Dieulafoy潰瘍の治験例

Dieulafoy's Lesions Treated by Gastrectomy and Endoscopic Bipolar Electrocoagulation, Report of Seven Cases

要旨　内視鏡的にDieulafoy潰瘍と診断し，胃切除または内視鏡的止血法により治療した7症例を提示した．大量出血のため緊急胃切除を要した初期の2症例の内視鏡所見は，胃体部の噴出性出血と浸出性出血であったが，切除胃にそれぞれ1.0mmと1.9mm径の破綻動脈を伴う小びらんを認めた．1980年以後の5例では内視鏡的バイポラー電気凝固法により止血した．なお初回止血時に12歳の女性では，6年後同様の誘因により大量出血を来し再止血を要した．Dieuiafoy潰瘍の臨床像，発生部位，内視鏡所見は孤在性出血性の急性胃粘膜病変に類似し，有効な内視鏡的止血法が発達した今日，出血血管の組織学的検索は行い難く，その独自性の立証は困難となっている．

　Solitary gastric erosive lesions of Dieulafoy have been increasingly recognized by endoscopy. Two surgically treated cases in 1977 and 5 cases treated by endoscopic bipolar electrocoagulation (BPEC) that we deveioped in 1980 are described. Development of effective endoscopic hemostatic methods has modified the definition of Dieulafoy's ulcers, since the caliber of submucosal arteries cannot be measured and their endoscopic appearances resemble solitary stress or druginduced acute erosions in the gastric body.

　Case 1 (Figs. 1-3) : A 47-year-old man who presented with melena had a solitary bleeding lesion in the mid-body. Spurting bleeding from an artery was recognized during the repeat endoscopy performed with the intention of monopolar electrocoagulation. Hypovolemic shock developed requiring 2,000 ml blood transfusions and he was immediately transferred for an operation. A ruptured artery was noted at the bleeding erosive lesion. The postoperative course was uneventful with no recurrence of bleeding.

　Case 2 (Figs. 4 and 5) : A 33-year-old man who felt palpitation the day before suddenly vomited a total of 1,500 ml fresh blood while waiting and being examined in a clinic. The systolic blood pressure was 84 mm Hg, Hgb and Hct being 5.9 g/dl and 17.9% respectively. Endoscopic examination performed after 3,200 ml blood transfusion showed seeping blood from one of the three erosive lesions in the body. Subsequently, proximal gastrectomy was carried out. A ruptured submucosal artery was noted in the erosive lesion.

　Case 3 (Fig. 6 b, Table 1) : A 55-year-old woman was noted to have bleeding from a visible vessel at endoscopy and treated successfully by BPEC.

　Case 4 (Fig. 7, Table 1) : A 12-year-old girl who was successfully treated by BPEC bled massively again 6 years later, when another BPEC stopped a spurting bleeding in the fornix.

　Clinical data of BPEC-treated cases are summarized in Table 1.