腸壁壊死，出血，潰瘍形成および穿孔など多彩な腸病変を呈した結節性動脈周囲炎（PN）の1例

A Case Report of Periarteritis Nodosa, Showing Various Intestinal Lesions such as Infarction, Bleeding, Ulcer and Perforation

　Kussmaul，Maierが1886年はじめて，結節性動脈周囲炎を報告して以来，本症は臨床的に，腹痛，食思不振，体重減少，嘔吐，腹部膨満，さらには下血などさまざまな腹部症状を伴うことが知られている¹⁾．また剖検では，胃腸管壁に多発性潰瘍がしばしば見いだされることが知られている．しかし臨床上，これらの腹部症状が重篤で外科手術の対象となる例は欧米では多数の報告^1)～11)があるが，わが国ではきわめて少ない¹²⁾¹³⁾．

　今回われわれはイレウス症状で発症し，2回の腸切除術後死亡，剖検しえた1例において，腸間膜，腸管にきわめて限局した本動脈炎の存在と，それのもたらす，腸壁壊死，潰瘍および穿孔，粘膜下の出血および線維化など多彩な腸管病変を観察したので，報告する．

　A case of polyarteritis, especially involving the bowel, is reported. A 70-year-old male was admitted to the hospital in November 1972 complaining of severe lower abdominal pain, distension of abdomen, constipation, nausea and vomiting. The first surgical exploration of the abdomen was performed shortly after admission. Two patchy areas of necrosis involving the ileum were found and partial ileal resection with anastomosis was performed. Study of ileum resected at that time confirmed only acute infarctions of the bowel wall. There was remarkable improvement until March 1973, when he was again admitted to the hospital with pain and distension in the right lower abdomen. On the second admission, there were hypoplastic anemia, hypoproteinemia, hypergammaglobulinemia and hypocholesteremia. A superior mesenteric arteriogram showed stenosis, meandering and development of collateral circulation of small branches of ileocolic artery. At the second operation, multiple ulcers and thickening of mesentery were found. Partial ileocaecal resection with anastomosis was performed. Multiple ulcers were based on the antimesenteric border, irregular in shape and surrounded by highly regenerated villi. Microscopically, the small arteries and arterioles of the mesentery and the bowel wall presented necrotizing arteritis with acute and chronic inflammatory changes, fibrinoid degeneration and intimal fibrosis, presenting stenosis and occlusion, in which lesions were of varying stages. The areas of thickening of the bowel wall were caused by mucosal and submucosal fibrosis. Postoperatively, the patient's condition remained poor. Melena and pneumonia developed, and in spite of treatment with steroids and antibiotics, he expired 2 months after the second operation.

　At autopsy, there were perforations of large intestine with focal suppurative peritonitis. Although widespread arteritis involved many organs, the lesion was not severe. The lungs revealed extensive interstitial pneumonia.

　Gastrointestinal involvement in polyarteritis has been frequently reported in Western countries but very rarely in Japan.