小腸型Crohn病に合併し回腸S状結腸瘻からの生検で術前診断しえた回腸癌の1例

Small Bowel Carcinoma in a Patient with Longstanding Crohn's Ileitis: Preoperative Diagnosis by Colonoscopic Biopsy from an Ileosigmoidal Fistula

要旨　患者は54歳，女性．1982年に小腸型Crohn病と診断され，栄養療法を行うも緩解と増悪を繰り返し，1993年には小腸造影検査で回腸S状結腸瘻を指摘された．2000年2月に水様性下痢と腹痛が増悪したため，当科入院となった．大腸内視鏡検査時のS状結腸の瘻孔開口部よりの生検から腺癌組織が検出されたため，瘻孔部を含めた回腸部分切除術およびS状結腸切除術を行った．切除標本の病理所見では，瘻孔部付近の回腸縦走潰瘍部を中心として固有筋層まで浸潤する高分化から中分化型腺癌を認めた．しかし，術前の画像診断はもとより切除標本の肉眼的観察においてさえも，癌の存在や浸潤範囲を認識することは困難であった．以上の症例の詳細な報告とともに，小腸癌を合併したCrohn病を文献的に集積し，その臨床像を解析した．

　The case of a 54-year-old female with Crohn's ileitis who developed adenocarcimona near an ileosigmoidal fistula was reported. When the patient was 36 years old, the diagnosis of Crohn's ileitis was made by endoscopic and radiologic examinations. Thereafter, she received nutritional therapy with an elemental diet. Eleven years after the diagnosis, an ileosigmoidal fistula was detected. In February 2000, she was admitted to our hospital because of deterioration of her condition, involving diarrhea and abdominal pain. Surprisingly, an adenocarcinoma was detected by microscopic examination of biopsy specimens taken from the orifice of the ileosigmoidal fistula during colonoscopy. Because of this, an ileosigmoidal resection was performed. Macroscopic examination revealed no findings of small bowel carcinoma, but, histopathologically, a moderately differentiated adenocarcinoma infiltrating the muscularis propria was confirmed at the ileum near the fistula. The patient recovered uneventfully and has been free from the condition during the last 22 months. Detailed information on this case and two reviews of Western and Japanese cases of Crohn's carcinoma of the small bowel were included in this report.