Standard Article
Standard
ArticleJ Vet Intern Med 2018;32:195–200
J Vet Intern Med 2018;32:195–200

Gallbladder Mucocele: Variables Associated with Outcome
and the UtilityMucocele:of Ultrasonography
to Identify
GallbladderGallbladder
Variables
Associatedwith Outcome
Rupturein219
Dogs(2007–2016)
and the Utility of Ultrasonography to Identify Gallbladder
J.A. Jaﬀey

2/24 西村

Rupturein E.219
Dogs(2007–2016), A. Graham,
E. VanEerde,
Hostnik,
W. Alvarez,
J. Arango, C. Jacobs, andA.E. DeClue

J.A. Jaﬀey , A. Graham, E. VanEerde, E. Hostnik, W. Alvarez, J. Arango, C. Jacobs, and【背景】犬における胆嚢粘液嚢腫(GBM)は多く認識されているが病態は不明である。
Background: Gallbladder mucocele (GBM) is an increasingly recognized extrahepatic biliary disease in dogs.
A.E.associatedDeClueObjectives:
investigate cases of GBM and identify
variableswith survival and the sensitivity and specificity
GBMToの周術期の死亡率は27%と報告されている。
of ultrasonography to identify gallbladder rupture.
Animals:
Two Gallbladderhundred and nineteen
client-owned
GBM. recognized extrahepatic biliary disease in dogs.
Background:mucocele(GBM) isdogs
an withincreasingly
現状、外科介入や死亡率の要因になる因子の報告が少ない。
Methods: Multicenter,retrospectiveof dogs
GBM,variables
presented fromJanuarywith
2007survival
to November
to 6 aca- and specificity
Objectives:
To investigate
cases studyof GBMandwithidentify
associatedand 2016
the sensitivity【目的】○下の４項目が胆嚢切除後の生存率に関連しているかどうか。
veterinary hospitals in the United States. Interrogation of hospital databases identified all cases with the inclusion criofdemic
ultrasonography
to identify gallbladder rupture.
teria of a gross and histopathologic diagnosis of GBM after cholecystectomy and intraoperative bacteriologic cultures of at
Animals:
hundredand nineteen
client-owned
with GBM.
・外科介入のタイミング
・細菌培養陽性 ・抗生剤の投与
least
1 of the Two
following:
gallbladderwall,・胆汁性腹膜炎を併発した胆嚢破裂
gallbladdercontents,dogs
or abdominal
eﬀusion.
Methods:
Multicenter,withcriteria.
GBM,Dogs
presented
fromandJanuary
2007
to November
Results: Twohundred andretrospective
nineteen dogs study
fulfilledofthedogs
inclusion
with GBM
gallbladderrupturewith bile 2016 to 6 aca○超音波検査による胆嚢破裂の感度と特異度を調べる。
peritonitis
at the timeof surgery
wereUnited
2.7 times
more likely
to die thanofdogs
withoutdatabases
gallbladderidentified
rupture andperitonitis
demic
veterinary
hospitals
in theStates.
Interrogation
hospital
allbilecaseswith the inclusion cri(P =of
0.001;
95% andconfidence
interval [CI], diagnosis
1.50–4.68; nof= GBM
41). Noafter
significant
associations were
between bacteriologic
survival and cultures of at【組み入れ基準】
teria
a gross
histopathologiccholecystectomy
andidentified
intraoperative
positivecultures,antibioticwall,
administration,or contents,
time (days)orfromultrasonographic
identification of GBM to theleast
1 ofbacteriologic
following:
gallbladdergallbladderabdominal
eﬀusion.
・2007
1theTwo
月〜2016
11 月に二次診療施設(6施設)で受診した症例。
time年of surgery.
The sensitivity,年
specificity,
positive, and negative likelihood ratios
for ultrasonographic identification of gallResults:
hundredandnineteendogs
fulfilledtheinclusion
criteria.
Dogs
with
GBM and gallbladder rupture with bile
bladder rupture were 56.1% (95% CI, 39.9–71.2), 91.7% (95% CI, 85.3–95.6), 6.74, and 0.44, respectively.
・胆嚢壁、内容物、腹水のどれかで培養検査を行なったもの。
peritonitis
at theof Importance:
surgery were
2.7in times
morelikelydieintraoperative
than dogs without
gallbladderand bile peritonitis
Conclusion
and time
