心筋梗塞の治療経過中に回腸穿孔を来した1手術例

An Operated Case of Ileum Perforation Occurred during Hospitalization of Myocardial Infarction

要旨　症例は89歳女性．脳梗塞の既往があり，シロスタゾールを服用していた．2012年3月末，呼吸困難で当院救急搬送された．胸部X線写真で心拡大，肺うっ血像，両側胸水貯留を認めた．心電図で_aV_F，V₁～V₃にQ波，V₄～V₆にST低下を認めた．心筋梗塞による急性肺水腫と診断し，アスピリン，トルバプタン，カルペリチド，ニコランジル，フロセミド，オメプラゾールを投与開始した．心不全は良好にコントロールでき，第6病日に酸素投与中止した．第7病日，侵襲的冠動脈造影を施行し，右冠動脈近位部に高度狭窄，中間部に完全閉塞の所見を認めた．右冠動脈に，経皮的冠動脈形成術を施行し，薬剤溶出性ステントを留置し再灌流が得られた．術直後より，クロピドグレルを投与した．第9病日，激しい右下腹部痛が出現し，腹部CT検査でfree airを認めたため外科で緊急手術が施行された．終末回腸に穿孔部を1カ所認め，回腸部分切除術と回腸瘻造設術が施行された．病理組織検査では特異的炎症所見は認めなかった．術後経過は良好で，第65病日軽快退院した．近年，アスピリンによる小腸潰瘍が注目され，本症例の回腸穿孔はアスピリンとの関連が疑われた．今回，われわれは心筋梗塞の治療経過中に回腸穿孔を来した1手術例を経験したので報告する．

　An 89-year old woman, who had been taking cilostazol for old cerebral infarction, was transferred to our hospital for dyspnea at the end of March, 2012. Chest X ray revealed cardiomegaly, pulmonary edema and bilateral pleural effusions. 12-lead electrography showed abnormal Q waves in leads _aV_F, V₁-V₃ and ST depression in leads V₄-V₆. Diagnosis of flash pulmonary edema by myocardial infarction was made and administration of tolvaptan, cariperitide, nicorandil, furosemide, aspirin and omeprazole was initiated. Congestive heart failure improved and she was weaned off oxygen inhalation six days after admission. Seven days after admission, angiography revealed a stenotic lesion at the proximal of RCA and occluded lesion at the middle of RCA. Percutaneous coronary intervention was performed and the occluded lesion was successfully recanalized. After PCI, administration of clopidogrel was initiated. Nine days after admission, severe right lower abdominal pain occurred and computed tomography showed free air. Emergent surgery was performed and the ileum end was perforated. Partial resection of the ileum was performed and ileostomy was created. Pathological findings revealed no specific inflammation. She was discharged uneventfully 65 days after admission. In recent years, aspirin has been noted as a cause of small intestinal ulcers. In this case, association between aspirin and ileum perforation was suspected. We report an operated case of ileum perforation during hospitalization for myocardial infarction.