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1 대한응급의학회지제 25 권제 6 호 Volume 25, Number 6, December, 2014 Medical 화농성간농양환자의임상적특성및패혈성쇼크의예측인자 원 저 울산대학교의과대학서울아산병원응급의학교실 선 이윤선 김윤정 고벽성 신 손창환 서동우 김원영 임경수 Clinical Characteristics and Predictive Factors of Septic Shock in Patients with Pyogenic Liver Abscess Sun Kim, M.D., Yoon-Seon Lee, M.D., Ph.D., Youn Jung Kim, M.D., Byuk Sung Ko, M.D., Shin Ahn, M.D., Chang-Hwan Sohn, M.D., Dong-Woo Seo, M.D., Ph.D., Won Young Kim, M.D., Ph.D., Kyoung- Soo Lim, M.D., Ph.D. (p<0.05). In multivariate analysis, systolic BP <90 mmhg (OR 95.79, 95% CI: ), BT 38 C (OR 1.95, ), BUN (OR 1.03, ), ALP (OR 1.003, ), and abscess size 5 cm (OR 2.31, ) were independent predictors of septic shock. Conclusion: Low systolic BP, high BT, elevated BUN and ALP, and abscess size 5 cm were independently associated with septic shock in patients with pyogenic liver abscess. Purpose: The aim of this study was to describe clinical, biochemical, and radiologic features in patients with pyogenic liver abscess and to investigate predictors of septic shock. Methods: We consecutively included subjects who were diagnosed as pyogenic liver abscess in the emergency department (ED) from January 1st, 2010 to June 30th, Through review of medical records, clinical, biochemical, and radiologic data were collected. The primary endpoint was septic shock during hospitalization. Results: A total of 228 patients were included, with a mean age of 60.8±12.8 years, and 63.2% were men. Among them, 198 patients presented with fever and GCS <15 was observed in 15. Klebsiella spp. was most commonly identified in 33.8%, followed by E. coli and Streptococci spp. in 7% for each. Septic shock occurred in 55 (22.4%) and mortality rate was 1.3%. In univariable logistic regression, GCS <15, systolic BP <90 mmhg, pulse rate 120/min, respiratory rate 22/min, body temperature (BT) 38 C, WBC, platelet, BUN, creatinine, albumin, AST, alkaline phosphatase (ALP), C- reactive protein (CRP), abscess size 5 cm, and bilobal involvement were significantly associated with septic shock 책임저자 : 이윤선서울특별시송파구올림픽로 43길 88 울산대학교의과대학서울아산병원응급의학과 Tel: 02) , Fax: 02) ysdoc@amc.seoul.kr 접수일 : 2014년 7월 25일, 1차교정일 : 2014년 7월 28일게재승인일 : 2014년 9월 25일 660 Key Words: Pyogenic liver abscess, Septic shock, Prediction Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Article Summary