虚血性小腸炎15例の臨床像およびX線像の分析

Clinical Features and Radiographic Findings in Ischemic Enteritis (Jejunoileitis)

要旨　虚血性小腸炎15例(狭窄型11例，一過性型4型)の臨床像およびX線所見を検討し，狭窄型10例についてはX線所見と切除標本病理所見とを比較検討した．高齢者(40～88歳，平均59歳)，男女比11：4で，初発症状は腹痛，下血，下痢であった．12例は急性に発症したが，3例は比較的緩徐な発症を示した。病変は3～38cmの長さで回腸に好発することが多かったが，3例では100cm以上の病変を有していた．狭窄型のX線像は急性期(12～41病日)に母指圧痕像と皺襞浮腫像，治癒期(27病日以降)には管状狭窄，口側腸管の拡張，小潰瘍の多発を認めた．切除標本病理所見ではUl-Ⅱを主体とする全周性の区域性潰瘍から成っていた．X線上，管状狭窄部の辺縁には凹凸不整像を認めたが，切除標本病理所見との対比によって，これが粘膜の過形成，肉芽組織，炎症性ポリープあるいは再生粘膜によって生じた顆粒状変化と小裂溝を反映した所見と解釈できた，狭窄型虚血性大腸炎の特徴的X線所見である偏側性変形と囊形成は1例のみにしか認めなかった．一方，一過性型のX線像も，急性期(2～37病日)には母指圧痕像も皺襞浮腫像を認めるが，49病日以降になると小潰瘍(開放性～瘢痕)の出現あるいはX線像の正常化へと推移した．以上のX線所見より，本症の鑑別診断上，急性期には小腸アニサキス症，治癒期には腸結核，Crohn病などが重要であると考えた．

　Fifteen cases of ischemic enteritis (jejunoileitis), 11 with the stricturing form and 4 with the tansient form, were studied to find the characteristic clinical features and radiographic findings. The average age of the patients was 59 years, the range being 40 to 88 years. The ratio of males to females was 11 : 4. The initial symptoms included abdominal pain, melena, and diarrhea. The onset of the illness was sudden in 12 cases and subacute in 3. The lesion was most frequently sited in the ileum. The intial area of involvement was 3 to 38 cm in length in all but 3 patients who had a more extensive lesion. The most characteristic radiographic findings were thumb-printing and edematous folds in the acute stage of this disease. In patients with the stricturing form, tubular narrowing, dilated proximal bowel, and multiple small ulcers were observed in the healing stage. Pathological finding of the resected specimen revealed zonal ulcer and annular stricture with relatively shallow ulcers. The irregular contour of tubular narrowing on the radiograph was consistent with granular appearance (histologically, consisting of mucosal hyperplasia, granulation tissue or regenerative mucosa) and/or multiple fissures. Eccentric deformity and sacculation were demonstrated in only one case. We consider that radiographic differentiation of this disease from other inflammatory bowel diseases such as intestinal anisakiasis, Crohn's disease, and intestinal tuberculosis is important.