穹窿部にみられた限局肥厚型RLHの1例

A Case of Localized Hypertrophic RLH in the Fornix

はじめに

　噴門部より上，いわゆる天井の病変として考えられるものに憩室，ヘルニア，粘膜下腫瘍，静脈瘤，潰瘍，癌などがあるが，筆者らは，術前悪性変化を強く疑い病理学的検索の結果，限局肥厚型のRLH（癌研中村文献番号1）であった症例を経験したので報告する．

　A 67-year-old female having no complaint was nevertheless found to have an abnormality in her stomach when she underwent a gastric mass survey. At the initial x-ray for thorough check-up, it proved to be a lesion located in the fornix near the posterior wall in the lesser curvature side. A Ⅱc lesion was strongly suspected then because it was associated with abrupt cessation of the mucosal folds around it with club-like swollen tips. However, from the second examamination onward, the focus of the mucosal convergence lacked enough evidence to substantiate whether it is multiple or malignant in its mucosal picture, nor was there any mucosal destruction except slightly rough mucosal surface to which small barium flecks adhered.

　The whole picture was more suggestive of either multiple, or multiple linear, ulcers. What was most outstanding in the endoscopy picture was that the tips of the rugae did not converge at one point, and one of them coursing transversely from the posterior wall to the lesser curvture was here and there almost being broken off, its swollen tip finally reaching a bleeding small ulcer. Those mucosal folds coming from the anterior wall as well as from the cardiac side were also knobby at their bleeding tips. As a whole, marked constriction and deformity of the wall together with its poor distensibility was apparent, but no definite Ⅱc-like depression was in evidence. However, in addition to the afore-mentioned rugal changes, multiple erosions were also recognized from the depressed center of the ulcer to the posterior wall, so that malignancy was after all very suspicious, nor could it be completely ruled out before the operation because biopsy was not performed.

　The gross specimen of the removed stomach presented an irregular linear ulcer with prominent mucosal folds converging toward it from the anterior wall. A Ⅱc-like depression was also seen on its posterior side. Histopathologically, no cancer cells were seen in the Ⅱc-like depression. After all, it was a Ul-Ⅲ linear ulcer associated with hypertrophic, localized RLH.

　Some retrospective comments on its clinical diagnosis before the surgical intervention have been added.