総胆管結石症の内科的治療

Medical Treatment for Choledocholithiasis

　総胆管結石症はその病態が複雑多岐にわたるため，正確な診断，病態の把握などに基づく的確な治療が必要となる．本症は治療上，内科，外科両領域にまたがる疾患で，内科的には，合併症を伴う有症状期における鎮痛・鎮痙剤投与，化学療法，経皮経肝胆管ドレナージ（PTCD）が主体であり，原則的には外科的手術が適応となる病態と考える．しかし，高齢化社会になるに従って，高齢者や社会の第一線から引退した人を診療する機会も多くなり，そうした症例では病状が非定型的で，しかも個々によって大きく異なるため，手術時期や適応など，治療に関して苦慮する場合が少なくない．

　本稿では内科的立場より，急性閉塞性化膿性胆管炎に播種性血管内凝固（DIC）を合併した症例を中心に有症状期の化学療法，胆道ドレナージなどについて述べると共に，主として高齢者の剖検例の検討から無症状期，無症状総胆管結石症における治療について私見を述べてみたい．

　Medical management for stones in the common bile duct has been studied in each of the stages when patients had some complaints and when they were free from symptoms, or had silent stones. When there are some symptoms the chief aim of medical treatment is how to cope with concomitant bacterial infection and obstructive jaundice. Bile duct drainage by PTCD or surgery is effective in patients with occlusive jaundice and acute obstructive suppurative cholangitis that show high mortality. After PTCD bacilli in the bile are often positive as the time passes by. Symptoms would often recur by the decreased bile flow caused by bacillary pollution.

　For the individuals that were symptom free or had silent stones we studied stones in the common bile duct by both clinical cases and those of autopsy. Of 1,236 cases autopsied in Nagoya KoseiHospital from March 1961 to December 1980, stones in the common bile duct were seen in 39 (3.3%). Of these, 13 cases (33%) belonged to the silent group. There was no difference between the silent-stone group and the group with some symptoms regarding age, the number of stones and the rate of associated gallbladder stones. However, the biliary duct when alive was far better opacified by excretory cholangiography (oral combined with peroral and intravenous) in the group with no symptoms (45%) than in the group with some symptoms. In clinical cases as well, stones were visualized in all five cases. For individuals with silent stones, surgical operation is indicated generally however, we consider that internal follow-up is possible for the advanced aged who have some basic other diseases and have retired from the active life and whose biliary tract is well opacified by excretory cholangiography.