ClinicalDogs
our study
with
GBMtoandevidence of
gallbladder rupture
rupture and(Pbile= peritonitis
0.001; 95%
interval[CI],of1.50–4.68;
n = 41).abdominal
No significant
associations
weresensitivity
identified
survival andhadconfidence
a significantly
higher risk
death. Additionally,ultrasonography
had low
for between
iden・胆嚢切除を行なった肉眼的、病理学的にGBMであったもの。
tificationbacteriologic
of gallbladder cultures,rupture. antibiotic administration, or time (days) from ultrasonographic identification of GBM to thepositivewords: Bile
peritonitis;
Cholecystectomy;
Cystic mucosal
hyperplasia;
Gallbladderperforation.
【方法】回顧的研究
time Keyof surgery.
The
sensitivity,
specificity, positive,
and negative
likelihood
ratiosfor ultrasonographic identification of gallbladder rupture were 56.1% (95% CI, 39.9–71.2), 91.7% (95% CI, 85.3–95.6), 6.74, and 0.44, respectively.
・胆嚢病理、腹部超音波、胆嚢破裂と胆汁性腹膜炎、48時間以内の抗生剤の投与、細菌培養検査、Conclusion and Clinical Importance: Dogs in our study with GBM and intraoperative evidence of gallbladder rupture and超音波検査から手術までの期間、生死、死の原因を記録。
bile
peritonitis
had a significantly
higherrisk of death.
allbladdermucocele(GBM) is anincreasingly
rec- Additionally, abdominal ultrasonography had low sensitivity for identification
gallbladder biliary
rupture.disease in dogs, but
Abbreviations:ognized ofextrahepatic
・各診療施設の超音波専門医が腹部超音波を評価した。
Key words:
Bile peritonitis;
Cholecystectomy;
Cystic mucosal
hyperplasia;
the pathogenesis
remains
unclear. Anecdotally,
the cliniCT
computedGallbladdertomography perforation.
・胆嚢破裂の診断は術中の肉眼所見と胆汁のリークと腹膜炎で行なった。
cal importance of GBM is thought to be primarily
GBM
gallbladder mucocele
related to risks of gallbladder rupture, infection, extra【結果】hepatic biliary duct obstruction, and systemic inflamma・219
頭が組み入れ基準に合致。
has been identified in 60.9 (14/23),1 23.3 (10/43),2 or
toryallbladderresponse
syndrome
can occur
to recmucocelethat(GBM)
is ansecondary
increasingly
3of dogs with GBM. However, preopera22.7% (5/22)
gallbladder necrosis or infarction. Gallbladder rupture
Abbreviations:ognizedシェルティー(10)、コッカー・スパニエル(17)、ビション・フリーゼ(12)他。
extrahepatic biliary disease in dogs, but
・犬種tive identification of rupture is often challenging. This is
the pathogenesis
remains unclear.
Anecdotally,
the cliniCTby the imperfection
computedoftomographyevidenced
abdominal ultrasonog・年齢
10 (1.5-17)歳
・性別
避妊メス(127)、去勢オス(85)、メス(3)、オス(4)頭。
the Department
of Veterinary
Medicine toand beSurgery,
cal From
importanceof GBMis thought
primarily
gallbladdermucoceleraphy toGBM
detect gallbladderrupturepreoperatively. The
Veterinary
HealthCenter,UniversityofMissouri,
Columbia,
MO・胆嚢破裂は匹中
42
匹（21.2％）の犬で認められ、残りの胆嚢は完全な胆嚢を有していた。
sensitivity of high-resolution ultrasound scanners used
relatedrisks DeClue);of198
gallbladderrupture,infection,(Jaﬀey, toGraham,Department
of Veterinary
Clinical extrato identify gallbladder wall defects in people is 70%4
Sciences,biliary
College ductof Veterinary
Medicine,and
IowasystemicState University,
hepatic
obstruction,
inflamma・抗生剤投与、細菌培養結果、死亡原因、超音波所見は裏のページで説明
198
et al 85.7%1 in dogs with GBM.
and Jaﬀey
Ames, IA (VanEerde); Department of Veterinary Clinical Sciences,
has asbeen
identified in 60.9 (14/23),1 23.3 (10/43),2 or
tory
response syndromethat
can occur secondary to as high
Veterinary Medical
Center, Ohio 日)と破裂なし(1State University, Columbus, OH・GBM
破裂あり(1日)のそれぞれで外科介入のタイミングに有意差はなかった。
The incidence of positivebacteriologic culture of gall3

