver traffic accident Cultivator accident Fall down Motorcycle accident 4 (33.3) 3 (25.0) 2 (16.7) 2 (16.7) 1 (8.3) Glasgow coma scale 11.2±4.2 Injury severity score 29.0±11.7 Abbreviated injury scale Head 2.1±1.4 Chest 3.2±0.7 Abdomen 2.4±1.6 Pelvicand extremity 2.3±1.2 Body mass index (kg/m 2 ) 24.0±2.9 Transfusion 12 (100) Massive transfusion 4 (33.3) Number of packed red blood cells (units) 24.3±31.7 Shock or catecholamine use 6 (50.0) Ventilator use 10 (83.3) Day of ventilator use 20.3±17.8 Nulli (non) per os periods (d) 12.4±8.2 Disseminated intravascular coagulation state (antithrombin-iii<70%) 6 (50.0) Number of other operation per one patient 1.9±0.9 Total other operation Extremity operation Chest operation Abdomen operation Spine & pelvic operation Facial operation 23 (100) 10 (43.5) 4 (17.4) 4 (17.4) 3 (13.0) 2 (8.7) Values are presented as mean±standard deviation, number (%), or number only. 54

4 Jong Beom Kim, et al: Acute Acalculous Cholecystitis in Severe Trauma Patients Table 3. Comparisons of clinical and laboratory outcome between the initial and diagnosis periods Initial emergency room visit At diagnosis p-value Systolic blood pressure (mmhg) 101.9± ± Heart rate (beats/min) 90.8± ± Body temperature ( o C) 35.9± ± Hemoglobin (g/dl) 11.2± ± White blood cell (10 3 /μl) 14,748±5,773 13,709±8, C-reactive protein (mg/dl) 0.47± ± Aspartate transaminase (IU/L) 249.1± ± Alanine transaminase (IU/L) 202.1± ± Alkaline phosphatase (IU/L) 66.0± ± Gamm-glutamyltranspeptidase 25.9± ± Total bilirubin (mg/dl) 0.59± ± Lactate (mg/dl) 3.7± ± Values are presented as mean±standard deviation. 중증외상환자의발생시점에서부터급성무결석담낭염의진단및치료결과를살펴보면초기수상이후부터평균 36.5±34.2 일후에발병하였으며, 급성무결석담낭염이발생한환자의평균중환자실체류기간은 26.1±21.4일이었다. 증상은우상복부통증호소가 7명 (58.3%) 으로가장많았으며, 급성무결석담낭염을진단하는방법으로는가장많은 8명 (66.7%) 의환자에서복부컴퓨터단층촬영술만을통해진단하였으며복부초음파만을통해 1명 (8.3%), 복부컴퓨터단층촬영술과복부초음파를동시에사용한경우가 3명 (25.0%) 을각각차지하였다. 급성무결석담낭염의일차적인치료방법으로 1명을제외한 11명 (91.7%) 의환자에서경피담낭조루술 (percutaneous cholecystostomy) 을시행하였고, 이중 6명의환자에서 bilirubin이상승한요인으로용혈, 약제, 간염등을제외하고담도계기원의원인을확인하기위해서담낭조루술도관을이용한담관조영술을시행하였고, 모두에서담도계에특이소견은보이지않았으며, 평균 21.5±11.6일이경과해서경피담낭조루술배액관을제거하였다. 1명의환자에서는담낭염의증상및혈역학적상태가양호하여경피담낭조루술을시행하지않았지만추후경과관찰중시행한복부컴퓨터단층촬영상담도협착소견을보여내시경역행담췌관조영검사를시행하였고, 담도에담즙찌꺼기소견을보여제거하고이후수술을시행하였다. 7명 (58.3%) 의환자에서평균적으로 58.7±67.6일이경과해서간격수술 (interval operation) 을시행하였고, 수술을시행한 7명모두에서복강경담낭절제술을시행하였다. 