Crohn病の長期経過―初診時X線所見からみた合併症出現の予測

Long-term Clinical Course of Crohn's Disease; with Special Reference to Initial Radiographic Findings for Predicting Development of Complications

要旨　初診時非手術Crohn病46例を5年以上X線検査で経過観察し，A群：初診後5年以内に重篤な合併症（口側腸管の拡張を伴う狭窄，内外瘻，膿瘍，穿孔，大出血）を伴った17例，B群：初診後5年以上の経過で合併症を認めなかった25例，C群：初診後アフタ様潰瘍のみを認めた4例，の3群に分類し，初診時の臨床像およびX線所見を比較検討し，以下の成績を得た．①AB両群間で有意な所見は病悩期間，小腸敷石像，小腸管腔狭小化，小腸裂溝，初回治療に対する反応性であった．②初診時X線所見をスコア化することにより，76％の症例（小腸病変86％，大腸病変56％）で合併症の出現を予測できた．これに初回治療に対する反応性を加えることによって，92％の正診率（小腸病変91％，大腸病変94％）を得ることができた．③罹患範囲の口側への進展は認めなかったが，3例で肛門側への進展を確認した．④C群の4例中3例は典型像へと進展したが，全例合併症の出現は認めなかった．以上の成績から，合併症出現を予知するうえで病悩期間，初診時X線所見，初回治療に対する反応性を組み合わせることが重要であると考えた．

　Forty-six patients with Crohn's disease who had not undergone bowel resection at the time of diagnosis and were followed up for more than 5 years, were studied to find the initial clinical and radiographic findings helpful for predicting the development of serious complications such as severe stricture, fistula, abscess, perforation, and massive bleeding, and to determine the time-course changes in the extent of the lesion. The results were as follows:

　1) The period from onset of symtoms to the initial visit was a significant indicator for predicting the development of complications. The period in cases where complications developed was shorter than in cases where there were no complications.

　2) Cobblestone appearance, narrowing of the lumem, and fissuring ulcer on initial radiographic findings were most useful indicators for predicting the development of complications.

　3) The effect of the initial treatment was also a significant predictor. In patients who developed complications, initial treatment was less effective than it was in those who didn't experience complications.

　4) The combination of these radiographic findings made it possible to predict development of complications in more than 90% of patients with unoperated Crohn's disease.

　5) The extent of involvement remained unchanged during the period of follow-up in all but 3 patients, in whom radiography showed spread from the small intestine into the large, or spread from the right-sided colon into the descending colon.

　6) In 3 of 4 patients initially having only aphthoid ulcers, follow-up radiography revealed longitudinal ulcer and/or cobblestone appearance. These 4 patients didn't develop complications during the long-term clinical course.