GG

dogswithwith
GBM.
preopera22.7%(5/22) of
gallbladdernecrosisof or
infarction.
Gallbladderrupture(Hostnik); Department
Small
Animal Clinical
Sciences, College
bladderwall or contents
GBM
theHowever,time
Table 1. Categorical variables associatedwith survival
based in
ondogschi-square
testatandrelative risk
1,2,5,6of Veterinary Medicine, University of Florida, Gainesville, FL
tiveisidentification
ofapproximately
rupture is oftenThis isof surgery
inconsistent and
22%.challenging.
(Alvarez); Department of Veterinary Clinical Sciences, Center for
Variable
Survivor
Nonsurvivor
P of
Value
95% CI
the imperfection
abdominalAlack evidencedof sensitive by
diagnostic
tests to identify
gallblad- RRultrasonogVeterinary
HealthSciences,
Oklahoma
State
University,
Stillwater,
From the Department of Veterinary Medicine and Surgery,derruptureandconcernfor
septicbile
peritonitis,
extraraphy
todetectgallbladderrupturepreoperatively.
The
OKGallbladder(Arango); Department
of
Small
AnimalMedicine
andSurgery,and bile peritonitis(16.1%)
15/36 (41.7%)
0.001
2.7
1.50, 4.68
Veterinary
Healthrupture
Center,University
ofof Missouri,
Columbia, 26/161
MO
hepatic
biliary ductobstruction, andsystemic scanners used
Collegeof Veterinary
Medicine,
Universityadministration
Georgia, Athens, GA 118/124
Pre- andintraoperative
antibiotic(95.1%)
27/28(96.4%)
0.834
sensitivityof high-resolution
ultrasound(Jaﬀey,Graham, DeClue); Department of Veterinary Clinical(Jacobs).
inflammatory
response
syndromesecondarytogallbladIntraoperative antibiotic administration
160/179 (89.4%)
30/35(85.7%) wall defects
0.736 in people is 70%4
to identifynecrosis,
gallbladder
Sciences,
Veterinary
Medicine, Iowa State University,
Work College
performedof
at these
institutions.
der inflammation,and 1thrombosis0.11
have led to
Bacteriologic
culturepositivity
22/181(12.2%)
9/29 (31.0%)
Corresponding
author:J.A.
Jaﬀey,
Department
of
Veterinary
and
as
high
as
85.7%
in
dogs
with
GBM.
Ames, IA (VanEerde); Department of Veterinary Clinical Sciences,
anecdotal recommendations of earlier, elective
cholecysMedicine
andSurgery,
Veterinary
HealthCenter,UniversityofVeterinary
Center,Ohio State interval.
University, Columbus, OH
The
incidenceof
positivebacteriologic
RR, Medical
relative risk;
CI, confidence
tectomy in dogs with GBM to avoid complicationsculture of gallMissouri Veterinary Health Center, Columbia, MO 65211; e-mail:(Hostnik);Department of Small Animal Clinical Sciences, College
associatedwith bileor septic
peritonitis.
bladderwall
or contents
in 1,3,6
dogs with GBM at the time
jaﬀeyj@missouri.edu
of Veterinary
Medicine,
University
ofFlorida,Gainesville,FL
Consideringthelimitedandvariable
information
per【ディスカッション】
Submitted August 19, 2017; Revised November 8, 2017;of
surgeryisinconsistentandapproximately
22%.1,2,5,6
significant
association
betweensurvivalandCentertime (days)
people.
Biledefinitive
constituentsaretoxic to tissues,causing(Alvarez);
Department
Veterinary
ClinicalSciences,fortaining to GBM,
the few
criteria for
determinAccepted
November15, of2017.
15
A lack of sensitive
diagnostic tests
identify gallblad1
胆汁性腹膜炎をもった胆嚢破裂は2.7倍の死亡リスクがあった。
Altered vasfrom
ultrasonographic
identificationof gallbladderruppermeability
and tonecrosis.
Veterinary
HealthSciences,
Oklahoma
University,
Stillwater,
Copyright© 2017The Authors.
JournalStateof Veterinary
Internal
ing
the needalterations
for surgical inintervention
and perioperative
1–3,5
der
ruptureand concern
for
septicbile
peritonitis,
cularpermeability
promotestransudationof extrafluid andture
to Department
the by timeof surgery
identified
published
WileyofPeriodicals,Inc. Medicine
onwas
behalf notof the
OKMedicine(Arango);Small
AnimalandSurgery,largerobsermortality
rates
of approximately
27%,
・以前の報告では胆嚢破裂の有無で有意差はなかった。
AmericanCollegeofrsVeterinary
Internal
hepatic
biliary
ductobstruction,andsystemicfrom=Medicine,!0.0483;
nMedicine.
= 34).of Georgia, Athens, GA