5명 (41.7%) 의급성무결석담낭염이발병한중증외상환자는기존의심한외상및다른동반질환등으로인한위험성으로최소침습적인치료방법인경피담낭조루술만을이용해치료하였다. Table 4. Diagnostic and therapeutic outcome Variable Total (n=12) Interval between trauma and diagnosis (d) 36.5±34.2 Intensive care unit stay (d) 26.1±21.4 Hospital stay (d) 101.2±70.1 Symptom Abdominal pain Fever Diagnosis modality Computed tomography Ultrasonography Computed tomography+ultrasonography Percutaneous cholecystostomy procedure Period of percutaneous cholecystostomy drainage maintenance (d) Interval period between percutaneous cholecystostomy and operation (d) Treatment modality Operation Laparoscopic cholecystectomy Open cholecystectomy Non-operation (only percutaneous cholecystostomy) 7 (58.3) 8 (66.7) 8 (66.7) 1 (8.3) 3 (25.0) 11 (91.7) 21.5± ± (58.3) 0 (0) 5 (41.7) Outcome Survival 9 (75.0) Expire a) 3 (25.0) Values are presented as mean±standard deviation or number (%). a) Two patients died due to sepsis, one patient died due to brain death. 총 12명의환자중에서 9명 (75.0%) 이생존하였고 3명 (25.0%) 이사망하였으며담낭절제술을시행한환자들중 1명, 수술을시행하지않은환자들중 2명에서사망환자가발생하였다 (Table 4). 55

5 J Acute Care Surg Vol. 5, No. 2, Oct 고찰 본연구를통해 ISS 15점이상의중증외상환자 629명중 1.9% 인 12명에서급성무결석담낭염이발생한것을확인하였다. 외상후발생하는급성무결석담낭염의발생빈도는 % 의빈도로보고되고있으며그중 Hamp 등 [7] 의연구에서는본연구와중증외상환자의기준에차이는있지만 2,625명중 2.0% 인 53명에서무결석담낭염이발생하는것을보여주고있어본연구와큰차이는보이지않음을알수있었다. 급성무결석담낭염의발생의위험요인으로는외상, 수술, 화상, 패혈증, 장기간금식, 비경구적영양요법, 수혈, 장기간의인공호흡기치료, 높은손상중증도점수등이보고되어있다 [2,3,8]. 본연구에서외상환자의중증도를평가하는 ISS가평균 29.0± 11.7점이었으며모든환자에서수혈을시행하였고그중 33.3% 인 4명의환자에서대량수혈을시행하였다. 전체환자중 50.0% 인 6명의환자에서입원기간중쇼크상태를경험하였거나카테콜아민을사용하였고초기수상이후부터평균적으로 12.4±8.2일의금식을진행하였다. 이러한요인들이종합적으로본연구의중증외상환자들에게급성무결석담낭염의원인이되었다고판단할수있다. 또한급성무결석담낭염의발생의병태생리가내장관류저하 (visceral hypoperfusion), 허혈 (ischemia), 재관류손상 (reperfusion injury) 과담즙정체 (bile stasis) 로알려져있는데 [9]. 본연구에서모든환자에서수혈을시행하였다는것과쇼크상태이거나카테콜아민을사용한환자가 50.0% 인 6명이라는상황을봤을때, 이는본연구의환자들에게수혈이필요할정도의쇼크상태가발생하여내장관류저하, 허혈, 재관류손상이라는상황을유발하여무결석담낭염의발생에영향을주었다고판단된다. 그리고본연구에서환자들의평균 12.4±8.2일의금식기간이환자들에게담즙정체를유발하여급성무결석담낭염발생의또다른원인이되었다고판단할수있다. 급성담낭염환자에서전형적으로나타나는우상복부통증, 고열, 백혈수증가및간기능이상등의소견이외상환자에서발생하는급성무결석담낭염에서는명확히나타나지않을수있는데 [2,10], 본연구에서도진단당시발열및복통이각각 66.7%, 58.3% 의환자에게서만나타났다 (Table 4). 급성무결석담낭염의진단이늦어질경우담낭의허혈및천공이급속하게발전할수있기에 [11] 중증외상환자에서는비전형적인발열, 백혈구증가, 간기능검사의이상소견이보일경우하나의임상양상으로고려해야한다. 중증외상환자의치료기간중전신염증반응 증후군, 상세불명열, 특별한원인이없는패혈증이발생할경우급성무결석담낭염의발생을염두에두며진단을위해노력해야한다. 본연구에서급성무결석담낭염을진단받은환자들이담낭염진단당시와수상후응급실에처음내원하였을상황과비교했을때는체온, CRP, ALP, total bilirubin, lactate에서통계적으로유의한차이를보였다 (Table 3). Peng 등 [12] 의연구에서일반적인담낭염환자에서는총담관결석이동반되었을때 bilirubin, ALT, ALP, r-glutamyl transpeptidase (r-gtp) 등이더상승할수있다고말하는데, 이것은총담관결석이동반되지않은일반적인담낭염에서는 bilirubin, ALT, ALP, r-gtp 가더상승하지않는다는것을의미한다. 이러한연구에비해, Owen과 Jain [2] 의연구에서는급성무결석담낭염은결석담낭염과는다르게그자체로도 ALP, aminotransferase, bilirubin 등이상승할수있다고말하고있었다. 