出血胃潰瘍の診断と治療

DIAGNOSIS AND TREATMENT OF BLEEDING GASTRIC ULCER

Ⅰ．緒言

　上部消化管出血はもっとも積極的な医療行為が要求される疾患群の一つであり，その診断と治療は迅速でしかも適切でなければならない．しかし，大量出血例において緊急事態下に出血源を確実に判定し，その予後を正しく推定することがしばしば困難をきわめることは．だれしも経験するところである．

　上部消化管出血の出血部位と出血源を正確に知ることは，適切な治療を加えうるか否かの決定的因子となることが多く，このため欧米では比較的古くから早期に積極的に胃鏡，食道鏡による内視鏡検査を実施することの必要性が強調されてきた．とくにPalmer¹⁾²⁾のVigorous Diagnostic Approachはもっとも有名であるがChandler³⁾，Jones⁴⁾⁵⁾ら早期胃鏡検査の重要性について述べたものが少なくない．

　In the active management of bleeding from the upper digestive tract, stress has been laid in Western countries on the need of early endoscopic examination by means of esophagoscope or gastroscope. The latter, however, has not so often been used as it should have been done due to its inherent mechanical limitations. The advent of fiberscope, or a pliable gastroscope, now makes it possible to perform early endoscopical study in cases of esophageal or gastric hemorrhage in far easier and safer way. Its effective use since then has often been reported in this country as well.

　Observation of bleeding stomach by fiberscope can almost as easily be done as in non-bleeding ulcer, provided that examiner is versed in the use of the tool, besides being careful in the process of examination.

　Various characteristic features have been found by endoscopic studies of many cases of gastric ulcer and based on their evaluation, four types of bleeding ulcer are classified as follows: typical bleeding type ulcer; atypical bleeding type ulcer; acute exacerbation type of chronic ulcer; and ulcer in its healing stage. Gratifying results have been obtained in the observation of these four types of bleeding ulcer, as they can be identified in most of cases even when endoscopy is done shortly after the onset of hemorrhage.

　Since the course of treatment in bleeding ulcer depends much on the identification of the source of bleeding by earliest possible fiberscopic examination, its effctive employment is specially stressed in this paper. It is furthermore expected that, according as fiberscope comes into wider use, many diagnostic difliculties in this respect will be far lessened in the future.