What is already known in the previous study Pyogenic liver abscess is a serious health problem and is associated with poor prognosis. Despite advances in therapeutic modalities, the mortality remains within the range of 10~40%. What is new in the current study Low systolic BP, high BT, elevated BUN and ALP, and abscess size 5 cm were independently associated with septic shock in patients with pyogenic liver abscess. 서 화농성간농양은비교적드문질환이지만, 우리나라를포함한아시아국가에서는서양국가들에비해비교적발생률이높은것으로알려져있다. 캐나다, 미국, 또는덴마크등의서양국가들에서화농성간농양이인구 10만명당 1.1에서 2.3명정도의낮은발생률을보이는반면, 대만에서는이보다높은 17.6명으로조사되었다 1-3). 그러나최근미국인구기반조사에의하면, 미국에서화농성간농양의발생이꾸준히증가하는추세를보이고있다. 과거에는수 론

2 선외 : 화농성간농양환자의임상적특성및패혈성쇼크의예측인자 / 661 술적치료가많이시행되었으나, 최근에는광범위항생제치료와더불어경피적배액술 (percutaneous transhepatic drainage) 과같은덜침습적인치료법이효과적으로널리사용되고있다. 이러한치료법의발달과함께화농성간농양환자의사망률은꾸준히감소하고있으나최근보고들에의하면 6~18% 로여전히높게보고되고있다 4-6). 이러한화농성간농양의높은치사율에도불구하고예후와관련된인자들에대한연구는국내외적으로매우부족한현실이고, 특히국내에서화농성간농양에관한연구는증례보고가대부분을차지하고있다. 이에저자들은일개대학병원응급실에서최근경험한화농성간농양환자들에서임상적, 생화학적, 방사선학적특징을조사하고, 이러한초기임상적특징중패혈성쇼크를예측하는인자들을밝히고자하였다. 대상과방법 1. 대상이연구는후향적연구로서 2010년 1월부터 2013년 6 월까지서울아산병원응급의료센터를방문한 18세이상의성인환자중화농성간농양을진단받았던환자들을대상으로하였다. 화농성간농양의진단은전산화단층촬영에서간내에공간점유병소가관찰되고, 혈액또는농양배양에서균이동정된경우또는항생제치료를통해전산화단층촬영에서관찰되었던간내병소가완전히치료된경우로하였다. 외부병원에서화농성간농양진단하에항생제치료중본센터로전원이된환자는연구대상에서제외하였다. 망 ) 도함께분석하였다. 패혈성쇼크는 International Sepsis Definitions Conference criteria에따라 1) 수축기혈압 <90 mmhg, 2) 평균동맥압 <60 mmhg, 또는 3) 적절한수액치료에도불구하고수축기혈압이기준보다 40 mmhg 이상감소한경우로정의하였다 8). 급성신부전은 RIFLE criteria에따라 1) 혈청 creatinine의 3배증가, 2) 사구체여과율 (GFR) 의 75% 감소, 3) 소변량감소 (24시간동안 0.3 ml/kg/hr 미만또는 12시간동안무뇨증 ) 로정의하였고, 급성호흡부전은 1) PaO 2 <60 mmhg 또는 2) PaCO 2 >50 mmhg로정의하였다 9,10). 3. 통계연속변수는평균과표준편차로표현하였고, 명목변수에대해서는빈도와백분율로표현하였다. 변수의통계적검정은연속변수에대해독립 t-검정을이용하였고, 명목변수는카이제곱검정을사용하였다. 패혈성쇼크에대한예측인자분석을위해로지스틱회귀분석을사용하였고, odds ratio (OR) 와 95% 신뢰구간 (confidence interval, CI) 을측정하였다. 단변량로지스틱회귀분석에서 p값이 0.1미만인인자들을대상으로후진제거법을이용하여다변량회귀분석을시행하였다. 통계분석을위해 SPSS version 20.0 (SPSS Inc., Chicago, IL, USA) 을이용하였고, p값이 0.05 미만인경우를통계적으로유의성이있는것으로해석하였다. 조사되지않은항목에대해서는결측값으로처리하였고, 수집한데이터의결측값은모두 5% 미만이었다. 결과 2. 방법 1. 대상환자의역학적및임상적특성 (Table 1) 대상환자의의무기록을통하여나이, 성별, 병력 ( 발열, 복통, 식욕부진, 구역또는구토, 피로감등 ), 내원시활력징후, 기저질환 ( 당뇨, 만성간염, 만성신질환, 간세포암, 담도암등 ), 일반혈액검사, 생화학검사, C-반응단백질 (C-reactive protein, CRP), 방사선학적특징및치료등을조사하였다. 이와함께혈액및농양배양검사결과를수집하였다. 동정된균의오염여부에대해서균의종류, 양성인배양세트의수, 동정된균의양등을고려하여판단하였다 7). 방사선학적특징으로응급의료센터내원후 24 시간이내에시행한전산화단층촬영에서간농양의크기, 병소의갯수, 병변의범위등을조사하였고, 치료에서간농양에대한경피적배농술또는수술여부와각치료까지의시간을조사하였다. 