糖尿病性ケトアシドーシスに合併した虚血性小腸狭窄の1例

Ischemic Stricture of the Small Intestine Combined with Diabetic Ketoacidosis, Report of a Case

要旨　糖尿病と冠動脈硬化症を有する53歳の男性が傾眠傾向を主訴に北里大学病院に入院．糖尿病性ケトアシドーシスとうっ血性心不全の診断のもとにインスリン持続静注療法が行われた．意識状態および諸検査成績は改善しつつあったが，入院前後より腹痛発作と嘔吐を繰り返しイレウスが疑われた．第19病日の小腸X線検査で中部小腸に多発性の分節性狭窄部が発見され，その後も狭窄の進展がみられたため第47病日小腸部分切除術施行．切除標本（59cm）では全周性潰瘍と線維性壁肥厚を伴う管状狭窄が多発し，組織学的にも循環障害による小腸病変と診断された．本病変の成因として，全身性動脈硬化症とコントロール不良の糖尿病を背景に，糖尿病性ケトアシドーシスに伴う血液粘稠度や血小板凝集能の充進が増悪因子となり，虚血性小腸狭窄へ進展させたと考えた．

　A 53 year-old man was admitted to our hospital complaining of abdominal pain and somnolence. He gave a history of uncontrolled diabetes mellitus in the past several years and an acute myocardial infarction two years prior to the admission. Physical examination and laboratory data led to the diagnosis, diabetic ketoacidosis (DKA) and congestive heart failure. Therefore, insulin was started intravenously by a microinfusion method. During the course of the recovery from DKA, the patient had several episodes of colicky abdominal pain and vomiting, which suggested a mechanical ileus of the intestine. Roentgenographic examination performed on the 19th hospital day revealed multiple strictures and a long segment of narrowing with thumbprinting in the middle portion of the small intestine. Selective superior mesenteric arteriography, however, failed to reveal any abnormality.

　Further deterioration of the intestinal obstruction prompted us to perform partial resection of the small bowel on the 47 th hospital day.

　The specimen obtained was 59 cm long, and showed three stenotic segments with circumferential ulcers and fibrotic walls. Histological evaluation disclosed three characteristic findings:

　1. Intense submucosal fibrosis with dilated and congested small vessels.

　2. Vascularized granulation tissue protruding from the base of the ulcer.

　3. Hemosiderin deposition through out the layers of the intestinal wall.

　These clinical course and pathohistological findings are, we believe, compatible with ischemic lesions of the small intestine.

　There were several contributing factors in causing these lesions in this case, such as :

　1. The patient had generalized arteriosclerosis and uncontrolled diabetes mellitus as background diseases ;

　2. Several features of DKA, such as increased viscosity of the blood and aggregation of platelets, may also have played an important role as aggravating factors.