食道静脈瘤の診断―内視鏡診断を中心として

Diagnosis of Esophageal Varices: especially its endoscopic diagnosis

　上部消化管出血に占める食道静脈瘤の意義は大きく，吐血例では，まず食道静脈瘤出血と他の潰瘍性出血との鑑別を考慮するのが常である．さらに，肝硬変症を主とする門脈圧亢進症に伴なう食道静脈瘤では，その破綻による出血が致命的となる場合が多く，したがって，食道静脈瘤の有無を明確にすることが基礎疾患の予後判定上および治療上にも大切である．ところで，従来食道静脈瘤を診断するにさいして，我国では主としてレントゲン検査にたよるのみで，内視鏡検査による診断は静脈瘤損傷による出血の危険性を考慮しすぎて，あまり行なわれなかった嫌いがある．しかし，最近ファイバースコープによる内視鏡検査の普及と共に，優秀なファイバー食道鏡も製作され，これを用いての食道内視鏡検査が容易となるにつれて，最近では食道静脈瘤に対してもファイバー内視鏡検査が普及しつつある．すでに我々も第12回日本内視鏡学会総会（昭和45年2月）でのシンポジウム「食道病変の内視鏡」において，“食道静脈瘤の内視鏡診断の限界”をテーマとし，ファイバー食道鏡による食道静脈瘤の観察は容易かつ安全であり，しかもX線診断に比べて診断能が高く，静脈瘤の疑われる疾患のすべてに対して行なう必要があることを主張したところである¹⁾．

　また今春の第58回日本消化器病学会総会・第14回日本内視鏡学会総会共催の国際セミナーにおいてA. E. Dagradiは“Endoscopy of esophageal varices”と題し，約20年間にわたる研究結果から，内視鏡診断の価値を高く評価すると共に，肝硬変症に対しては食道鏡をルーチンに使用するとしている．

　For the past 20 years Brick, Palmer and Dagradi have urgently stressed on the need of propagating endoscopy for the diagnosis of esophageal varices, which was a relatively neglected procedure. In recent years we have done a total of 126 fiber esophagoscopic examinations for 104 cases of esophageal varices, with no unexpected complications.

　Varices of the esophagus were seen in 82 per cent of liver cirrhosis, but they were also observed in such other diseases as chronic hepatitis, fatty liver, metastatic carcinoma of the liver, toxic hepatitis and obstructive jaundice.

　We have attempted to establish the criteria for the severity of esophageal varices by dividing it into three stages. We have also studied the relationship between endoscopic findings of varices and changes of pressure within the esophagus. It was noted that endoscopic pictures of the esophagus greatly vary in accordance with changes of pressure within it.

　X-ray diagnosis was hard to arrive at in varices of slight degree. Endoscopy was most effective for them. For such an examination it is most important to see to it that the amount of air should be barely adequate for endoscopy with resultant lowered pressure within the esophagus. Pressure of the peripheral blood vessels within the submucosa by means of a cursor equipped at the tip of fiberesophagoscope emphasizes any possible finding. Neither the use of esophagoscope with cuffs attached, intravenous injection of color materials, nor co-employment of Valsalva's method proved of no avail for our purpose.

　Some relationship was seen between varices and clinical symptoms of liver cirrhosis, but no connection was found between varices and such findings as enlargement of the liver, edema, plasma gamma globulin and BSP level. On the other hand, varices were slightly related with spleen enlargement. The severity of varices was also found to be closely connected with venous stasis in both the ligamentum teres of liver and the parietal peritoneum.