難治性胃潰瘍―EUS所見を中心に

Diagnosis of Intractable Gastric Ulcer by Endoscopic Ultrasonography

要旨　難治性胃潰瘍の超音波内視鏡（EUS）像について検討した．8週間以内に白苔の消失をみなかったものを難治として，活動期からH₂ブロッカー単独あるいは防御因子増強剤併用にて94病変を治療し，プロトンポンプ阻害剤（PPI）単独あるいは併用にて46病変を治療し経過観察した．H₂ブロッカー治療群全体の8週後の内視鏡的累積治癒率は68％であった．H₂ブロッカー投与時の難治性胃潰瘍のEUS所見は，①Ul-Ⅳ，②Bf type，③潰瘍領域の断面積が400mm²以上，④潰瘍領域の収縮率が不良，の4点であった．PPIが投与された46病変全例で8週間以内に白苔が消失した．しかし，H₂ブロッカー抵抗性潰瘍にPPIを投与し白苔が消失した例では，深部に幅広く潰瘍エコーが残存していた．真の意味で難治性胃潰瘍を克服するには潰瘍内部の治癒が不可欠と考えられた．

　We studied the findings of intractable gastric ulcer by endoscopic ultrasonography (EUS). It was possible to diagnose the depth of ulcer by EUS. The echo pattern in Ul-Ⅳ were subclassified into six types, that is Hn, Bsub n Bn, Hf, Bsub f, Bf. We measured the diameter of ulcer and ulcer area in EUS pictures by using a video processor, EXCEL. In this report, we observed the endoscopic cumulative healing rate in 140 patients with active gastric ulcer, and compared the healing rate of H₂ blocker with that of proton pump inhibitor.

　Ninety-four patients with gastric ulcer were treated with H₂ blockers. The endoscopic cumulative healing rates after 8 weeks of H₂ blocker treatment were 89% in Ul-Ⅱ ulcer, 82% in Ul-Ⅲ ulcer, and 64% in UI-Ⅳ ulcer. In Ul-Ⅳ ulcer, the lowest cumulative healing rate among 6 echo patterns during the same periods was 33% in the Bf type under H₂ blocker treatment. The healing rate in an ulcer area larger than 400 mm² was below 50%. Likewise, the contraction rate of the ulcer area in the healed group was significantly lower than that in the non-healed group (p＜0.001). Thus the EUS findings of intractable gastric ulcer were found to be Ul-Ⅳ, Bf type in the internal echo pattern, ulcer area larger than 400 mm², and poor contraction rate of the ulcer area. Histologically, this type of gastric ulcer had thick, wide, dense fibrosis, and fusion between the muscularis mucosae and the proper muscle layer.

　All 46 patients in the omeprazole treatment group had achieved endoscopic healing within 8 weeks. Between H₂ blocker and proton pump inhibitor treatment group, there was no difference in ulcer depth, echo pattern, and ulcer area. When endoscopic healing was verified in patients with intractable gastric ulcer by omeprazole, a comparatively large ulcer area in EUS picture remained and patients relapsed a short time after discontinuance of omeprazole. It was suggested that internal ulcer healing should be maintained during gastric ulcer treatment.