大量下血を主訴とした単発性空腸憩室の1治験例

Massive Bleeding from Jejunal Diverticulum: Report of a case

　消化管憩室に占める小腸憩室の頻度はMeckel憩室を除けばきわめて低く，剖検時および開腹時に偶然に発見される場合が多い．われわれは本邦第1例目と思われる大量出血をきたした単発性空腸憩室の稀な症例を経験したので報告する．

　The patient was a 48-year-old man who entered the Ehime Rosai Hospital on May 9, 1975, with a history of several tarry stools of about thirteen hour's duration with abdominal pain, nausea, vomiting and dizziness. He had frequently complained of epigastric discomfort for a year. Two months prior to his admission, he had the radiographic examination of the upper gastrointestinal tract which showed no peptic ulcer. Nevertheless, he had complained of epigastric discomfort, general fatigue and anorexia in the past month.

　On admission he was pale and physical examination revealed the following: the blood pressure, 94/54 mmHg; the pulse rate, 64; and the temperature, 36.5℃. Abdominal examination revealed nothing abnormal except for the presence of tarry stool on rectal examination. The nasogastric suction was clear. He received 500 cc of dextran and 500 cc of Hartmann's solution and his vital sign stabilized.

　Four hours later after admission, he had having to pass frequent maroon colored blood through the rectum. He became hypovolemic shock. The blood pressure was 78/50 mmHg and the pulse rate 116. The red blood cells was 235×10⁴, the hemoglobin 8.1 g/dl and the white blood cells 7,500. His vital sign improved after being transfused with 500 cc of dextran and 1,200 ml of whole blood.

　The emergency operation revealed that the small intestine and the large bowel were filled with blood. The duodenum was opened but no ulcer or bleeding point was discovered. A large solitary saccural diverticulum was found about 60 cm distal to the ligament of Treitz, which pouched out from the lateral wall of the jejunum. A segmental resection of this portion of the jejunum was accomplished with end to end anastomosis. Finally, he was transfused with 1,000 cc of dextran and 3,800 cc of whole blood. There was no further bleeding and his postoperative course was uneventful.

　The resected diverticulum measured 4.5×2.5×2.0 cm in size and the ostium was 1.5 cm in diameter. There was a linear ulcer in its fundus. When examined microscopically the sac was found to be a true diverticulum with the muscle layer containing the linear ulcer and the scar of an ulcer. However inflammatory changes were not seen. This was a first case reported in Japan, which showed massive bleeding from a solitary jejunal diverticulum.