回盲部結核症の診断―手術例12例についての考察

Diagnosis of Ileocecal Tuberculosis: A clinico-pathological study on 12 operated cases

　回盲部結核症は，本邦においては現在においてもまれな疾患ではなく，相当数の症例が報告されているが^{21)24)31)37)38)43)48)52)}，臨床診断の段階で腸結核であるとの確診が得られる症例はわずかである．一方，腸結核症は，クローン病，ときには潰瘍性大腸炎などとの鑑別診断がむずかしい場合もあるといわれている．また，臨床的に腸結核の可能性がもっとも高いと診断した時点においても，今度は治療法の選択ということになると，明確な結論がだせない場合がよくある．

　そこで，われわれは，回盲部結核の診断をより正確なものにするために，最終的に回盲部結核と診断されている手術例12例を用いて，①X線検査，②内視鏡検査（生検），③糞便の細菌学的検査，④切除標本上の細菌学的検査，⑤切除標本の病理組織学的検査，の5項目を中心に再検討し，これらの症例について，①結核と診断する根拠を考察し，つぎに，その結果をふまえて，②回盲部結核の臨床的診断の可能性を検討してみた．

　Radiological, endoscopical, bacteriological and histopathological study was done on 12 cases of ileocecal tuberculosis which had been operated upon in the period of 17 years from 1956 to 1973, and the following result was obtained.

　1, Radiologically, the diagnosis of tuberculosis was made in 8 of 12 cases. In the remaining 4 cases, 1 case was diagnosed as ulcerative colitis; 1 cases as cecal carcinoma associated with ulcerative colitis ; 1 case as carcinoma of the ascending colon and 1 case as Crohn's disease. In the radiological diagnosis, it is most important to visualize not only deformity and shortening of the bowel as a whole but also details of lesion such as linear ulcer, ulcer scar and pseudopolyps by the double contrast radiography. The diagnosis of the ileocecal tuberculosis is made possible by radiological reproduction of macroscopic pathology.

　2. Fibercolonoscopy was performed in 3 cases and they were dianosed as tuberculosis by the characteristic finding of linear ulcer and pseudopolyps. Biopsy was done in 3 cases and a granuloma with a giant cell was found in only one case. In the endoscopical diagnosis careful observation of lesions is required in order to establish the correct diagnosis of tuberculosis. For effective biopsy it is necessary to obtain fragments from the deeper portion of ulcer-margin and ulcer-floor.

　3. Bacteriological examination by stool culture and smear test was performed in 5 cases. Of these, tube-rcle bacillus was identified in only one case by continuous stool culture for 19 days, and smear test was positive for tubercle bacillus in 2 cases. These examinations should be performed in every suspected case, although it is relatively difficult to obtain positive result by them.

　4. Fluorescence method for demostration of tubercle bacillus in the operated material was positive in 9 of 12 cases. However, its result was regarded to be unreliable and excluded from the discussion, because 2 cases were positive for tubercle bacillus in the control study of other 12 cases which had been finally diagnosed as non-tuberculous benign ulcerative disease of the ileocecal region.

　5. In the histological study, characteristic tuberculous granuloma with caseation necrosis was observed in 2 of 12 lesions and in 4 cases of the lymph nodes of all cases. The non-caseous granulomatous lesions which were the main histological finding in most cases could be diagnosed as tuberculosis by the fact that they were similar to non-caseous granulomatous lesions coexisting with characteristic tuberculous granulomas with caseation necrosis.