臨床よりみたDieulafoy潰瘍―診断を中心に

Diagnostic Aspects of Dieulafoy's Ulcer

要旨　Dieulafoy潰瘍は，上部消化管出血の原因として頻度は少ないものの，その急激な変化のため，的確な診断を早急につける必要がある．また，最近内視鏡的止血法の発達により保存的な止血の可能性もあり，その診断における内視鏡の意義は大きい．Dieulafoy潰瘍は胃体上部の小彎近くの前後壁を好発部位とし，Ul-Ⅱの小さな浅い潰瘍の中に太い血管による小隆起を有し，潰瘍周囲にconverging foldや，周堤や，明らかな再生の反応を伴わないことが内視鏡的特徴である．Dieulafoy潰瘍の本態は，粘膜下層を異常走行する太い動脈と思われるが，その異常動脈の太さ，およびその血管の上の浅い粘膜欠損の大きさなどについて，未だ一定した基準はない．Dieulafoy潰瘍が自然止血を繰り返して長い経過をとったり，また今後内視鏡的止血法などにより，潰瘍および血管に急性期と異なる変化が加わってくる可能性があると思われる．

　Dieulafoy's ulcer, though rare as a cause of upper gastrointestinal bleeding, requires prompt diagnosis because of its rapid clinical course. Endoscopy plays an important role as a diagnostic method and more so as endoscopic hemostasis has recently made conservative hemostasis possible. Dieulafoy's ulcer occurs most frequently on the anterior or posterior wall near the lesser curvature of the upper gastric body.

　Endoscopically it is characterized by a slight elevation due to large artery in a small, shallow Ul-Ⅱ accompanied by neither a converging fold, surrounding elevation nor apparent regenerative reaction. Although the essential feature of Dieulafoy's ulcer is generally considered to be an abnormally tortuous and large artery in the submucosa, diagnostic criteria regarding the size of the artery or shallow mucosal defect are not yet firmly established. There is a possibility that repetitive spontaneous hemostasis for long period of time or endoscopic hemostasis causes pathological changes in the ulcer and artery, quite different from the acute phase findings.