臨床からみたDieulafoy潰瘍―治療を中心として

Clinical Features of Dieulafoy's Ulcer with Special Reference to Its Therapy

要旨　出血性胃潰瘍により緊急手術で胃切除され病理組織学的検討が可能であった34例のうちDieulafoy潰瘍は5例14.7％であり，全例軽快治癒した．また出血性胃潰瘍に対して，5施設において内視鏡的HSE局注療法が施行された370例のうち，内視鏡所見よりDieulafoy潰瘍と診断されたのは40例10.8％であり，その永久止血効果は38例95％である．以上よりDieulafoy潰瘍は外科的緊急手術をせずに，内視鏡的治療法により十分に止血治癒できる疾患である．

　We report in this paper clinical features of Dieulafoy's ulcers and compare hemostatic effects for those ulcers of emergency operation with endoscopic local injection of hypertonic saline epinephrine (HSE).

　Thirty-four cases with bleeding gastric ulcers were surgically treated on an emergency basis at our hospital between January 1973 and December 1979. The diagnostic criteria for Dieulafoy's ulcer were as follows: (1) solitary ulcer smaller than 10 mm in size, (2) depth of ulcer not exceeding submucosa (Ul-Ⅱ), (3) diameter of an exposed vessel greater than 1 mm. According to these criteria, 5 (2 males and 3 females) of 34 cases were diagonosed as having a Dieulafoy's ulcer (14.7%). The longest diameter of ulcers and exposed vessels were 3-7 mm and 1.12-2.75 mm, respectively. Distal gastrectomy was performed for all five cases with successful results.

　A total of 370 cases with bleeding gastric ulcers treated at five hospitals by endoscopic local injection of HSE were reviewed. From the standpoint of endoscopic ovservation, the diagnostic criteria for Dieulafoy's ulcer are as follows; (1) solitary ulcer smaller than 10 mm in size, (2) gastric ulcer located either in C or M-segment of the stomach, (3) gastric ulcer with an exposed vessel large for ulcer size. Out of 370 cases, 40 cases (32 males and 8 females) were diagnosed as Dieulafoy's ulcer (10.8%). They ranged in age from 34 to 82 years (mean 57.2), and the history of previous episodes of gastric ulcers was obtained in 10 cases (25%). Twenty-four ulcers were found in C-segment and 16 in M-segment of the stomach. Distribution of 40 Dieulafoy's ulcers on the lesser curvature, posterior wall, anterior wall and the greater curvature was 12, 12, 11 and 5, respectively. Pooling of fresh blood in the stomach was observed in 24 cases (60%). Types of bleeding at the time of endoscopic examination was pulsating in 4 (10%), oozing in 14 (35%), forming blood coagula in 7 (17.5%) and responsible vessel being exposed in 15 (37.5%). Endoscopic local injection was conducted 1-5 times (mean 1.9). The hemostatic effect was permanent in 38 (95%) and temporary in 1 (2.5%).

　In conclusion, we believe that endoscopic local injection of HSE is an effective therapeutic method for patients with Dieulafoy's ulcer.