経過観察中に潰瘍の消失が認められたスキルスの1例

A Case of Gastric Scirrhus Showing Disappearance of Ulcer in the Course of Follow-up

症　例

　患　者：Y. H　58歳　主婦

　主　訴：心窩部痛

　既応歴：33歳子宮外妊娠．46歳急性肺炎．48歳より高血圧症にて加療中．50歳甲状腺腫にて甲状腺切除術を受く．

　家族歴：特記すべきことなし．

　現病歴：昭和47年12月20日頃より心窩部痛出現．その直後から食欲不振となり某医を受診し，12月26日の胃レ線検査で胃体中部大彎側の潰瘍を指摘され，精査を目的に通院加療．翌48年1月6日に胃内視鏡検査および胃生検を施行し，胃生検の結果（mucocellular adenocarcinoma）により本院内科を紹介され，1月25日外来受診ののち2月19日入院．

　The patient, a housewife 58 years of age, complaining of pain in the epigastrium, was found at the initial examination by roentgenography and endoscopy to harbor an ulcer in the greater curvature side of the mid-body. Biopsy specimens taken from the ulcer margins were positive for cancer (adenocarcinoma mucocellulare). However, roentogenography and endoscopy done about one month later showed that the ulcer was gone and no erosion was in sight. One noticed only hypertrophy of the mucosal folds and rigidity of the mucosa in the greater curvature side of the middle corpus. Subsequent twice-conducted endoscopy examinations failed to exactly locate the ulcer scar. Biopsy specimens, totalling to 15 pieces, taken from in and around the greater curvature of the mid-dody where the ulcer had been noticed, were all negative for malignancy. Since the first biopsy was positive and overall pictures of roentgenography and endoscopy were highly suggestive of scirrhus, we performed total gastrectomy. Macroscopically the resected stomach was thickened in general and was of elastic hard consistency. The mucosal folds over the greater curvature of the body were hypertrophic. A scar-like finding was also noticed on the greater curvature of the mid-body with a hint of convergency of the thickened rugae there, but grossly it was hard to discern any Ⅱc finding. Histologic reconstruction of the resected stomach finally made it clear that an Ul-Ⅱ ulcer in the greater curvature of the mid-body was associated with a small area of cancer in the surrounding mucosa. On the other hand, in or beneath the submucosa was found extensive scirrhus (adenocarcinoma mucocellular) with only a small part of the pyloric antrum remaining free from malignancy.

　In retrospect, the present case was an extraordinary one, posing difficulty in clinical diagnosis (biopsy dia-gnosis) because we had to take into account of the so-called malignant cycle of ulcer as it had disappeared in its course and we had difficulty in locating it.