発病初期に非典型的病像を呈した潰瘍性大腸炎の1例

Ulcerative Colitis with a Peculiar Duodenal Lesion at the Onset, Report of a Case

要旨　発病初期に非典型的な形態を示した潰瘍性大腸炎（ulcerative colitis；以下UC）の1例を報告した．患者は15歳，男性．1998年，腹痛，粘血便を主訴に入院．薬剤服用歴なし．注腸X線，内視鏡検査にて直腸より横行結腸まで連続性にびまん性の粗糙粘膜を認め，更にS状結腸には多発大型たこいぼ様びらんがみられた．生検組織上UCに矛盾しない像であった．上部消化管内視鏡検査では，十二指腸第二部（下行部）にひだの途絶および，びらんが散見され，一部は縦走配列していた．この所見はCrohn病（以下CD）の十二指腸病変に酷似していた．組織学的には上部および下部消化管にCDを示唆する所見はなく，UCを疑うも確定診断には至らなかったがSASPの服用で症状は改善した．約4か月後の増悪時の注腸X線検査では，直腸のたこいぼ様びらんは消失しており，連続性の粗糙粘膜と鉛管状腸管を呈しており，典型的UCの所見であった．しかし，十二指腸第二部にひだの途絶や小びらんは軽度ながら散見された．この時期，副腎皮質ステロイド剤（以下PSL）が著効した．初診より1年7か月後の注腸X線検査は前回再燃時と同様であり，典型的なUCの像を呈していた．十二指腸第二部の小びらんは消失しほぼ正常化していた．以上，発病初期にCDを疑わせる十二指腸病変を有した非典型発症様式のUCの1例を報告した．

　We report a case of ulcerative colitis (UC) with atypical intestinal lesions at the onset of his illness. The patient, a 15-year-old male, was admitted to our hospital complaining of abdominal pain and bloody stool. Endoscopy revealed a colonic lesion presenting diffuse mucosal erosions and which was continuous from the rectum to the distal transverse colon.

　Multiple verrucous erosions, which were histologically compatible with UC, were detected in the sigmoid colon. Upper gastrointestinal endoscopy disclosed multiple erosions, which seemed to locate in a longitudinal fashion, on the Kerckring's fold in the second part of the duodenum. This finding seemed to be similar to the duodenal lesion of Crohn's disease (CD), but histological data of the upper and lower GI tract were not compatible with CD. This patient was successfully treated with salazosulfapyridine. Four months later, his colonic lesion showed continuous coarse mucosa similar to a typical finding in UC. Although his clinical course, with standard medical care, involved frequent relapse, his duodenal lesion disappeared later on. This is the first case reported of UC with a distinctive aphthous lesion in the duodenum.