腸結核疑診例の意味するもの

What is meant by “Probable” Intestinal Tuberculosis

病理学的“非特異性潰瘍”の考え方

　われわれが日常臨床の場で腸疾患に遭遇した場合，一般的には，病歴，臨床所見，血液理化学，X線などの検査所見を綜合して診断を下す．そして一定の治療方針の下に治療を行い，治療経過をみてその診断が正しかったかどうかを判定する．

　しかし経過途上，なんらかの理由で病変部の全部または一部が切除され，病理学的な検索が行なわれて，病理学的に“非特異性潰瘍”または“非特異性炎症”と診断された場合，われわれはどう対処するであろうか？

　Pathological diagnosis of“non-specific ulcer”of the intestine indicates an intestinal ulcer in which any specific findings are not pathologically obtainable. However it does not imply that the ulceration has been caused by non-specific inflammation because ulcers of such diseases as intestinal tuberculosis and typhoid reveal non-specific inflammation in the healed stage.

　Definite diagnosis of intestinal tuberculosis has been made exclusively to those patients in whom mycobacteria or caseation necroses were confirmed in the intestinal wall or mesenteric lymph nodes. However, it is impractical because under such a criterion definite diagnosis cannot be made in the patients who did not undergo an operation.

　Lately patients of intestinal tuberculosis without pulmonary tuberculosis have been frequently encountered and moreover mycobacteria in the feces were negative in many of them. Intestinal tuberculosis heals spontaneously in many patients, not to mention those after anti-tuberculous therapy, and in many of them the pathological feature is“non-specific ulcer”. Therefore some means for the diagnosis should be figured out for such patients.

　For such reasons, when intestinal tuberculosis is clinically suspected and when the gross and pathological findings of the resected specimens are consistent with those of healed intestinal tuberculosis, it should be handled as“probable intestinal tuberculosis”.

　Fine examination of the resected specimen and extensive study of the X-ray films including non resected tract are very important for the approach.

　Non-specific multiple ulcers of the small intestine (Okabe et al, 1968) ― chronic hemorrhagic ulcer of the small intestine (Yao, Okabe et al, 1978) and primary ulcer of the mesenteric small intestine (Goldstein, 1964) should be discriminated. The former disease is considered to be a quite different disease from intestinal tuberculosis. However the ulcer is located adjacent to the proximal side of the stenosis in the latter disease, as pointed by Wilson et al (1967); it is possible that the circular stenosis has been caused by intestinal tuberculosis and that some medicine such as KCl has induced the ulceration in proximal side of the stenosis.