再発を繰り返したクローン病の検討

Case Study of Recurrent Crohn's Disease

　クローン病は，口腔から肛門までの消化管のどの部位にも発生し得る線維化や潰瘍を伴う肉芽腫性，全層性炎症性病変で非乾酪性類上皮細胞肉芽腫などを組織学的特徴とする疾患であるが，しばしば再発を繰り返すこと，腹部の瘻孔，腸の狭窄や栄養障害，貧血，関節炎，虹彩炎，肝障害などによって患者が長期間病苦にあえぐことはよく知られている．われわれの経験した数例のクローン病のうち2例の再発症例をとりあげ，その臨床像を検討したので，若干の文献的考察を加えて報告する．

症例

〔症例1〕初診時25歳，現在27歳，男子，会社員（営業担当）

　主　訴：右下腹部痛，るいそう

　家族歴：特になし

　既往歴：17歳の時急性虫垂炎にて虫垂切除をうけているほか特記すべきものはない．

　現病歴：1974年5月頃より，食事摂取や排便とは無関係に右下腹部のしくしくする痛みがあり，上腹部の重圧感，腹部膨満感，嘔気などを伴っていた．近医にて十二指腸潰瘍を指摘され，注射療法で上腹部の愁訴は改善されたが，下腹部のとう痛は次第に増強してきたので，1975年4月8日，当科外来を受診した．初診時，身長170cm，体重49kgで過去8カ月間に8kgの体重減少をみていた．食欲は普通で，毎日1行普通便があり，血便，粘液便などの異常はみない．白血球増多12,300，CRP（+++），α2-グロブリン高値15.0％，などを認め，腹痛は一進一退であったので精査の目的で1975年8月29日入院した．

　Case 1. A 27 years old. man.

　For two years the patient had suffered from lower abdominal pain. Laboratory data showed leukocytosis, exceedingly positive C-reactive protein, a high content of α2 globulin, accelerated sedimentation rate of erythrocyte, and hypoproteinemia. X-ray examination revealed strictures, round or linear ulcerations at the distal half of the ileum. Besides these ulcers a submucosal tumor-like protrusion at the end of the ampulla recti was found by proctoscopy, and characteristic findings of Crohn's disease i. e., non-caseating granuloma with polynuclear giant cells were obtained through biopsy specimen from the tumor-like lesion. The diagnosis was reconfirmed by the operation done eight months later. He regained a comfortable life. About 16 months later; he again complained of occasional abdominal pain and emaciation, and was hospitalized. Recurred longitudinal ulcers and spicular shadows near at the anastomosed part of the small intestine were found by X-ray examination. He has been carefully observed under hospitalization.

　Case 2. A 30 years old. man.

　The patient developed diarrhea, loss of weight and fever since 23 years of age. Right hemicolectomy with terminal ileum resection was done at 24 years of age. One year after operation, he suffered from periproctal abscess, diarrhea and abdominal pain. Reoperation was done when he was 26 years old. Histological findings of the resected intestine showed non-caseating giant granulomas, pseudopolyps and crypt abscess. Therefore the disease has both characteristics of Crohn's disease and ulcerative colitis on histopathology, but clinical course suggests Crohn's disease. He is now complaining of several external fistulas on the abdominal wall and living a miserable life.