小腸血管造影の新しい展開―大量小腸出血症例の診断と治療を中心に

Angiographic Examination and Intervention of Small Intestinal Hemorrhage

要旨　過去7年間に経験した小腸出血23例の血管造影診断および血管造影手技を用いた塞栓療法について述べた．23例中20例は大量出血のため救急で血管造影が施行されたもので，17例に21回の救急動脈塞栓術が施行された．その内訳は，小腸潰瘍からの出血8例，上腹部の術後，縫合不全などの合併症のため炎症が血管壁に波及し出血したもの5例，Meckel憩室2例，動静脈奇形および空腸平滑筋腫からの出血各々1例であった．17例中2例の術後合併症例と動静脈奇形の1例が再出血し，再度塞栓術が施行された．止血後7例に待機的手術が施行されたが，粘膜下の浮腫を伴った粘膜の炎症を認めたものが3例で重篤な合併症は認められなかった．小腸大量出血には救急血管造影は極めて有用な診断法であり，超選択的動脈塞栓療法は第一選択されるべき治療法と考えられる．術後合併症で惹起された出血症例では止血後，原因疾患の除去なくして永久止血はありえない．

　The angiographic examination and treatment on 23 patients with small intestinal bleeding were reviewed. All but three patients (one with Behçet's disease and two with Meckel's diverticulum) were presented to us as emergent cases. Immediate or urgent angiographic examinations in 20 patients revealed extravasation of contrast medium or pseudoaneurysm. Seventeen out of these 20 patients underwent 21 emergent superselective embolizations using a microcatheter. Hemorrhagic reasons were identified follows : eight patients with an ulcer, five patients with a pseudoaneurysm which was induced by postoperative complications such as intraperitoneal abscess, two patients with Meckel's diverticulum, a patient with arteriovenous malformation and a patient with leiomyoma. Although complete hemostasis was initially achieved in all cases, hemorrhage recurred later in two patients with pseudoaneurysm caused by postoperative complications and a patient with arteriovenous malformation. There were no major complications such as massive infarction of tissue, ileus or misplacement of embolic materials. After the patient's condition was stabilized by hemostasis, elective surgeries were performed in seven patients. Histopathologic examination of the resected specimens showed no bowel infarction, but mild mucosal inflammation with submucosal edema in the jejunum in three patients. These findings suggested that emergent embolization of microcoils with superselective catheterization technique using a coaxial catheter should be considered as the initial treatment of choice for life-threatening small intestinal hemorrhage. Principal goal of treatment for the patient with bleeding due to postoperative complications is to eliminate inflammatory source after homeostasis.