大腸Crohn病と鑑別が困難であった区域型潰瘍性大腸炎の1例

Segmental Ulcerative Colitis Diagnosed by Follow-up Study, Report of a Case

要旨　23歳の男性，主訴として粘血下痢便，発熱．約2年余前の発病以来，他医にて痔核および大腸Crohn病と診断され治療を受けていた．注腸造影ではS状結腸に不整の浅い潰瘍ならびに狭小化を，下行結腸上部辺縁には線状様潰瘍および炎症性ポリープを，上行結腸下部から盲腸にかけては辺縁不整と多数の小バリウムフレックを認めた．入院後，徐々にテネスムスおよび高熱が出現．これらの症状はCrohn病や大腸結核ではあまりみられないので，X線所見も加味し，区域型潰瘍性大腸炎を疑った．内科的療法が奏効せず，入院後約1カ月して手術（全結腸切除術ならびに回腸直腸吻合術）を施行した．切除標本では，主病変は盲腸から上行結腸下端，脾彎曲部付近，全S状結腸から直腸の3カ所に存在し，いずれも不整形の浅い潰瘍と炎症性ポリープが，全周性かつ連続性に認められた．組織学的には，Ul-Ⅰ～Ⅱであり，全層性の炎症やfissuring ulcerは認めなかった．crypt abscessは多数認められた．これらの肉眼ならびに組織学的所見から本症例を区域型潰瘍性大腸炎と診断した．術後4年経過した現在，患者は健康に社会復帰している．

　A 23 year-old man was admitted to our hospital for investigation and treatments, complaining of mucoid bloody diarrhea and low grade fever.

　On physical examination, he was noted to have mild tenderness in the ileo-cecal region and midlower abdomen. Lobaratory examination disclosed C reactive protein of three positive and erythrocyte sedimentation rate of 34 mm per hour. Barium enema study showed following findings: Irregularly-shaped shallow ulcers and narrowing in the sigmoid colon, linear-like ulcer and inflammatory polyps in the proximal descending colon, and irregular margin and multiple barium flecks from proximal ascending colon to cecum. The intervening colon among the lesions were seemed to be almost normal. The terminal ileum was not involved.

　Total colectomy with partial rectal resection and ileorectostomy were accordingly performed.

　Grossly, circumscribed and continuous lesions with irregularly-shaped shallow punched-out ulcers and erosions were recognized in skipping at the following areas; from cecum to proximal ascending colon (8 cm in length), proximal descending colon (15 cm in length), and from whole sigmoid colon to rectum (35 cm in length). Neither stricture formation nor fistula formation was recognized, and neither longitudinal ulcer nor cobblestone appearance was recognized.

　Histologically, the ulcers were Ul-Ⅰ～Ⅱ, and multiple crypt abscesses were recognized in the colonic glands. Neither transmural inflammation nor fissuring ulcer was recognized. Caseating granuloma was not also found in the intestine and regional lymph nodes. These macroscopic and microscopic findings wese compatible with “segmental ulcerative colitis”.

　Now four years have passed since the operation, and he is completely free of preoperative symptoms.