十二指腸球部の線状潰瘍，とくに環状潰瘍について

Linear Ulcer of the Duodenal Bulb, Especially its Circular Line Ulcer

　線状潰瘍の定義は胃においては比較的明らかで，一般には3cm以上の長さの潰瘍をいう．十二指腸においてはまだはっきりした基準はなく，いわゆる線状潰瘍の存在を認識しながらも，はっきりした定義となると人により多少異なっている．

　十二指腸の線状潰瘍が胃の場合と同様な意義をもつものかどうかまだ多少の疑問がないわけではないが，多くの十二指腸潰瘍を内視鏡的に観察していると，成因的にも経過の上でも円形・不整形などの潰瘍を含めた「線状以外の潰瘍」とはやはり多少異なるという印象をいだく．この中でもとくに長く，ほぼ完全に十二指腸全周を取り巻いており，輪状の変形を内視鏡的に呈するような線状潰瘍をとくに環状潰瘍（circular line ulcer）と称してはどうかと考えている．

　As no definite criteria have been established yet regarding linear ulcer of the duodenum, we have considered endoscopically those ulcers that have a length about more than one fourth of the mural circumference as linear ulcer and the other long ulcers as either line-shaped or linear-like ulcer. When an ulcer is so elongated as to extend to almost the entire circumference of the wall, causing ring-like deformity of the bulb and roentgenologically recognized as hourglass-like deformity, we call it a circular line ulcer, as is exemplified in this paper.

　The patient, a 46-year-old woman, had a previous history of gastric ulcer diagnosed 10 years before. Since then every year in May or June she had suffered periodically from pain in the epigastrium and heartburn. Toward the end of December 1972 she was found to harbor duodenal ulcer at an x-ray examination of the digestive tract, so that she was reterred to our Center. Gastric analysis with 4μg/kg tetragastrin demonstrated hyperhydrochlorhydria, that is one-hour total acid output after stimulation revealed 21.39 mEq/hr.

　Endoscopy revealed a ring-like deformity of the duodenal bulb extending to almost the whole circumference of the wall. A long linear ulcer was seen to start from the anterior wall along it, coursing transversely to the lesser curvature, and on reaching the posterior wall to curve toward the greater curvature, finally ending there near the anterior wall. Bariumfilled x-ray picture showed sharp incisurae on both sides of the bulb, but mucosal relieves tugged from just behind the pyloric ring were not conspicuous, so that the entire bulb looked deformed like an hourglass. It was difficult to depict the long linear ulcer in double contrast picture, but compression made it possible to delineate a linear shadow that suggested a linear ulcer.

　Observation of such a long ulcer is now sufficiently done by the introduction of GIF-D or PFS that permits one to see satisfactorily the greater curvature side. During the period November 1971 through July 1973 we have come across 566 cases of ulcer in the duodenal bulb observed by endoscopy, but we have encountered only a single case of such a long ulcer. In the course of its development the present ulcer showed at one time a picture of shorter linear ulcer linking both sides of kissing ulcer. Perhaps it suggested a formation process of linear ulcer. The area of the circular line ulcer was not strictured as it allowed the endoscope to pass through. How it may undergo morphological changes in the future is very interesting.