十二指腸球部にⅡa型早期癌を，胃角部にカルチノイドを合併したintraluminal duodenal diverticulumの1例

Intraluminal Duodenal Diverticulum Combined with Early Duodenal Cancer and Gastric Carcinoid, Report of a Case

要旨　慢性腎不全の53歳の女性．X線検査で十二指腸の拡張を指摘され来院した．X線検査および内視鏡検査で，十二指腸球部から球後部にかけて高度の拡張と食物残渣の貯溜があり，拡張した球部に表面に凹凸のある平盤状の隆起を認めた．球後部は管腔内閉塞症の状態を呈し，スコープを辛うじて通過させうるぐらいの小孔を有するintraluminal duodenaldiverticulum（IDD）が認められた．このIDDは口側の内圧を上げると肛門側に押し下げられ，内圧を下げると口側に膨隆した所見を示した。胃角部後壁にはむらのある発赤を有する小隆起を認めた．IDDと十二指腸球部Ⅱa型早期癌の合併例と診断し，手術で確認しえた．胃の隆起はカルチノイドであった．3病変の合併は文献上見当たらず，大変珍しく，また病因についても興味のある症例である．

　A 76-year-old woman was referred and admitted to our hospital because routine x-ray films in a private clinic had disclosed duodenal dilatation and gastric protruded lesions. She had been. complaining of occasional vomiting since her youth.

　Five days prior to admission, she complained of anorexia and epigastric discomfort. An upper gastrointestinal series first demonstrated a large smooth hemispheric protrusion extending toward the oral direction in the dilated duodenal bulb. Next time, this protrusion had reversed in the direction of the anus and had the appearance of a sack-like structure surrounded by a thin radiolucent line in the second portion of the duodenum. A flat elevated lesion with irregular surface was detected in the greater curvature of the dilated duodenal bulb. A small submucosal tumor in the gastric antrum and a small polypoid lesion in the lower gastric body were detected. Endoscopic examination showed an IDD which was found to be attached to the whole circumference of the duodenal lumen. A small aperture was found in the center of the IDD and permitted narrow passage for a videoendoscope, from time to time by peristalsis, a hemispherical protrusion in the dilated duodenal bulb was found to have transformed into a deep sack, just like the sail of a yacht. A flat elevated lesion in the duodenal bulb, a submucosal tumor in the antrum and a polypoid lesion with irregularred surface in the lower gastric body were noted. Preoperative diagnosis was an IDD, early duodenal cancer of type IIa, aberrant pancreas of the gastric antrum and polyp of the lower gastric body. Postoperative and pathological diagnosis revealed IDD, early duodenal cancer of type Ⅱa, m, a carcinoid and aberrant pancreas of the stomach. Tbis case of IDD associated with early duodenal cancer and with gastric carcinoid is extremely rare and has never been reported. I suggested the posibility that IDD is related to the derivation of duodenal cancer and gastric carcinoid.