그렇기에본연구에서 ALP, total bilirubin의상승은담관조영술과내시경역행담췌관조영검사에서담관결석이진단된환자가없었던것처럼총담관결석이동반되어상승한것이아니라급성무결석담낭염에그자체에의한영향일것이라볼수있다. 중증외상환자에서발생한급성무결석담낭염의진단적검사로는초음파, 컴퓨터단층촬영술, hepato-iminodiacetic acid scan 등이있으나결석담낭염에비하여진단율이떨어지고, 이중복부초음파나복부컴퓨터단층촬영술의진단기준으로는담낭벽의비후 (3 4 mm 이상 ), 담낭주위의체액저류, 장막하층의부종등이있으나이는반드시모든환자에서나타나는것이아니라비특이적으로나타날수도있다 [13,14]. 중증외상환자의경우중환자실에서주로치료를하며기계적환기를비롯하여여러기구및장소의제약으로인해검사의제약이있어상황에따라초음파나컴퓨터단층촬영술을통해검사를통해진단을해야한다. 본연구에서는총 11명 (91.7%) 의환자에서복부컴퓨터단층촬영술을시행하였는데이는본연구에서급성무결석담낭염이발생한환자중 9명 (75%) 의환자에서뇌손상을동반하고있는것과같이, 일반적인중증외상환자에서는동반된뇌손상을비롯한타장기손상, 진통제의투여및기계적환기로인해환자본인이명확한증상의표현이어려울수있으며발열및복통이또한나타나지않는비전형적인환자들많은상황에서, 전형적인급성무결석담낭염의증상이나타나지않는상세불명의열이나패혈증을유발한원인을찾기위해복부의전반적인평가를위한검사로서초음파보다컴퓨터단층촬영술을시행하였다고판단된다. 급성무결석담낭염치료의가장확실한방법은가능하다면 56

6 Jong Beom Kim, et al: Acute Acalculous Cholecystitis in Severe Trauma Patients 담낭절제술을시행하는것이다 [2,15-17]. 하지만주로본연구의대상군이되는환자들처럼혈역학적으로안정되지않은중환자들의경우에는경피담낭조루술을시행해담낭의감압을하고, 감염된담즙을배액시킴으로써담낭절제술을고려하기전에환자에게급성기에서회복하는시간을줄수있다 [15-17]. 물론급성무결석담낭염에서도담낭출구의만성적인폐색을보이지않는경우와괴저담낭염으로진행하는경과에서담낭벽에괴사가없는상황이라면경피담낭조루술만으로도기존의심한외상및다른동반질환등으로인한위험성을가진환자들에게는충분한치료가될수있을것이고 [15], 85 90% 의무결석담낭염환자가담낭조루술만으로도조절될수있다고도알려져있다 [18,19]. 본연구에서는 1명에서경피담낭조루술을시행하지않고, 담낭절제술을시행하였고, 나머지 11명 (91.7%) 의환자에서는경피담낭조루술을통해우선적으로담낭염의염증을호전시켰으며그중 6명의환자에서는이후간격수술로담낭절제술을시행하였는데, 모두복강경담낭절제술이시행되었다. 이는다른일반적참고문헌들의급성담낭염의 6 35% 의개복전환비율보다낮은비율로경피담낭조루술이후간격수술의효과를추정할수있었다 [20]. 5명 (41.7%) 의환자에는경피담낭조루술을우선적으로시행한이후에이것만으로환자의상태가호전을보인경우, 다른동반손상및질환등으로인한높은전신마취의위험성으로경피담낭조루술만시행한경우, 그리고환자의상태가악화되어사망하게된경우들이포함되었다. 담낭조루술배액관은평균적으로 21.5±11.6 일이경과해서제거하였고, 이후수술은평균적으로58.7±67.6 일이경과해서진행하였는데, 이는급성기로부터회복까지의시간을위해지연한목적과환자에따라서는퇴원후재입원하여간격수술을받은경우도있었기때문이다. 12명중 3명 (25%) 의환자가사망하였는데담낭절제술을시행한환자들중 1명, 수술을시행하지않은환자들중패혈증과중증뇌손상으로각각 1명의사망환자가발생하였다 (Table 4). 담낭절제술을시행한후사망한환자의경우급성무결석담낭염은경피담낭조루술과담낭절제술을통해치료하였으나회음부에발생한욕창이괴사성근막염으로진행하여패혈증으로사망하였다. 본연구는중증외상환자중급성무결석담낭염이발생한환자에대해서만후향적으로분석하였고, 연구대상환자수가적으며, 다른동반손상이많아치료방법선택의제한이있기에본연구를통해중증외상환자에서발생한급성무결석담낭염환자의치료방법등에대한결론을내리는것에한계가있을것으로추후 중증외상환자에대한대규모의전향적인연구를통한급성무결석담낭염이발생한환자군과발생하지않은환자군에대한비교연구와치료방법에대한다방면의접근을통해급성무결석담낭염의발생, 병태생리및치료경과등을확인하는데도움을얻을 수있을것이다. 중증외상환자의치료기간중복통, 발열, lactate 상승, CRP 및간기능수치가상승하는경우급성무결석담낭염에대한가능성을염두에두고이를진단하고조기에치료하기위한노력을해야할것이고, 중증외상환자의치료과정에서는항상급성무결석담낭염뿐만아니라기존의심각한외상과동반되어나타날수있는다른심각한질환들에대해서도항상경각심을가지고치료를해야할것이다. References 1. Barie PS, Eachempati SR. Acute acalculous cholecystitis. Curr Gastroenterol Rep 2003;5: Owen CC, Jain R. Acute acalculous cholecystitis. Curr Treat Options Gastroenterol 2005;8: McChesney JA, Northup PG, Bickston SJ. Acute acalculous cholecystitis associated with systemic sepsis