潰瘍性大腸炎との鑑別が困難であった大腸結核の1例

Tuberculous Colitis Simulating Ulcerative Colitis: Report of a case

　大腸結核は回盲部を中心とする右側結腸にみられることが多いため，Crohn病との鑑別が問題となり，最近にわかに注目を集めるようになってきた．わが国においては，この部位の腸結核はCrohn病よりむしろ頻度が高いのではないかと推定されるほど，日常遭遇する機会が決して少なくない．しかし，潰瘍性大腸炎と鑑別を要するような大腸結核の症例はほとんどないといってもよい．

　われわれの経験した症例は，潰瘍性大腸炎ときわめてよく類似しており，また過去にそのように治療されていたという点が興味深いので，ここに提示したい．

　A 50-year-old lady was admitted to our clinic with a long history of diarrhea and abdominal pain. She had a history of intestinal tuberculosis 26 years previously. Her symptoms of diarrhea and abdominal pain continued for five years since 1969 without blood discharge. In 1972 she was admitted to a local hospital due to severe diarrhea, abdominal pain and high fever. She had anemia. Barium enema showed multiple ulcerations of the entire colon, the appearances suggesting active ulcerative colitis. She was treated by oral steroid with good result and was discharged. However, since then she was readmitted to the hospital twice due to similar symptoms until 1974 when she was transferred to our clinic for surgical treatment of ulcerative colitis. On admission she had a tender mass of the ileocecal region, diarrhea and slight hypoproteinemia. Barium enema showed shortening of the colon with inflammatory polyposis, the appearances suggesting healed ulcerative colitis. However, colonoscopic biopsy showed granulomas of the lamina propria, suggesting tuberculous colitis which was never suspected previously. Steroid was withdrawn and antituberculous drugs (PAS & INH) were administered with slight improvement of her symptoms. Her Mantoux reaction was positive but continuous fecal culture for tuberculous bacillus was always negative. Her rectum was not involved. As her symptom was not improved very much by antituberculous drugs, total colectomy with ileorectal anastomosis was carried out.

　The operation specimen showed shortening of the entire colon with thickening of the pericolic fatty tissue, atrophy of the mucosa and inflammatory polyposis. The histology cofirmed mucosal atrophy with numerous sarcoid-like, atrophic granulomas throughout the bowel wall. The mucosal findings were similar to those of ulcerative colitis, whereas the presence of granulomas was similar to those of Crohn's colitis. However, one of the mesocolic lymphnodes showed a large granuloma with central hyalinisation which was very suggestive of tuberculous colitis. Postoperative course was uneventful and she has been doing well since discharge.

　The clinical course and histological appearances of this case were rather unusual for tuberculous colitis. Hewever, it should be remembered that tuberculous colitis could mimick any from of other colitis clinically and histologically, and histological examination of regional lymphnodes is of vital importance for the differential diagnosis of colitis.