임상적결과 ( 세균혈증, 중환자실입실, 패혈성쇼크, 급성신부전, 급성호흡부전, 입원기간중사 총 228명의화농성간농양환자가연구에포함되었다. 전체대상환자의평균연령은 60.8±12.8세이었으며, 남자가 144명 (63.2%), 여자가 84명 (36.8%) 이었다. 환자가호소하는임상증상으로는발열이 86.8% 로가장흔했고, 복통 (62.3%), 식욕저하 (32.0%), 구역또는구토 (29.4%), 피로감 (26.3%) 등의순서로빈도가높았다. 내원시 GCS (Glasgow Coma Scale) 점수가 15점미만을보인환자는 15명 (6.6%) 이었다. 기저질환으로당뇨와만성간염이각각 16.7% 와 45.2% 에서조사되었고, 간세포암과담도암이각각 3.5% 와 27.2% 에서관찰되었다. 대상환자 228명중 143명 (62.7%) 에서경피적농양배액술이시행되었고, 9명 (3.9%) 에서수술적치료가시행되었다. 입원중패혈성쇼크를보인환자는총 51명 (22.4%) 이었다. 패혈성쇼크로진행하지않은 177명과비교하여, 패

3 662 / 대한응급의학회지 : 제 25 권제 6 호 2014 혈성쇼크를보인환자들이나이가많았고, GCS 15점미만이더흔히관찰되었다. 활력징후에서는패혈성쇼크환자들이패혈성쇼크를갖지않은환자들에비해내원시수축기혈압이유의하게낮았고, 맥박수가빨랐으며, 체온이높았다. 혈액검사에서백혈구, 혈소판, BUN, creatinine, 알부민, 아스파테이트아미노전이효소 (AST), 알칼리성인산가수분해효소 (ALP) 등에서두군간에의미있는차이를보였으나, 헤모글로빈, 알라닌아미노전이효소 (ALT), 감마지피티 (γ-gpt), 총빌리루빈등에서는두군간에유의한차이는없었다. CRP는패혈성쇼크가있었던군과없었던군에서각각 19.5 mg/dl와 15.0 mg/dl 로패혈성쇼크가있었던군에서유의하게높았다 (p=0.002). 패혈성쇼크로진행했던환자들이진행하지않았던환자들에비해간농양병변의크기가컸고 (5.7 cm vs. 4.5 cm, p=0.008), 양측간엽을모두침범한경우가더흔한경향을보였다 (17.6% vs. 7.9%, p=0.061). 그러 Table 1. Baseline characteristics of the study subjects with pyogenic liver abscess. Total (N=228) Yes (N=51) Septic Shock No (N=177) p value Age (years) 60.8± ± ±13.4 <0.037 Gender, male (%) 144 (63.2%) 30 (58.8%) 114 (64.4%) <0.511 Symptom and sign Fever 198 (86.8%) 48 (94.1%) 150 (87.4%) <0.100 GCS< (06.6%) 07 (13.7%) 008 (04.5%) <0.047 Vital signs SBP (mmhg) 119.2± ± ±17.80 <0.001 PR (per minute) 095.5± ± ±17.8 <0.029 RR (per minute) 20.6± ± ±5.10 <0.062 BT ( C) 37.5± ± ±1.00 <0.043 Underlying diseases DM 038 (16.7%) 12 (23.5%) 026 (14.7%) <0.141 Chronic hepatitis 103 (45.2%) 25 (49.0%) 078 (44.1%) <0.632 CKD 007 (03.1%) 0 (0%) 007 (04.0%) <0.354 HCC 008 (03.5%) 01 (02.0%) 007 (04.0%) <0.688 CCC 062 (27.2%) 19 (37.3%) 043 (24.3%) <0.076 Laboratory studies WBC ( 10 3 /ul) 012.6± ± ±5.30 <0.010 Hb (g/dl) 011.8± ± ±2.00 <0.107 Platelet ( 10 3 /ul) 213.2± ± ±135.9 <0.018 BUN (mg/dl) 17.1± ± ±11.1 <0.004 Creatinine (mg/dl) 00.91± ± ±0.35 <0.001 Albumin (g/dl) 02.79± ± ±0.57 <0.001 AST (IU/L) 75.7± ± ±77.4 <0.018 ALT (IU/L) 71.8± ± ±101.3 <0.577 ALP (IU/L) 204.9± ± ±132.5 <0.029 GGT (IU/L) 162.6± ± ±156.7 <0.163 Total bilirubin (mg/dl) 02.3± ± ±2.3 <0.063 CRP (mg/dl) 16.0± ± ±9.0 <0.002 Radiologic findings Size of Abscess (cm) 04.8± ± ±2.8 <0.008 Multiple lesions 065 (28.5%) 15 (29.4%) 050 (28.8%) <0.862 Bilobar involvement 023 (10.1%) 09 (17.6%) 014 (07.9%) <0.061 Treatment Percutaneous Drainage 143 (62.7%) 36 (70.6%) 107 (60.5%) <0.103 Time interval from admission to drainage (hours) 30.7± ± ±4.10 <0.174 Surgery 009 (03.9%) 01 (02.0%) 008 (04.5%) <0.128 Time interval from admission to surgery (days) 20.3± ± ±6.90 <0.712 GCS: glasgow coma scale, SBP: systolic blood pressure, PR: pulse rate, RR: respiratory rate, BT: body temperature, DM: diabetes mellitus, CKD: chronic kidney disease, HCC: hepatocellular carcinoma, CCC: cholangiocarcinoma

4 선외 : 화농성간농양환자의임상적특성및패혈성쇼크의예측인자 / 663 Table 2. Bacterial isolates from the total 228 patients with pyogenic liver abscess. Pathogens Blood (n=225) Pus (n=142) Klebsiella spp. 48 (21.3%) 77 (54.2%) Escherichia coli 23 (10.2%) 16 (11.3%) Streptococci spp. 10 (04.4%) 16 (11.3%) Anaerobes 10 (04.4%) 14 (09.9%) Pseudomonas spp. 02 (00.9%) 06 (04.2%) Staphylococcus aureus 01 (00.4%) 04 (02.8%) Enterococci spp. 08 (03.6%) 02 (01.4%) Enterobacter spp. 01 (00.4%) 01 (00.7%) Table 3. Clinical outcomes in patients with pyogenic liver abscess. 나, 당뇨, 만성간염, 만성신질환, 간세포암과담도암에서는두군간에의미있는차이를보이지않았다. 2. 원인균 (Table 2) 대상환자 228명중 225명에서혈액배양이, 142명에서농양배양이시행되었고, 혈액과농양배양에서각각 103명과 136명에서균이동정되었다. 그중혈액과농양배양모두가장흔하게관찰된균은 Klebsiella spp. 로혈액동정균중 21.3%, 농양동정균중 54.2% 에서확인되었다. 다음으로 E. coli, Streptococci spp., 혐기성균등의순서로관찰되었다 (Table 2). 혈액배양과농양배양이모두시행된 141명중양쪽모두에서균이동정된것은 48 건 (32.7%) 이었다. 혈액배양에서균이동정되지않았으나, 농양에서만동정된경우는 73건 (51.8%) 이었다. 두가지이상의복합균이동정된경우는혈액과농양배양검사에서각각 13건과 17건이었다. 균의종류에따라서패혈성쇼크의발생에차이는없었고, 단일균과복합균에서패혈성쇼크발생의차이도관찰되지않았다 (p>0.05). 3. 임상적결과 (Table 3) No. (%) of patients Bacteremia 85 (37.3%) Admission to ICU 25 (11.0%) Septic shock 51 (22.4%) Acute renal failure 07 (03.1%) Acute respiratory failure 06 (02.6%) Death during hospital stay 03 (01.3%) ICU: intensive care unit 간농양진단후입원기간동안세균혈증은 228명중 85 명 (37.3%) 에서관찰되었고, 25명 (11.0%) 이중환자실에입실하였으며, 7명 (3.1%) 에서급성신부전, 6명 (2.6%) 에서호흡부전이발생하였고, 입원기간중 3명 (1.3%) 이사망하였다. 4. 패혈성쇼크에대한로지스틱회귀분석 (Table 4) 단변량로지스틱회귀분석에서패혈성쇼크와유의하게연관된인자는내원시 GCS <15점, 수축기혈압 <90 mmhg, 맥박수 120/min, 호흡수 22/min, 체온 38 C, 백혈구, 혈소판, BUN, creatinine, 알부민, AST, ALP, CRP, 농양크기 5 cm, 양측간엽침범등이었다 (Table 4). 단변량회귀분석을통해 p<0.10으로나타난변수들을다변량로지스틱회귀분석을이용하여패혈성쇼크와의관계를분석한결과, 수축기혈압 <90 mmhg (OR 95.79, 95% CI: ), 체온 38 C (OR 1.95, 95% CI: ), BUN (OR 1.03, 95% CI: ), ALP (OR 1.003, 95% CI: ), 농양크기 5 cm (OR 2.31, 95% CI: ) 이패혈성쇼크와유의하게연관되어있었다. 