下腸間膜静脈閉塞を伴った腸間膜脂肪織炎の1例

Mesenteric Panniculitis of the Colon with Obstruction of the Inferior Mesenteric Vein, Report of a Case

要旨　症例は69歳，女性．左下腹部痛と下痢，さらに左下腹部に圧痛を伴うおよそ10cmの索状物を触知して，当科を受診した．注腸透視では，S状結腸の腸間膜付着側辺縁に偏側性の不整鋸歯状変化と，さらにその口側に硬化像を伴う腸管の狭小化がみられた．大腸内視鏡検査では，S状結腸に浮腫性変化と思われる低い敷石状の隆起性変化が観察され，隆起頂部にはびらんが存在し，送気による内腔の拡張も不良であった．血管造影検査にて，下腸間膜静脈閉塞と上直腸動静脈瘻が確認された．保存的治療では症状は軽快せず，むしろ所見上，びらん潰瘍の増悪がみられたため，手術を施行した．切除標本では，結腸および腸間膜が硬化・肥厚し，粘膜面には，腸間膜側と対側に沿って縦走びらんがあり，中心部ではそれらが融合して亜輪状を呈していた．組織学的に，S状結腸壁の腸間膜に脂肪織炎がみられ，腸間膜から粘膜下層の静脈は中膜肥厚で壁肥厚と内腔狭窄を示し，臨床的に増悪した虚血性病変を併発していた．本例は脂肪壊死とfoamy macrophagesが主体の腸間膜脂肪織炎が先行し，これに静脈系障害による虚血性病変を随伴したものと診断された．

　A 69-year-old female complained of left lower abdominal pain and diarrhea. Physical examination revealed a firm mass with mild tenderness, measuring approximately 10 cm in length, in the left lower quadrant area. A double-contrast barium enema showed narrowing and stiffness of the sigmoid colon and sawtooth-like appearance on its mesenteric side. Colonoscopic examination showed narrowing of the lumen, edematous and erosive mucosa of the sigmoid colon. Angiography of the inferior mesenteric artery showed occlusion of the inferior mesenteric vein and arteriovenous fistula of the superior rectal artery and vein. The patient was operated on, because conservative therapy was unavailable. Pathological examination showed marked fibrosis in the colonic wall and fat necrosis of the mesenterium near the mucosal erosions. In this case, occlusion of the inferior mesenteric vein in addition to mesenteric panniculitis had caused irreversible severe ischemic change of the colon.

　1) Department of Surgery, Fukui Prefectural Hospital, Fukui, Japan

　2) Department of Pathology, Fukui Prefectural Hospital, Fukui, Japan

　3) Department of Radiology, Fukui Prefectural Hospital, Fukui, Japan