急性局所性上部小腸炎の2例

Duodenojejunitis Regionalis Acuta, Report of Two Cases

　非特異性局所性腸炎については，本邦においても数多くの報告がみられる．Crohn¹⁾が記載したEnteritis regionalisのⅠ期（急性型），Ⅱ期（亜急性型），Ⅲ期（慢性型），Ⅳ期（腸瘻期）の4病型のうち，外国報告例ではⅢ，Ⅳ期の慢性型が圧倒的に多く，急性型は3～15％と少ない．しかるに本邦では長洲²⁾の集計で局所性腸炎511例中，急性型（亜急性型を含む）は72％であり，石倉³⁾⁴⁾は急性型876例に対し慢性型（亜急性型を含む）227例と報告しており，圧倒的に急性型が多いことが注目される．従って本邦で報告されている急性型の局所性腸炎が，総てCrohn病の急性型であるとは考え難く，現に報告例の大多数は治癒しており，慢性型への移行を証明された症例も見当らない．外国でもBockus⁵⁾は病理学的に急性型から慢性型への回腸終末炎の移行を証明されたものはないというRappaport et al.の言を支持しており，本邦においても同様の考え方が強く，長洲²⁾は本邦急性局所性腸炎の報告例のうち，Crohn病急性型（非特異性局所性腸炎と呼称）の存在は否定し得ないが，大部分は別個のentity（急性局所性腸炎と呼称）に入れている．また石倉³⁾⁴⁾⁶⁾は北海道に多発した急性局所性腸炎は，アニサキス幼虫の感染によるアレルギー性変化であり，本邦報告の急性局所性腸炎の大部分が組織学的にアニサキス症またはそれに酷似あるいは類似のものであると述べている．本邦では急性虫垂炎またはイレウス等の急性腹症の疑いで開腹された結果，回腸の急性局所性腸炎であったという例が主として外科の立場から報告されたものが圧倒的に多く，臨床経過あるいはX線像についての経過観察を行なった症例にはほとんど接しない．

　筆者らは非手術例ではあるが，特異な臨床像を示し，X線検査，内視鏡検査および生検を行なって，経過を観察し得た十二指腸から空腸上部に限局した非特異性の急性局所性腸炎を経験したので報告する．

　Two cases of regional enteritis, localized in the duodenum and the oral segment of the jejunum and completely healing with a subacute course, have been described here for their clinical symptoms, laboratory findings and x-ray observations. In one case duodenofiberscopy was coemployed with biopsy.

　The patients, both male and aged 70 and 50, respectively, had the onset of the disease both in August with an antecedent history of eating greasy food. At the outset the symptoms in both cases were those of acute gastroenteritis, but medical treatment was of no avail and they were admitted to the hospital 10 days after they had fallen ill. They complained of pain in the upper part of the abdomen, nausea, vomiting and loss of appetite. No diarrhoea was seen. The abdomen was not tender, nor was there defénce musculaire. No tumor mass was palpated. Examinations at admission showed positive occult blood in the feces (++ to +++), moderate degree of neutrophilia and hypoproteinemia with increase in α₂-gl level. X-ray pictures of the small bowel disclosed string-like narrowing of the loop, marked edematous swelling of the mucosal folds, irregular and slightly rigid intestinal contour. No ulcer was recognized.

　Subjective symptoms and occult blood in the feces disappeared after two weeks; hypoproteinemia and abnormal x-ray findings were corrected in one month and a half to two months. There was no reccurrence during one year and a half in one case and four years in the other.

　Endoscopy of the 70-year-old man showed unevenness of the mucosal surface due to edema and a lot of erosions with white coat and reddening. After one month and a half erosions and edema went away. Biopsy at the initial endoscopy revealed edema of the lamina propria mucosae accompanied with inflammatory changes such as vascular dilatation and manifest infiltration with neutrophils.

　Both cases are considered different from the acute type of Crohn's disease. The cause is as yet unclarified. At present we are unable to rule out some allergic changes for the manifestations in our cases.