大腸クローン病―著明なmucosal bridgeを形成した1例を中心に

A Case of Crohn's Disease Associated with Formations of Aggregated “Mucosal Bridge”

　クローン病は潰瘍性大腸炎とともに原因不明の炎症性大腸疾患inflammatory bowel disease(IBD)を代表する疾患で，慢性の経過をたどり，治療に難渋することがきわめて多い．最近われわれは長期間の経過観察中に再発し，再手術を余儀なくされた大腸クローン病を経験した．切除標本の病変部はmucosal tag，mucosal bridgeを形成する著明なinflammatory polyposisを伴っており，特異な肉眼形態を呈していた．本稿ではこの症例の臨床並びに病理所見を紹介し，併せて結核や潰瘍性大腸炎との鑑別診断につき，若干の考察を加える．

　症　例

　患　者：塩○俊○　44歳　男　織物業

　主　訴：右臍部の有痛性腫瘤，腹部膨満感

　家族歴：特記すべきことなし

　既往歴：30歳の時虫垂切除術

　現病歴：32歳の時右下腹部の鶏卵大の腫瘤ならびに腸管狭窄症状をきたし，金沢大学第1外科にて大腸右半切除術を受け(1965年4月3日)，病理診断により大腸クローン病であることが判明した．その後約10年間腹部症状はなく，順調に経過しているが，初回手術半年後より，手指，足，膝関節などに非対称性，かつ移動性の関節炎をみており，鎮痛剤やステロイド投与などにより軽快している．1976年1月頃より右臍部に再び有痛性の腫瘤を認め，某病院にてクローン病の再発として内科的治療を受け，一時寛解した．しかし，同年6月再び腹痛が増悪し，腹部膨満，るいそうが著明となり，subileus症状を呈したため，当科へ転科した．

　Recently our interest in Crohn's disease has been coming up also in Japan because of gradual increase of its incidence and as one of recent topics in the modern gastrointestinal diagnostics. A case of Crohn's disease associated with inflammatory polyposis formed by aggregated mucosal bridge is reported.

　The patient was a 44-year-old male, who in 1965 (he was then 32-year-old) developed clinical symptoms of Crohn's disease with a tender mass in the lower right part of the abdomen and showed the radiological findings such as longitudinal streaks of barium indicating ulcerations in cecum and distal half of ascending colon. In April 1965 the constricting lesion of inflamed bowel including terminal ileum, cecum and ascending colon was resected. Histological examination of resected bowel revealed transmural inflammatory changes consisting with Crohn's disease. The post-operative course was uneventful and he had a good recovery. About two months later after operation he suffered from a peripheral arthritis which was considered as joint manifestation of Crohn's disease. He was treated with corticosteroids for about one year and his peripheral arthritis regressed. In Jan. 1976 he had a recurrent abdominal mass with marked tenderness and temporarily his symptoms responded well to Azulfidine. In June 1976 his abdominal trouble became worse with an occasional bowel obstruction and marked weight loss. In Aug. 1976 right ileocolectomy including the prior anastomotic site was carried out because of frequent attacks of partial colonic obstruction. Grossly there was marked involvement of inflammatory process in the proximal transverse colon measuring 11 cm long from the anastomotic site, where inflammatory polyposis formed by aggregated mucosal tag and mucosal bridge and multiple undermined ulcerations were seen. Histological findings, fissuring ulcers and submucosal fibrosis, so that the diagnosis of recurrent Crohn's disease was made.

　Because of very few cases of this kind of Crohn's disease associated with mucosal bridge reported so far in the literature in Japan, emphasis is laid on discussion of differential diagnosis from colonic tuberculosis and ulcerative colitis.