and visceral arterial hypoperfusion: a case series and review of pathophysiology. Dig Dis Sci 2003;48: Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. Am Surg 1998;64: Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: which scoring system? Injury 2004;35: Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol 2010;8: Hamp T, Fridrich P, Mauritz W, Hamid L, Pelinka LE. Cholecystitis after trauma. J Trauma 2009;66: Raunest J, Imhof M, Rauen U, Ohmann C, Thon KP, Bürrig KF. Acute cholecystitis: a complication in severely injured intensive care patients. J Trauma 1992;32: Laurila JJ, Ala-Kokko TI, Laurila PA, Saarnio J, Koivukangas V, Syrjälä H, et al. Histopathology of acute acalculous cholecystitis in critically ill patients. Histopathology 2005;47: Laurila J, Laurila PA, Saarnio J, Koivukangas V, Syrjälä H, Ala-Kokko TI. Organ system dysfunction following open cholecystectomy for acute acalculous cholecystitis in critically ill patients. Acta Anaesthesiol Scand 2006;50: Orlando R 3rd, Gleason E, Drezner AD. Acute acalculous cholecystitis in the critically ill patient. Am J Surg 1983;145: Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg 2005;92: Mirvis SE, Vainright JR, Nelson AW, Johnston GS, Shorr R, 57

7 J Acute Care Surg Vol. 5, No. 2, Oct Rodriguez A, et al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR Am J Roentgenol 1986;147: Mirvis SE, Whitley NO, Miller JW. CT diagnosis of acalculous cholecystitis. J Comput Assist Tomogr 1987;11: Jarnagin WR. Blumgart's surgery of the liver, pancreas and biliary tract. 5th ed. Philadelphia: Elsevier Saunders; p Granlund A, Karlson BM, Elvin A, Rasmussen I. Ultrasoundguided percutaneous cholecystostomy in high-risk surgical patients. Langenbecks Arch Surg 2001;386: Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999;134:727-31; discussion Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol 2002;43: Lee MJ, Saini S, Brink JA, Hahn PF, Simeone JF, Morrison MC, et al. Treatment of critically ill patients with sepsis of unknown cause: value of percutaneous cholecystostomy. AJR Am J Roentgenol 1991;156: Berber E, Engle KL, String A, Garland AM, Chang G, Macho J, et al. Selective use of tube cholecystostomy with interval laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 2000;135:

노영남

노영남 Purpose: Delayed massive hemorrhages from pseudoaneurysm rupture of the peripancreatic large arteries, after pancreaticoduodenectomy, are fatal. We reviewed the clinical course and outcome of bleeding