그밖에 60세이상의나이가 OR 1.03 ( , p=0.054) 로통계적으로유의하지는않았으나패혈성쇼크와연관된경향을보였다. 고찰본연구는화농성간농양의후향적역학연구로서총 228명의환자를대상으로하였는데이중패혈성쇼크가 22.4% 에서발생하였고, 1.3% 가사망하였다. 기존연구에서는화농성간농양의단기간사망률이 5.6% 에서 19% 까지보고되었고, 최근들어화농성간농양의사망률은감소하는추세를보이고있다 1,2,11,12). 본연구에서는과거연구와비교하여비교적낮은사망률을보였다. 최근화농성간농양의사망률감소는진단법의발달, 경피적배액술시행의증가및적절한항생제사용등에기인하는것으로사료된다. 본연구에서수술적치료가 4% 미만의환자에서시행된반면, 경피적농양배액술이 63% 의환자에서실시되

5 664 / 대한응급의학회지 : 제 25 권제 6 호 2014 었다. 경피적농양배액술시술에따라예후의차이를보이지는않았다. 그러나, 기존연구에서경피적배액술이효과가있음이발표되어화농성간농양의치료에서항생제사용과함께경피적배액술의시행이권장되고있다 13-15). 본연구에서패혈성쇼크와연관된초기임상적인자들을분석한결과, 내원시낮은수축기혈압, 높은체온, BUN의상승, ALP의상승, 5 cm 이상의농양크기등이패혈성쇼크의발생과유의하게연관되어있었다. 60세이상의나이는통계적으로유의하지는않았으나, 패혈성쇼크의위험도를 3% 정도증가시키는경향을보였다. 염증지표로서 CRP 상승은다변량분석에서의미가없는것으로나타났다. 과거화농성간농양에대한역학연구는매우제한적이고, 본연구에서패혈성쇼크에대한예측인자를분석한것 과는달리사망에대한예측인자를분석한연구들이대부분이며분석에이용한변수들도매우다양하다. 스페인의한연구결과에의하면, 사망과연관된인자로서패혈증또는패혈성쇼크가있었고, 또다른연구에서는담도질환, 병변이다수인경우, 낮은헤모글로빈수치, 높은 BUN 등이사망과연관되어있었다 13,16). 최근미국의인구기반연구에서는나이, 보험형태, 그리고간경화, 만성신질환, 암등의기저질환이사망과유의하게연관되어있는것으로보고하였다 11). 본연구에서는당뇨, 만성신질환, 만성간염, 간암및담도암등의기저질환과패혈성쇼크의연관성은없었다. 다만, 담도암은패혈성쇼크와통계적으로유의한상관관계를보이지는않았으나, 담도암환자에서패혈성쇼크발생의위험도는증가하는경향을보였다. 본연구에서패혈 Table 4. Logistic regression analysis for septic shock in patients with pyogenic liver abscess. Univariable Multivariate OR (95% CI) p value OR (95% CI) p value Age 60 (years) 1.77 ( ) < ( ) <0.054 Female 1.27 ( ) <0.467 Symptom and sign Fever 2.88 ( ) <0.094 GCS< ( ) <0.026 Underlying diseases DM 1.79 ( ) <0.139 Chronic hepatitis 1.22 ( ) <0.532 CKD 1.35 ( ) <0.478 HCC 0.50 ( ) <0.533 CCC 1.85 ( ) <0.069 Vital signs SBP<90 mmhg ( ) < ( ) <0.001 PR 120 /min 3.10 ( ) <0.007 RR 22 /min 2.78 ( ) <0.005 BT 38 C 2.14 ( ) < ( ) <0.001 Laboratory studies WBC ( 10 3 /ul) 1.08 ( ) <0.002 Hb (g/dl) 0.88 ( ) <0.108 Platelet ( 10 3 /ul) ( ) <0.018 BUN (mg/dl) 3.31 ( ) < ( ) <0.004 Creatinine (mg/dl) ( ) <0.001 Albumin (g/dl) 0.37 ( ) <0.001 AST (IU/L) ( ) <0.030 ALT (IU/L) ( ) <0.582 ALP (IU/L) ( ) < ( ) <0.034 Total bilirubin (mg/dl) 1.11 ( ) <0.071 CRP (mg/dl) 1.06 ( ) <0.002 Radiologic findings Size 5 cm 2.40 ( ) < ( ) <0.031 Bilobar involvement 2.50 ( ) <0.047 Multiple lesions 1.06 ( ) <0.871 GCS: glasgow coma scale, DM: diabetes mellitus; HCC: hepatocellular carcinoma, CCC: cholangio-carcinoma, SBP: systolic blood pressure, PR: pulse rate, RR: respiratory rate, BT: body temperature

