十二指腸憩室，特に傍乳頭憩室の臨床的意義について

Clinical Significance of Diverticulum in the Duodenum, Especially in the Peri-Vaterian Region

　十二指腸憩室に関してはCaseらがレ線的に診断してから，諸家により多くの報告がみられるが，近年，膵，胆道疾患への関心が高まるとともに低緊張性十二指腸造影（以下HDG）が日常検査として行なわれるようになり，十二指腸憩室に遭遇する機会も増加してきている．十二指腸憩室の大部分は無害であると考えられ，従来等閑視される傾向にあったが，傍乳頭憩室についてLemmelはPapillensyndromの呼称のもとにparapapillären Divertikelの臨床的重要性を指摘している．本邦においても第14回日本消化器病学会秋季大会で「十二指腸憩室の臨床」と題するシンポジウムがもたれて討論されたが，憩室の臨床的意義が十分把握されたとはいいがたい．その理由の1つとして憩室が解剖学的にきわめて複雑な位置にあり，近接する諸組織の変化を的確につかむことが容易でないことがあげられる．また，憩室に遭遇する機会が多い割には臨床家の関心がうすかったことも一因であろう．

　Clinical significance of the duodenal diverticulum, especially of Peri-Vaterian diverticulum has been studied in 4,494 clinical cases, 90 cases with confirmed cholelithiasis and 82 autopsied cases. Both in clinical and autopsild cases the rate of detection of diverticulum increased with advancing age. Its incidence in clinical cases was 6.2 per cent and in autopsied cases it was 37 per cent (diverticula more than 5 mm in diameter). Peri-Vaterian diverticulum is defined here in autopsied cases diverticulum in an area from the anal end of papillar protrusion, including that adjacent to it, up to the papilla minor, while in HDG (hypotonic duodenography) it is defined as diverticulum developing within less than 3 cm oral from the papilla major. Symptoms of Peri-Vaterian diverticulum over 10 mm in diameter in cases unaccompanied with other diseases in the digestive tract were non-specific. Slight pain or unpleasant sensation in the upper abdomen was observed in a relatively high percentage. The rate of concomitant biliary tract diseases in 84 cases of Peri-Vaterian diverticula exmined by HDG was 8 per cent. When pancreatic diseases were included it rose up to 11 per cent.

　Association of Peri-Vaterian diverticula with confirmed cases of gallstone was seen in 31 per cent. Choledocholithiasis associated with Peri-Vaterian diverticula more than 20 mm in diameter were seen in a higher rate than in cholelithiasis. In autopsied cases association of gall-sands and gall-stones was seen in 36 per cent in non-diverticular cases, 26 per cent in cases with diverticula and 28 per cent in cases with Peri-Vaterian diverticula (over 10 mm in diameter). X-ray study of Peri-Vaterian diverticula in autopsied cases showed that both bile and pancreatic ducts were dilated. With growth in dimensions of diverticulum it was the bile duct that tended to dilate in a higher degree than the pancreatic duct. Histological examination of 13 cases of Peri-Vaterian diverticula over 10 mm in diameter revealed that they were more often adjacent to the bile duct embedded within the pancreas than to the pancreatic duct.

　Influence of Peri-Vaterian diverticula on the neighboring organs has thus been studied with emphasis laid on their clinical importance.