瀑状胃の内視鏡検査

ENDOSCOPIC STUDY OF CASCADE STOMACH

Ⅰ．はじめに

　胃疾患の診断，治療，研究の分野において内視鏡はすでに不可欠のものとしてその実績をあげつつある．X線検査法との組合わせによる相乗的な効果は多くの人々の認めるところであろう．

　ところで，胃内視鏡検査において噴門，宥薩部，体上部後壁などの部位は，その観察に多少の技術的な問題があり，更に胃内視鏡の構造上の制約があったり，病変の出現頻度が幽門部や胃角部などに比して少ないということもあって，しばしば十分な観察をすることなく終るという恐れがないとはいえない．X線検査においてもこの部位は診断学的に容易とは言いにくいこともまた事実であろう．しかし，ここまで進歩した胃疾患の診断学において，多少観察しにくくても，また病変発現頻度が比較的低くても，それを理由にこの部位がとりのこされることはもはや許されない．胃内視鏡検査は「すべての部位を十分に」（Complete and thorough）把握するものでなければならない．

　反転法やすでに開発されている新型Vb型胃カメラなどは，強い変形を伴わない胃におけるこの種の問題をかなりな程度まで解決していると思われ，先の第11回日本内視鏡学会総会におけるシンポジウムの中で遠藤，斉藤らがなした総括は記憶に新らしい．

　そこでここには変形胃のうちで最もしばしば遭遇する瀑状胃の内視鏡検査について2，3述べてみたい．

　Cascade stomach, a morphological designation in roentgenology of a gastric deformity, is now interpreted in a wider sense irrespective of its causes. One of its characteristics is a stricture of the upper posterior wall directly distal to the cardia in such a manner as the fornix is cut off like a sack to the left and backward. In the neck are often found mucosal changes.

　Endoscopic study of this variety of gastric deformity is mostly not difficult, but in cases of outstanding deformity, some “knacks” are expedient to endoscopic maneuver.

　The tip of an endoscope, entering the gastric lumen down from the cardia, first runs against the posterior wall in the fornix which forms the upper loculus. If pushed forward as it is, the endoscope is apt to damage the mucosa and to provoke nausea, giving the patient unnecessary pain. For further insertion down into the corpus, an endoscope must be given an “up” and axis rotation to the left, to watch the stricture and pass it over. If rotated axially to the right, the endoscope will go deeper into the fornix. In case of an endoscope with its tip for observation is fixed, it must be inserted with enough air in the phase of inspiration putting the patient on his right side.

　In cascade stomach mucosal changes such as ulcer or cancer lesions are often found in the constricted part on the upper posterior wall. Observation of this area is therefore of major importance along with the confirmation of any extragastric pressure. For sufiicient study of this region, the corpus must be fully stretched and the endoscope must be given right axis rotation and a “down” so that bending part of upper posterior wall might be the better observed with enough distance in between.

　Cascade stomach was observed in our center during three months from August to October 1968 in 57 cases (5.7 per cent) of a total of 1002 which were examined fluoroscopically after administration of Buscopan. Of these, ulcer on the upper posterior wall was observed in five cases and cancer in four likewise on the upper posterior wall.