6 선외 : 화농성간농양환자의임상적특성및패혈성쇼크의예측인자 / 665 성쇼크와유의하게상관관계를보였던 ALP의상승은연구에다수포함되어있는담도암환자에서흔히동반되는소견으로담도폐색에의한간농양발생의경우예후가불량할수있음을시사하는소견으로사료된다. 이에대해좀더자세한조사와광범위한연구가필요할것으로보인다. 본연구에서는간농양의크기가 5 cm 이상으로큰경우패혈성쇼크의위험도를 2.3배증가시키는것으로나타났다. 그러나, 병변이양측간엽을침범하는것과병변의수는패혈성쇼크의발생과는연관성이없는것으로분석되었다. 이전연구들은간농양의방사선학적특징과예후와의연관성에대해다양한결과들을보고하고있다. 병변의크기와위치에따라서는예후와연관이없었으나, 병변의수가다수인경우사망률이증가한다는보고가있었다 13). 또한, 병변의크기가큰경우배액술이예후에도움이된다는보고들이있다 11,13,15,17). 본연구에서는패혈성쇼크가있었던군에서경피적농양배액술이 60.5% 에서시행되어패혈성쇼크가없었던군의 70.6% 에비해시행률이낮았고, 시술이시행된시간도패혈성쇼크가있었던군에서지연되는경향이있었으나시행률과시행시간에서통계적으로유의한차이는없었다. 그러나, 경피적농양배액술의시행과시행시간에따라예후에차이가있는지보기위해서는향후자세한연구와평가가필요할것으로사료된다. 화농성간농양의원인균에대해서는아시아와서양국가들에서차이를보인다. 본연구에서는가장흔하게동정된균은 Klebsiella spp. 로서혈액에서 21%, 농양에서 54% 에서관찰되었고, 다음으로 E. coli, Streptococci spp. 가약 10% 정도에서관찰되었다. 국내에서최근발표된연구에서도비슷한결과가보고되었다 18). 이와달리서양국가들에서는 Streptococci와 E. coli가흔하게관찰된다 11,13,16). 아시아국가들에서흔하게관찰되는 Klebsiella pneumoniae에의한간농양은당뇨병환자에서흔히발생하며, 전신에전이성병변을잘일으키는것으로알려져있다 19). 또한, Klebsiella pneumoniae에의한간농양환자에서사망률이증가한다는보고가있었다 20). 본연구에서는단일균외에복합균은혈액과농양에서각각 13건과 17건에서동정되었고, 단일균과복합균을가진두군사이에패혈성쇼크의발생에차이를보이지는않았다. 그러나, 본연구결과와는달리기존연구에서는복합균에의한화농성간농양이단일균과비교하여예후가불량하다는보고가있었다 13). 따라서, 원인균의종류또는복합균과단일균이예후에미치는영향을평가하기위해서는좀더광범위하고철저한연구가필요할것으로사료된다. 결론본연구에서저자들은 2010년 1월부터 2013년 6월까 지일개대학병원응급실에서화농성간농양을진단받은 228명의환자들을대상으로패혈성쇼크와연관된인자들을분석하였다. 그결과, 내원시낮은수축기혈압, 높은체온, BUN과 ALP의상승, 5 cm 이상의농양크기등이패혈성쇼크와연관된것으로나타났다. 따라서, 초기에이러한임상적특징을보이는화농성간농양환자들에게는좀더신중하고적극적인치료가필요할것으로사료된다. 참고문헌 01. Jepsen P, Vilstrup H, Schonheyder HC, Sorensen HT. A nationwide study of the incidence and 30-day mortality rate of pyogenic liver abscess in Denmark, Aliment Pharmacol Ther. 2005;21: Kaplan GG, Gregson DB, Laupland KB. Population-based study of the epidemiology of and the risk factors for pyogenic liver abscess. Clin Gastroenterol Hepatol. 2004;2: Tsai FC, Huang YT, Chang LY, Wang JT. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis. 2008;14: Barakate MS, Stephen MS, Waugh RC, Gallagher PJ, Solomon MJ, Storey DW, et al. Pyogenic liver abscess: a review of 10 years experience in management. Aust N Z J Surg. 1999;69: Chen W, Chen CH, Chiu KL, Lai HC, Liao KF, Ho YJ, et al. Clinical outcome and prognostic factors of patients with pyogenic liver abscess requiring intensive care. Crit Care Med. 2008;36: Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS, et al. Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration. Hepatology. 2004;39: Hall KK, Lyman JA. Updated review of blood culture contamination. Clin Microbiol Rev. 2006;19: Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, et al SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31: Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R Lewandowski K. Contributions to the epidemiology of acute respiratory failure. Crit Care. 2003;7: Meddings L, Myers RP, Hubbard J, Shaheen AA,

