malignant cycle症例

malignant cycle

患　者：木○和○　72歳　♂

職　業：医師

主　訴：眩暈，冷汗およびタール便

現病歴：以前より時々腹部膨満感，胸やけを来たしていた．昭和43年10月30日早朝，眩暈，一時的意識障害を来たし，タール便に気づいて来院し即時入院．貧血（++）．図1，2及び3は，その時のレ線，内視鏡像で隣接再発性潰瘍と考えたが，内視鏡的に辺縁の不整から癌も考えられた．その後潰瘍は著しく縮小し，約2カ月余後にはほぼ瘢痕化したので一応良性と判断して退院．しかしⅡc＋Ⅲの疑いもあり，以後，昭和46年3月までに，レ線検査9回，内視鏡検査11回（図4と5，6と7はそれぞれ同時期）施行している（この間明らかな潰瘍の再発は認めていない）．また，昭和44年6月に胃生検を行なっているが癌陰性であった．昭和46年4月6日夜再び眩暈，冷汗，タール便を来たし再入院．

　The case here reported is, strictly speaking, not early gastric cancer, but it was unassociated with lymph node metastasis and had a histological picture closely resembling early cancer.

　Case: K. K., 72-year-old male doctor.

　Chief complaints: vertigo, cold sweat and tarry stool.

　Present history: Since years before he had felt occasional full sensation in the abdomen and heartburn. Early in the morning on Oct. 30 1968, he was dizzy followed by temporary loss of consciousness. As he noticed later tarry stool, he came to our hospital to be admitted at once. Anemia (++). Figs. 1, 2 and 3 show the x-ray and endoscopy pictures exposed then. At first we took them to be recurrence of two neighboring ulcers, but marginal irregularity seen by endoscopy suggested cancer as well. Since then the ulcers became smaller and more than two months later they were almost cicatricized. Tentatively diagnosed as ulcers of benign nature, the patient was discharged. However, we, kept him on our follow-up lists, because a Ⅱc＋Ⅲ lesion was still suspected. Up to March 1971 he had been examined 9 times by x-ray and 8 by endoscopy (Figs. 4 and 5 were taken at the same period and so were Figs. 6 and 7). No definite recurrence of ulcers was recognized in the interim. Gastric biopsy done in June 1969 was negative for cancer. On April 6 1971 he was readmitted because he had another episode of vertigo, cold sweat and tarry stool.

　Physical and laboratory examinations: The patient, of large stature, was well nourished, but slightly anemic. White coat on the tongue. No lymph node was palpated. The stools were positive for occult blood. Sedimentation rate was 27 mm in 1 hour, 72 mm in two hours. Total protein was 6. A/G ratio was 0.7. Red blood cells were 3,550,000 with hematocrit 35.5％ and white blood cells 4,900.

　The course in the hospital: On the 7 th day of admission he had another severe bout of tarry stool with subsequent anemia. In 8 days 1,200 ml of blood transfusion was done. X-ray and endoscopy revealed a highly suspicious Ⅱc＋Ⅲ-like lesion with the second biopsy positive for cancer (in the beginning of June). On 11 June, GPT, GOT and serum bilirubin levels greatly rose, so that he was treated as serum hepatitis until August 3, when he was transferred to the department of surgery. The operation was done on August 12. Pictures of x-ray and endoscopy prior to surgey are shown in Figs. 8 and 9. Histological examination of the resected stomach disclosed Ⅱc＋Ⅲ subtype quasi-early gastric cancer.

　Refection of the case: ―

The tempo of ulcer diminution, regularity of mucosal convergency as well as negative result of biopsy had induced us to treat this benign. Furtheremore, insufficient adhesion of barium meal on the gastric mucosa in the subsequent x-rays, together with the site of the lesion high posterior wall of the body, and the difficulty in obtaining tissue from there led us to the wrong track. More energetic and exhaustive examinations should have been employed.