非典型的症状で発症した小腸大腸型Crohn病の1例

The Diagnosis of Crohn's Disease from the Onset of an Unusual Clinical Symptom, Report of a Case

要旨　症例は35歳，女性．便性帯下を主訴に近医産婦人科を受診．産婦人科的には異常を認めず，次第に下痢，腹痛などの消化器症状を呈したため精査し，回腸直腸瘻，直腸腟瘻，左水腎症，左腸骨窩膿瘍，高位痔瘻を合併した小腸大腸型Crohn病と診断．ステロイド，免疫抑制剤を投与するも瘻孔は閉鎖せず，外科的治療にて症状軽快．Crohn病では肛門病変を合併することが多いが，直腸腟瘻の合併は比較的少なく，帯下増加を初発症状として診断に至った例はまれである．Crohn病における直腸腟瘻の合併は女性のQOLを著しく低下させるので早期に診断し，QOLの向上を図ることが重要である．

　A 35-year-old woman was admitted to our hospital with the chief complaint of fecal vaginal discharge. The cause of the episode had not been detected from a gynecological point of view in the previous hospital. After admission to our hospital, some examinations were performed. Barium enema, small bowel radiography, and enhanced CT scan examinations showed ileorectal and rectovaginal fistulas with left hydronephrosis, an abscess in the left iliac area and complicated anal fistulas. With these findings, we made a diagnosis of ileocolic Crohn's disease with rectovaginal fistula, which we thought caused fecal vaginal discharge. The patient was initially treated with total parenteral nutrition (TPN), and steroid and immunosuppressive therapy was performed for a few weeks. However, her clinical symptoms did not improve. Therefore, she underwent partial resection of the ileum, sigmoid colon, rectum and sigmoid colostomy, including ovariectomy and nephrectomy. Anorectal lesions are highly associated with Crohn's disease, but there is sometimes complication of rectovaginal fistulas. The rectovaginal fistulas associated with Crohn's disease tend to be complex and they lower the quality of life (QOL) in female patients remarkably. Therefore, it is important to make an early and correct diagnosis of Crohn's disease from the initial clinical symptom, especially anorectal lesions.