術後早期に再発を繰り返したCrohn病の1例

Crohn's Disease with Repeated Early Recurrences After Operations, Report of a Case

要旨　症例は20歳，男性，下腹部痛，発熱，体重減少を主訴として，1975年5月，当科に入院した．現症で，会陰部瘻孔を認めた．X線・内視鏡検査にてCrohn病と診断され，内科的治療を行ったが，再燃を繰り返し，1979年6月，狭窄のため右半結腸と回腸末端切除術が施行された．術中内視鏡検査で残存小腸は正常であり，組織学的にも切除断端は健常であるのを確認したが，術後42日目に吻合部に再発を認めた．1980年1月には癒着性腸閉塞で手術が施行され，病変部の切除が行われたが，術後40日目に再発した．その後も再燃を繰り返し，会陰部瘻孔のため2期的に手術が施行された．現在，会陰部瘻孔は治癒するも，回腸瘻周囲の瘻孔が新たに生じ，入院加療中である．本症の外科的手術による根治は困難であり，その適応は慎重であるべきと考えられた．

　A 20 year-old man was admitted to our hospital with lower abdominal pain, fever and weight loss of two years' duration on May 26, 1975. On admission, physical examination disclosed perineal fistulae without abdominal tenderness or mass. He was diagnosed as having Crohn's disease by means of barium enema study and colonoscopy.

　He was treated with corticosteroids, sulfasalazine, metronidazole and/or total parenteral nutrition, but did not achieve a complete remission. He underwent right hemicolectomy with terminal ileal resection in June 1979. Intraoperative endoscopy revealed no abnormality in the retained small intestine. Histopathologically, the diagnosis was confirmed and the resected bowel margins were free of the disease. Seven days later, he complained of diarrhea and abdominal pain. Forty-two days after the operation, colonoscopy proved recurrence at the anastomosis.

　In January 1980, reoperation was done for adhesion ileus and the diseased segment was resected. But, 40 days after the second operation, colonoscopy revealed recurrence of the disease at the anastomosis.

　Thereafter, perineal fistulae and perianal abscess gradually deteriorated and medical treatment became ineffective. He had resection of the diseased intestinal segment with ileostomy and fistulotomy in May and rectal amputation, fistulectomy and cholecystectomy in September 1982.

　In March 1983, endoscopy via ileostomy disclosed longitudinal ulcers in the ileum.

　He is now suffering from external fistulae of the peri-ileostomy region under hospitalization.

　The clinical course of the patient suggests that treatment of patients with Crohn's disease should be medical as possible and indications for surgery should be more restrictive because of high recurrence rate following surgery.