難治性胃潰瘍―X線所見を中心に

Radiographic Findings of Intractable Gastric Ulcers

要旨　H₂受容体拮抗薬あるいはomeprazole治療にて8週間で治癒しなかった胃潰瘍47例（難治群）と8週以内に治癒し，かつ難治群と大きさをマッチさせた62例（易治群）の間で，治療開始時のX線所見を最初に単変量分析で比較し，次いで多重ロジスティックモデルを用いていかなる要因が両群の判別に有効であるかを検討した．単変量分析にて難治群に有意に多かったX線所見は胃角小彎の線状潰瘍，深い潰瘍，Schwellungshof以外の潰瘍壁のあるもの，粘膜集中高度なもの，粘膜のまくれこみ，潰瘍底の不整，線状潰瘍の間接所見としての前庭部小彎短縮，囊状胃，小彎のU字変形であった．多重ロジスティックモデルを用いて，X線所見からみた難治性潰瘍の予測を行ったところ，小彎のU字変形，Schwellungshof以外の潰瘍壁のあるもの，および粘膜集中高度の3要因が有意かつ独立の難治要因となり，それぞれの相対危険度は14倍，14倍，12倍となった．そして，小彎のU字変形のあるもの，Schwellungshof以外の潰瘍壁のあるもの，および粘膜集中高度なものが難治性潰瘍である確率はそれぞれ72％，72％，69％と判定された．これらの要因が2つ以上あればほぼ100％が難治性潰瘍と予測できた．X線所見に内視鏡所見を加えても両群の判別率は向上しなかったが，上記X線所見に治療開始後2週間以内の症状消失の有無が加われば両群の判別率は更に向上した．

　Radiographic and endoscopic findings, and clinical characteristics of patients were analyzed in 109 cases of gastric ulcers which were treated with H₂-receptor antagonists or omeprazole. Intractable ulcers are designated as ulcers which did not heal within 8 weeks of treatment (n＝47), and tractable ones those which healed within that time (n＝62). In order to exclude the effect of size of ulcer upon healing, lesions over 15 mm in size were selected from the tractable group for study, so that the size of ulcers was matched between the two groups. The following radiologic findings in the intractable group were present in significantly higher incidence than those in the tractable group: location on the angle, linear ulcers, greater depth, an ulcer wall without edema, severe fold convergence, overhanging of surrounding elevated mucosa (so-called makurekomi), irregular base, shortening of the lesser curvature, and a U-shaped deformity on the lesser curvature. Endoscopically, uneven surrounding mucosal elevation, greater depth, and linear ulceration had a significant delaying effect on healing. Concerning patient characteristics, a past history of gastric ulcer and the persistence of symptoms despite greater than 2 weeks of treatment had significant delaying effects on healing.

　As these factors may be related, a multiple logistic regression analysis was performed to clarify the relative importance of various factors associated with healing. The result showed that the following three factors had a significant and independent delaying effect on healing: a U-shaped deformity of the lesser curvature, an ulcer wall without edema and persistence of symptoms despite 2 weeks of treatment. The relative risk of these factors were 24.4, 23.7 and 10.7 respectively. A U-shaped deformity of the lesser curvature on radiologic examination predicted a 71% likelihood of intractability. Similarly, an ulcer wall without edema and persistence of symptoms for more than 2 weeks of treatment predicted that 70% and 51% respectively would be intractable ulcers. Cases with more than two of these factors are nearly always intractable.