内視鏡的胆道造影法によって術前診断した早期胆囊癌の1例

Early Cancer of the Gallbladder Diagnosed Preoperatively by Endoscopic Retrograde Cholangiopancreatography, Report of a Case

　最近，胆道疾患診断法の進歩と共に，少数ながら，早期の胆道癌が術前に診断されるようになった．著者らもERCPによって術前診断できた早期胆囊癌を経験したので報告し，若干の考察を加える．

症例

　患　者：78歳，女，無職．

　主　訴：心窩部痛，発熱，黄疸．

　家族歴：実母が胃癌で死亡．

　既往歴：特記すべきことなし．

　現病歴：20年来，本態性高血圧症にて内科的治療を受けていたが，1977年12月5日夜，心窩部痛を来し，翌朝近医を受診，鎮静剤の注射で疼痛は軽減した．12月9日，心窩部痛が再発し，嘔吐も併発したので前医の往診を受け，発熱と黄疸を指摘され，胆嚢炎の診断のもとに当科に紹介され，入院した．

　A 78-year-old woman patient was hospitalized with epigastric pain, fever and jaundice. Symptoms subsided with antimicrobial agents and symptomatic treatment. Intravenous dripping infusion cholangiography revealed the dilated extrahepatic bile duct, but failed to visualize the gallbladder. The result prompted us to perform ERCP which revealed dilatation of the extrahepatic and intrahepatic bile duct with no shadow defect, stenosis or compression; in the well-visualized gallbladder, a protruded lesion with irregular surface and contour and with rigidity, and a floating shadow defect were detected. Our preoperative diagnosis was of a polypoid cancer of the gallbladder (probably confined to muscle layer) and a floating blood coagulum. Gallbladder was resected along with regional lymph nodes.

　A polypoid lesion (2.7×1.8×0.5 cm) and a small blood coagulum were found. Histological examination revealed that the cancer (well-differentiated papillary adenocarcinoma) was confined within the mucosal layer with no lymph nodes involvement. The patient is in good health 44 months after the operation.

　Subsequently, we have experienced two more cases of protruded type of early cancer of the gallbladder which were found by abdominal ultrasound and diagnosed preoperatively by ERCP; benign polypoid lesions as small as 2 mm in diameter have also been detected by abdominal ultrasound. These experiences led us to believe that the abdominal ultrasound is useful to find a polypoid lesion of the gallbladder and that the differential diagnosis between benign and malignant lesions can be made by ERCP or percutaneous transhepatic cholangiography (PTC); this radiological differential diagnosis can be compared to that of polypoid lesion of the stomach. However, it is difficult at present to assess the depth of cancer infiltration and it remains to be evaluated whether there is a way of radiological interpretation specific to cancer of the gallbladder. Moreover, histological studies on the surgically resected specimens have revealed that many of the superficial type of gallbladder cancers (equivalent to Ⅱa, Ⅱb, and Ⅱc type of stomach cancers) can not be identified even on macroscopic examination.

　In summary, we have just taken the first little step towards the accurate diagnosis of early cancer of the gallbladder despite the recent remarkable advancement in the diagnosis of the diseases of the hepato-biliary tract.