残胃にみられたDieulafoy潰瘍の1例

Exulceratio Simplex at the Gastric Stump, Report of a Case

要旨　残胃のDieulafoy潰瘍の典型例を報告する．23年前，Billroth Ⅱ法にて胃切除を受けている44歳の男性がタール便を主訴に入院した．内視鏡検査で出血部位は確認できなかった．人院4日目タール便と貧血の増悪がみられたため血管造影を行い左胃静脈分枝にextravasationを認め，塞栓術を施行し止血した．8日後，再び下血があり，内視鏡検査で縫合部小彎の粘膜ひだの部位から新鮮血の出血を認めたため残胃全摘術を行った．切徐標本では，縫合部の粘膜ひだ上に血管露出を伴うUl-Ⅱの粘膜欠損を認め，組織学的には口径1.2mmの破綻した動脈を認めた．しかし，その動脈の周囲には潰瘍性変化はなかった．

　A 44-year-old man was admitted to our hospital on an emergency basis because of tarry stool. He had undergone distal gastrectomy with end-to-side anastomosis 23 years prior to the admission. Endoscopy on admission failed to demonstrate a bleeding source. On the 3rd hospital day he developed melena requiring 1,200 ml of blood transfusion. However, no lesion was identified on the second endoscopy. A selective angiography demonstrated extravasation on the lesser curvature of the gastric stump and embolization successfully stopped the bleeding. On the 11th hospital day, he again developed melena and the endoscopy this time demonstrated bright red pulsatile jets of blood from the lesser curvature near the stump. Subsequently total resection of the gastric remnant was carried out.

　Histological examination of the resected specimen showed an abnormal submucosal artery. The artery measuring 1.2 mm in diameter was ruptured near a small ulceration of 16 mm in size. Histological changes indicative of peptic digestion of submucosa were lacking.