孤在性の原発性非特異性小腸潰瘍穿孔例

Primary Nonspecific Ulcer of the Small Intestine

　最近本邦では小腸の非特異性潰瘍が注目されており，特に岡部，崎村が提唱した，いわゆる“非特異性多発性小腸潰瘍症”の報告が多くなされるようになった²⁶⁾．これらの症例は貧血，低蛋白，浮腫，発育障害などを主徴とし，腸管透視により術前に診断されるものも多い．これに対し欧米における“原発性非特異性小腸潰瘍”の報告例は，1805年Baillieが最初に記載して以来，孤在性潰瘍が大部分で，穿孔，出血，閉塞などのため手術をうけ，はじめて発見されることが多く，両者の臨床像がかなり異なることから，同一疾患であるかどうかは異論のあるところである^21)～23)．

　筆者らは76歳女性における回腸潰瘍の穿孔例で，本邦では記載が稀であるが，欧米の報告では大部分を占める孤在性の原発性非特異性小腸潰瘍と考えられる症例を経験したので報告するとともに，多発性慢性潰瘍との比較検討および発生機序についての考察を加えた．

　A 76-year-old female was admitted because of abdominal pain, nausea and vomiting, For the past 8 months she had been suffering from episodes of vague abdominal pain. The days after admission the pain had become severe and peritonitis was suspected by physical examinations. Immediate laparotomy disclosed an area of concentric narrowing accompanied with a perforated ulcer at the mesenteric side of the proximal ileum. The mesentery in this region showed no abnormalities and no lymphadenopathy was present. A segmental resection of the ileum containing the lesion following entero-enterostomy were carried out. The post-operative course was completely uneventful.

　Gross examination of the surgical specimen revealed a small perforation surrounded by localized fibrosis which caused moderate stenosis of the intestinal lumen. In this area the mucosa contained a punched-out ulcer 0.8 by 0.5 centimeters in diameters. Microscopically the lesion was a subacute ulcer with perforation. Moderate fibrosis, inflammatory cell infiltration and congestion were observed in the submucosal space adjacent to the ulcer. Vascular changes such as thrombosis, embolism and arteriosclerosis were not discerned. The findings suggesting diseases caused by the foreignbody, parasite and fungus were not recognized. Specific inflammations such as tuberculosis. Crohn's disease and typhoid fever were also excluded histologically from the cause of the lesion.

　Since 1964, the reports of the nonspecific small bowel ulceration in foreign countries have been remarkably increased. The recently popularized treatment by potassium chloride or diuretics for cardiovascular or renal diseases have been suspected as one of the main reasons for such increased incidence of this lesion in foreign countries. On the contrary, ulcerations possibly caused by these drugs have rarely been reported in Japan.

　In this paper, we have reported a case of a perforated ulcer in the proximal ileum. The result of the clinical and laboratory examinations showed none of such causes mentioned above. So we diagnosed this case as primary nonspecific ulcer of the small bowel. Review of Japanese as well as foreign literature was done putting stress on the etiology of this peculiar lesion.