translocationofendogenous
anaerobic
bacteria(P =Collegeof 0.784;
Veterinary
University
vational studies are needed to describe prognostic indiThis is an open access article under the terms of the Creative・症状の発生から手術までのタイミングが超音波を実施した時からではなかった可能性。
theliver,
andinto thetoperitoneum.
(Jacobs).
inflammatory
response
syndromesecondarygallblad- 15
cators. The
primaryaimintestines,of our study
wasblood
to determine
Commons Attribution-NonCommercial License, which permits use,Work
performed
atthese
institutions.
Furthermore,
bile
in
the
peritoneal
cavityimpairs
whether
antibiotic
administration,
timingofsurgery,
der inflammation, necrosis, and thrombosis
have led tohost
distribution and reproduction in any
medium, provided
theoriginal
Discussion
・ヒトにおいて胆嚢穿孔から72時間以上経過すると死亡率が上昇。
16
Corresponding
author:Jaﬀey,
Department
of Veterinary
bacteriologic
culturerecommendations
positivity, or gallbladderruptureThese
sequelaedefensemechanisms
againstbacteria.
work
is properly citedand is J.A.
not usedfor commercial
purposes.
anecdotalof earlier,electivecholecysDogs
GBM
and gallbladderwall
rupturewith
were associatedwith survival
after
DOI:
10.1111/jvim.14898
Medicine
and with
Surgery,
Veterinary
Health Center,
University
ofandbile peritonitis
likely augment
the systemic
inflammatory
response as2
細菌培養結果、抗生物質投与は生存に関与しなかった。
tectomy
in
dogs
with
GBM
to
avoid
complications
bile Veterinary
peritonitisHealthidentified
the timeof65211;surgery
had aMissouriCenter,atColumbia,MOe-mail:well increase susceptibility to sepsis 1,3,6
and multiple organ
・過去の報告でも細菌陽性率は22%と低い。死亡した症例の培養検査が取り止められたりするこwith bile or septic peritonitis.
jaﬀeyj@missouri.edu
significantly higher risk of death than thosethat did not associateddysfunctions.
Considering
theultrasonography
limited and variablein our study.
wasNovember
found between
Submitted
AugustNo
19, association
2017; Revised
8, 2017;surAbdominal
had informationa sensitivity perof 56%とが影響した可能性がある。また、採取する部位や技術の問題かもれない。
to GBM,gallbladderthe few definitive
criteriabefore
for determinvival November
and bacteriologic
Accepted
15, 2017. culture or antibiotic administra- taining
to identify
wall rupture
surgery in
・抗生剤投与しなかった
3/7
で陽性だったことと敗血症を考え抗生剤の投与はするべきである。
tion nor©wasassociation
foundofbetween
survival
Copyright
2017anThe
Authors. Journal
Veterinary
Internaland ing our
the needforThissurgicalintervention
study.
resultis lower andthanperioperative
the sensitivity
Medicine
Wiley
Periodicals, Inc. onidentification
behalf of the of mortality
time published(days) byfromultrasonographic(70%) rates
of high-resolution
ultrasoundused tolarger obserof approximately
27%,1–3,5scanners
3
超音波の感度は低く、特異度は高かった。
Americanof Veterinary
Medicine.
GBMCollege
gallbladder
to Internal
the timeof surgery. Abdominal vational
lower
identify
gallbladderwalltodefects
in prognostic
people4 andstudiesareneededdescribe
indi・尤度比が高いので、比較的信頼のできる検査である。
1,8,17This
is an open accessarticleunder
the terms(56.1%)of the Creative
ultrasonography
hadpoor
sensitivity
but good cators.
thanThepreviously
reported
sensitivities(75–85.7%)
primary aim of our study was to determine ofCommons
Attribution-NonCommercial
License, which
permits use,rupspecificity(91.7%) for identificationof gallbladderconventional ultrasonography to identify gallbladder
・腹水中の胆汁酸濃度を調べることは胆嚢破裂の診断に役立つ。
whether antibiotic administration, timing of surgery,
distribution
in any medium, provided the original
ture inand
ourreproduction
study.
rupture in dogs with GBM. In contrast to its poor senculture positivity, or gallbladder rupture
4
外科介入の生存期間に差がなかった。
work
isGallbladderproperly cited perforationand is not usedisfor
purposes.
a commercial
life-threatening
complica- bacteriologic
sitivity, ultrasonography had good specificity (91.7%)
with
bile
peritonitis
associated rupture
with survival
DOI:
10.1111/jvim.14898
tion of nontraumatic acute cholecystitis in people, withfor identification wereof gallbladder
beforeafter
surgery

