多発型傍乳頭総胆管十二指腸瘻の5例

Multiple Parapapillary Choledochoduodenal Fistulas, A Report of Five Cases and Etiological Consideration

　1973年，池田らは内視鏡で観察された傍乳頭総胆管十二指腸瘻の8例を報告し，本症が総胆管結石の自然脱落と関係の深いものであることを指摘すると共に，その発生機序と関連した分類を提唱した¹⁾．その後，胆石症の患者において本症の診断に注意が払われるようになり，十二指腸ファイバースコープの普及と相俟って報告例が急速に増加してきた^2)～11)．

　筆者らも最近10年間に，先に報告した25例²⁾を含め83例の傍乳頭総胆管十二指腸瘻を内視鏡的に診断したが³⁾，その中にまれな型として乳頭近傍に各々2個ずつの瘻孔を有する5症例を経験した．このような傍乳頭総胆管十二指腸瘻の多発型についてはまだ文献上に記載を見ないので，その臨床的特徴と内視鏡像を中心に，若干の考察を加えて報告する．

　Two choledochoduodenal fistulas can be formed at or near the papilla of Vater. Five such cases, two males and three females, found in our experience with 83 consecutive patients with choledochoduodenal fistula in the parapapillary region are the basis of this report.

　As previously described, choledochoduodenal fistula would be classified into two groups. The ones on the longitudinal fold come under Type Ⅰ; the others at or just orad to the upper margin of the longitudinal fold Type Ⅱ. Multiple choledochoduodenal fistulas in the five patients reported can be expressed as a combination of these two type: Ⅰ+Ⅰ in two cases and Ⅰ+Ⅱ in three. Endoscopic or tube cholangiography showed hepatocholedocholithiasis in one patient, choledocholithiasis without bile duct stone in one, and merely dilatation of the bile duct in one. Reflux of barium into the bile duct was noticed only in one case. A history of biliary colic associated with jaundice and fever was obtained in four of the five patients, one of whom had experienced two such episodes. The other one denied any bout of a jaundice-associated pain. It can thus be conjectured that some fistulas may be formed without interrupting the bile flow. Furthermore, two patients had a past history of a cholecystectomy and common bile duct exploration, at the time of which one or two of their fistulas might possibly be made by a false passage of the metal probe into the duodenum.