血行再建術後に発生した虚血性腸病変の1例

An Ischemic Enteritis Associated with Aorto-iliac Arterial Reconstruction, Report of a Case

要旨　患者は63歳，男性．18年間の糖尿病と高血圧の既往歴を認めた．閉塞性動脈硬化症に対して腎動脈下に大動脈を遮断し，大動脈の血栓内膜摘除術，大動脈～両側大腿動脈バイパス術を施行した．術後1病日に右下腹部痛，発熱，白血球増多がみられ，同時に心筋梗塞を発症した．腹部所見が比較的軽度であり，心筋梗塞急性期であったため禁食，抗生物質投与，輸液療法で保存的治療を行った．術後36病日の注腸造影で回腸～上行結腸瘻，回腸～回腸瘻が確認された．その後も経口摂取を開始すると消化管通過障害を訴え，炎症所見の増悪がみられたため，初回術後4か月目に回腸，上行結腸切除術を行った．病理組織学的所見で虚血性腸炎による粘膜の広範な脱落，再生と粘膜下の著明な線維化がみられた．また，粘膜下の小動脈にコレステリン結晶塞栓と漿膜下の中小動脈にも動脈硬化の所見を認めた．以上から動脈硬化症を基礎としたコレステリン結晶塞栓による虚血性腸炎が考えられた．患者は再術後2週間目に軽快退院した．

　A case of ischemic enteritis due to aorto-iliac occlusive disease is reported. A 63-year-old man underwent aorto-iliac arterial reconstruction. On the postoperative day 1, he developed abdominal pain with localized tenderness in the right lower quadrant abdomen, leukocytosis and positive CRP. Abdominal pain and diarrhea were cured within several days by intensive medical treatment. Barium enema on the postoperative day 38 revealed narrowing and fistula formation between the ascending colon and ileum. A partial resection of the small intestine and ascending colon was performed for the persistent stenotic symptoms four months after the first operation. Histological examination demonstrated severe segmental and circumferential ischemic changes with ulcers and a fistula. Submucosal and serosal arterioles throughout the ascending colon and ileum had cholesterol emboli. He was discharged without complaint two weeks after the second operation and remained well. The follow-up angiography showed segmental occlusion in a branch of the superior mesenteric artery, which was not found preoperatively.