Dieulafoy潰瘍の1手術例

Dieulafoy's Ulcer, Report of a Case

要旨　患者は63歳，男性．主訴は吐下血．7年前に原因不明の下血あり．1984年4月突然心窩部痛が出現し，その翌日吐下血があり入院した．入院時のHb値は12.7mg/dlで翌日の内視鏡検査にて体中部前壁に皺襞集中の明らかでない露出血管が目立つ浅い小潰瘍を認めた．cimetidineの経静脈的投与にて出血の兆候なく，第4病日の内視鏡検査では潰瘍は指摘できなかった．しかし第5病日に再び下血し，Hb7.4g/dlまで低下した．第6病日の内視鏡検査では初回と同じ部位に露出血管のある浅い小潰瘍を再び認めた．HS-E局注法を試みたが完全には止血せず第8病日に胃亜全摘出術を実施した．切除標本で胃体部前壁に径6mmの浅い小潰瘍を認め，その底部に径3mmの露出血管：を認めた．組織学的には浅いUl-Ⅱの潰瘍で胃底腺粘膜内にあり，粘膜下層に筋性中膜の発達した径約1.5mmの太い動脈を認めDieulafoy潰瘍と診断した．術後約3年を経過したが再吐下血はない．

　A 63-year-old male who had a past history of melena of unknown origin seven years ago was admitted to our hospital on April 18, 1984 because of sudden onset epigastralgia, melena and hematemesis. Emergent endoscopy revealed a small shallow ulcer with a vessel exposed at its center on the anterior wall of the middle corpus. The second endoscopy performed two days later failed to reveal the ulcer. The third endoscopy, done during the acute phase of rebleeding after five days of conservative management, found an oozing vessel in the same ulcer again. We injected HS-E solution around the vessel, but the bleeding did not stop.

　Subtotal gastrectomy was carried out on April 25, 1984. A shallow ulcer, measuring 6 mm in the maximal diameter with an exposed vessel measuring 3 mm in diameters, was located on the anterior wall of the middle corpus. The ulcer had a depth of Ul-II and was histologically surrounded by fundic mucosa. An abnormally large artery plugged by thrombus was found in the submucosa. These histological findings led to the diagnosis of a so-called Dieulafoy's ulcer.

　The patient has been in excellent health in the subsequent three years of follow-up.