7 666 / 대한응급의학회지 : 제 25 권제 6 호 2014 Laupland KB, Dixon E, et al. A population-based study of pyogenic liver abscesses in the United States: incidence, mortality, and temporal trends. Am J Gastroenterol. 2010; 105: Tian LT, Yao K, Zhang XY, Zhang ZD, Liang YJ, Yin DL, et al. Liver abscesses in adult patients with and without diabetes mellitus: an analysis of the clinical characteristics, features of the causative pathogens, outcomes and predictors of fatality: a report based on a large population, retrospective study in China. Clin Microbiol Infect. 2012; 18: Alvarez Perez JA, Gonzalez JJ, Baldonedo RF, Sanz L, Carreno G, Junco A, et al. Clinical course, treatment, and multivariate analysis of risk factors for pyogenic liver abscess. Am J Surg. 2001;181: Ferraioli G, Garlaschelli A, Zanaboni D, Gulizia R, Brunetti E, Tinozzi FP, et al. Percutaneous and surgical treatment of pyogenic liver abscesses: observation over a 21-year period in 148 patients. Dig Liver Dis. 2008;40: vansonnenberg E, Wittich GR, Goodacre BW, Casola G, D'Agostino HB. Percutaneous abscess drainage: update. World J Surg. 2001;25:362-9; discussion Ruiz-Hernandez JJ, Leon-Mazorra M, Conde-Martel A, Marchena-Gomez J, Hemmersbach-Miller M, Betancor- Leon P. Pyogenic liver abscesses: mortality-related factors. Eur J Gastroenterol Hepatol. 2007;19: Johnson RD, Mueller PR, Ferrucci JT Jr, Dawson SL, Butch RJ, Papanicolaou N, et al. Percutaneous drainage of pyogenic liver abscesses. AJR Am J Roentgenol. 1985; 144: Wie SH, Chang UI, Kim JD, Lee JR, Paik CN, Chung WC, et al. Clinical features of 141 cases of pyogenic liver abscess over a 10-year period and antibiotic sensitivity to the causative organisms. Infect Chemother. 2008;40: Siu LK, Yeh KM, Lin JC, Fung CP, Chang FY. Klebsiella pneumoniae liver abscess: a new invasive syndrome. Lancet Infect Dis. 2012;12: Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: Recent trends in etiology and mortality. Clin Infect Dis. 2004;39:

김범수

김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis