膵管像における診断基準をどう考えるか

How to Think about Pancreatographic Diagnosis of Chronic Pancreatitis

　「膵管像からみた慢性膵炎の診断基準は」と問われれば，答は「分からない」の一語につきてしまう．ここでは，膵炎（あえて慢性膵炎とは言わない）の膵管像，すなわち膵管像からみた膵炎についての私見を述べてみたい．

　筆者は，以前より慢性膵炎の膵管像については，明らかな，所見の明白なものからアプローチをするようにしていたが，この考えは今日でも変わりはない．この一文を書くにあたっての筆者の立場は，次のように要約できると思う．膵管造影については，造影手技にまだ多少の問題は残しているが，膵管の変化を忠実に描写し，特に，限局性の変化の把握に威力を発揮する．膵管像に異常のある場合には，組織学的にも何らかの変化が膵管に存在せねばならないと考えている．次に，現在の慢性膵炎の診断基準に関しては，病理組織学的にも部位により組織像に大きな違いがみられることが少なくない，膵石の成因は一様でなく⁶⁾，しばしば末期像として膵石症という形がとられる，PS試験の成績は経過中に変化することがある，などの問題点を持っていると考えている．また，PS試験は本質的には膵の外分泌腺の機能をみているのであって，膵管の形態をみる膵管造影とは基本的に立場を異にしている．

　As I set a great value on the presence of cases with fibrosis and cellular infiltration localized in a part of the pancreas, an attempt has been made, apart from the present diagnostic criteria of chronic pancreatitis, to divide pancreatic inflammation into (1) diffuse progressive, (2) acute-scarring and (3) inflammation of the pancreatic ducts, diffuse or localized. By taking into account (4) degenerative changes and (5) mechanical factors to the above classification, I have tried to build up a working hypothesis for interpretating chronic pancreatitis. Based mainly on localized changes, pictures of the pancreatic ducts have been classified into patterns obtained from my personally experienced cases.

　The subjects of the present study were 206 patients diagnosed as having pancreatitis with well visualized pancreatic ducts. They were cases admitted to the Institute of Gastroenterology, Tokyo Women's Medical College. I have divided pictures of the pancreatic ducts into 18 patterns, examining such factors as sex, age, pancreatic stones, pseudocyst and necrosis, habit of heavy drinking and cholelithiasis.

　On the basis of pancreatographic pictures and my working hypothesis, I have roughly divided patterns of pancreatic ducts into diffuse, localized and mixed types, excluding patterns unconnected directly with pancreatitis and some exceptional patterns. Pancreatic stone was found in 78 per cent in the diffuse type, 43 per cent in the mixed type and only 4 per cent in the localized variety. The percentage of necrosis or pseudocyst was 0, 21, and 42, respectively in the above-mentioned order of types.

　In 14 cases satisfactorily followed up and in 25 cases in which pathologic tissue was obtained, I have attained the results strongly in favor of the presence of localized pancreatitis that is neither diffuse nor progressive.

　In the examination of pancreatitis I believe one could set up the afore-mentioned working hypothesis and discriminate between diffuse and localized types of pancreatitis. I personally regard the former as diffuse pancreatitis and the latter as localized pancreatitis.