抗血栓薬服用中に小腸壁内血腫によりイレウスを発症した1例

Jejunal Intramural Hematoma in Anticoagulant Ileus, Report of a Case

要旨●患者は50歳代，男性．心臓弁膜症治療後のワルファリン長期内服症例で，アルコール多飲によりワルファリンのコントロールがしばしば増悪していた．腹部膨満感と嘔吐で入院．プロトロンビン時間の高度延長を認め，腹部造影CTで上部空腸に全周性かつ均一な壁肥厚を認め小腸閉塞と考えられた．絶食・経鼻胃管で症状改善した．入院5日目に経口的ダブルバルーン内視鏡を施行し，選択的空腸X線造影では肥厚したKerckring's foldによると考えられる“stack of coins” appearanceが観察された．内視鏡による直接観察では上部空腸に15cmにわたる全周性の発赤・肥厚したKerckring's foldが観察され，その前後の部分に粘膜下の黒色血腫が透見された黒色粘膜が観察されたため，anticoagulant ileusと診断された．

　A 57-year-old man received warfarin therapy for a history of heart valve replacement. Because of his alcohol dependency, PT/INR（the prothrombin time/international normalized ratio）fluctuated frequently. He was admitted to hospital for persistent abdominal distention and vomiting. The laboratory findings showed extremely prolonged prothrombin time. Contrast-enhanced abdominal CT on admission revealed complete obstruction of the upper jejunum caused by circumferential and homogeneous jejunal wall thickening. Double-balloon endoscopy was performed 5 days after the admission. A selective contrast study of the jejunum revealed the “stack of coins” appearance due to thickened mucosal folds. Direct endoscopy showed a 15-cm circumferential erythematous and edematous jejunal mucosa, and there were black pigmented areas along both the proximal and distal border of the lesion. The patient was diagnosed with anticoagulant ileus.