・１番と同様に本来の症状発症からの期間に違いが存在した可能性が考えられる。
survival as low as 58% and incidence as high as
in our study. Our findings are similar to previously【批評】
11%.10–13 The incidence of gallbladder wall rupture
reported specificities (81–100%).1,8,17 The high speciassociated
with
GBM
in
dogs
is
not
known,owing
toaficity for ultrasonography to detect gallbladder rupture
・胆嚢破裂が疑われる症例にたいするインフォームドの１つとして活用できる。
limited number of reports, small study populations, andhighlights its clinical utility in guiding therapeutic inter・基礎疾患や血液検査の情報も合わせて多変量解析にできればよかったのではないか。
short evaluation periods. However, the prevalence
vention in dogs with GBM. If ultrasonography indicates3
1
from 22.7 (5/22) to 60.9% (14/23). The prevathe presence of gallbladderrupture, the probability of a・2ranges
次診療施設では症状を呈してからの治療介入が難しいため
1 次診療での研究が望ましい。
1,8,17lence of gallbladder wall rupture identified intraoperatively in our study was 21.4%.
We found that 21.2% of dogs had gallbladder rupture and bile peritonitis, and the risk of death in these

Likelihood
false-positive result is low (0–19%).
ratios allow quantitation of probability of disease for
an individual patient with a positive or negative test
result and are independent of prevalence.18 The farther

抗生剤の使用状況
48 時間以内抗生剤投与を受けていない

71/153

術中に抗生剤投与を受けた

24/214

抗生剤投与を受けていない

7/152
145/152

術前と術中に抗生剤投与を受けた
細菌培養の材料 255 検体
胆嚢内容物(57) 胆嚢組織(127)
胆嚢組織と肝臓(5)腹水(3)胆嚢組織と胆嚢内容物(14) 腹水と胆嚢内容(2)

腹水と肝臓(2) 胆嚢内容物と肝臓(2)３検体(4)

培養検査結果
188/219 (85.8%)

培養陰性

抗生剤投与あり 166/188

培養陽性

31/219 (14.2%)

抗生剤投与受けた陽性
抗生剤投与なし

28/31

3/7

Escherichia coli (5), Enterococcus sp (5)他
38/219 (17.4%)

死亡原因

安楽死(18)

敗血症(5)

多臓器不全(2)

胆汁性腹膜炎(4)不明(4)急性呼吸器症候群(3)

術中破裂あり 術中破裂なし
23
11
18
122

感度 56.1%(23/41)

DIC(1) ショック(1)超音波検査
超音波検査 破裂あり
超音波検査 破裂なし

特異度 91.7%(122/133)
陽性尤度比 6.74 陰性尤度比 0.44