消化管結核の治療と合併症

The Treatment and Complications of Intestinal Tuberculosis

要旨●本稿では腸結核の治療と合併症について主に述べるが，最近，生物学的製剤（Bio）投与中の炎症性腸疾患の結核併発が問題になっており，まずそれについて述べる．潜在性結核感染症がある場合は，Bio開始3週間前よりイソニアジドを少なくとも6〜9か月間投与する必要がある．また，Bio投与中に結核が発症した場合は，原則Bioは中止するが，継続すべき場合もみられる．腸結核の治療については，肺結核と同様に抗結核薬4剤投与で始めるのが原則である．肺結核に比べて腸結核では菌が検出できないことも多く，診断的治療を行わなければならないことも比較的多い．肺結核の効果判定は菌の消失で行うが，腸結核では内視鏡検査による潰瘍の観察で行う．判定時期は明らかな根拠はないが，2か月後が適当と筆者は考える．腸結核の合併症については，抗結核薬治療中の穿孔と腸閉塞が特に問題であり，あらかじめ患者に説明しておくことが重要である．

　Recently, problems associated with the increased incidence of tuberculosis in patients with IBD（inflammatory bowel disease）undergoing treatment with biological drugs have emerged. In principle, isoniazid is administered for a period of 6 to 9 months in case of IBD patients with latent tuberculosis infection 3 weeks before starting the administration of biological drugs. In case of IBD patients suffering from tuberculosis, the treatment with biological drugs must be stopped. For the treatment of intestinal as well as pulmonary tuberculosis, it is necessary to initiate four anti-tuberculosis drugs. Detection of bacteria in the cases of intestinal tuberculosis is less compared with the detection in pulmonary tuberculosis. For this reason, we must often perform a diagnostic treatment. The effectiveness of anti-tuberculosis drugs in case of pulmonary tuberculosis is determined by the disappearance of bacteria, while their effectiveness in case of intestinal tuberculosis is determined by the observation of ulcers during colonoscopy. Although there is no apparent basis for the timing to judge about the effectiveness of anti-tuberculosis drugs in the case of intestinal tuberculosis, I think that it is appropriate to do so in 2 months of starting the treatment. The complications of intestinal tuberculosis such as perforation and obstruction encountered in anti-tuberculosis therapy are particularly problematic. It is therefore important to explain these complications to the patient in advance.