超音波内視鏡像からみた胃潰瘍形態と治癒過程―難治性潰瘍診断を目指して

The Use of Endoscopic Ultrasonography for the Diagnosis of Peptic Ulcers and the Detection of Intractable Ulcers

要旨　難治性潰瘍の臨床診断を目的に超音波内視鏡（EUS）で観察される消化性潰瘍像を解析，検討した．EUS施行胃潰瘍例80例（延べ128回）のうち急性潰瘍ならびに急性胃粘膜病変を除いた72例（延べ102回）を対象とした．潰瘍EUS像は，欠損部の深さ，周囲胃壁構造の変化を明瞭に描出し，その形態学的解析が可能であった．Ul-Ⅲ以上の病変についてEUS像と内視鏡的時相との関係，治癒過程を検討すると，内視鏡像に相関するEUS像が理解できたが，瘢痕期については粘膜下層の集中の完全程度を基準にEUS像からみた治癒判定が可能であった．治癒過程および治癒像から難治性潰瘍のEUS像を解析すると，潰瘍周囲から底部に低エコー線維化層が壁状に観察され，潰瘍難治化に大きな影響を与えるものと考えられた．

　Endoscopic ultrasonography (EUS) was performed on 80 patients with peptic ulcers of the stomach. Eighty cases of peptic ulcer were examined before and/or after treatment one or more times each for a total of 128 examinations using EUS. This was done in order to study the clinical course of peptic ulcers, and to detect intractable ulcers.

　This study was based on the analysis of the 5-layerd structure of the gastric wall observed by EUS. In the EUS images, we were able to detect not only the depth of ulcerative defects but also the characteristic images of each stage of the ulcer. Endoscopically, in the active stage of the ulcer, the swelling of both sides of the ulcerative wall caused by hypoechoic edema was detectable in the layered structure. In the healing stage, the swelling of the wall disappeared and the defect grew smaller. In the scanning of the early stage, the defect of the ulcer disappeared showing the tapered submucosal layer with or without the appearance of the hypoechoic mass of fibrosis beneath the submucosal layer. In the late scarring stage, each layer tapered to the center of the scar. Recurrent ulcer showed a defect in the hypoechoic gastric wall with the EUS image of fusion. Intractable ulcers were observed to have hypoechoic masses of fibrosis.

　As mentioned above, EUS diagnosis of peptic ulcer was useful in the evaluation of the clinical course of peptic ulcers and intractable ulcers. However, at present, it is difficult to evaluate the volume of the hypoechoic mass of fibrosis objectively. Further investigation with respect to this problem is necessary for a precise diagnosis of intractable ulcers.