pyoderma gangrenosumを合併した壊死型虚血性結腸直腸炎の1治験例

Gangrenous Ischemic Procto-colitis with Pyoderma Gangrenosum, Report of a Case

要旨　患者は34歳の女性で，下痢，下血，下腹部痛を主訴に入院した．入院時，大腿内側にpyoderma gangrenosumが認められた．注腸X線および内視鏡検査で直腸から下行結腸に多発する不整形の深掘れ潰瘍とびまん性の炎症所見が認められた．保存的治療を試みたが病勢が進行したため，10日後に左半結腸切除術（Hartmann術式），更に，1週間後に直腸切断術を施行した．切除標本では肉眼的に上部直腸の一部を除き，粘膜はほとんど完全に剝脱していた．組織学的には特異性炎症像や血管の閉塞所見はなく原因不明の粘膜の広汎な壊死性病変であり，その臨床像から考えて，本例はpyoderma gangrenosumを合併した壊死型虚血性結腸直腸炎と診断した．

　A 34-year-old woman was admitted to our hospital. She had been complaining of diarrhea, melena, and lower abdominal pain for about three weeks. When admitted, the patient had pyoderma gangrenosum in the medial thigh, and tenderness and muscle guarding were noted in the subgastric region by physical examination of the abdomen. Clinical laboratory data provided no special findings except for leucocytosis and anemia. Barium enema and colonoscopy revealed multiple irregular ulcerative lesions and diffuse inflammation in their surrounding mucosa in the region from the rectum to the descending colon. The disease was exacerbated although the treatment was conservative. Ten days after admission, emergency treatment (left colectomy using Hartmann's operation) was performed. However, persistent bleeding from the residual rectum required further anterior-perineal resection one week later.

　The two resected specimens showed necrotic lesions of the mucosa from the descending colon to the dentate line with a normal segment at the upper rectum. No significant findings such as specific inflammation and vascular occlusion were obtained by histological examination, and it was thought to be a necrotic lesion of unknown origin. On the basis of the above clinical features, the patient was diagnosed as having gangrenous ischemic procto-colitis with pyoderma gangrenosum. As far as we could find by consulting medical literature, there has been no report on complication of pyoderma gangrenosum with ischemic colitis.