腹腔リンパ節結核による十二指腸狭窄

Duodenal Stenosis due to Tuberculous Peritoneal Lymphadenitis

　腹腔リンパ節結核症は現在臨床的にはまれな疾患であり診断もまた容易ではない．筆者らは最近十二指腸下行脚の狭窄像を呈し，膵癌の疑いを捨て切れず診断未確定のまま開腹手術を行なった結果，腹腔リンパ節結核症と判明した症例を経験したので報告する．

　Tuberculosis of the abdominal lymph nodes is now a relatively uncommon disease. Recently, however, a 32-year-old man, having complained of epigastralgia and remarkable weight loss, came to our clinic and was admitted. Physical examination revealed no abnormalities except for a tender resistance at his epigastrium. Laboratory examinations showed an accelerated ESR, two plus CRP, positive Mantoux reaction and slightly elevated serum globulin level, but almost all other studies, including blood count, blood chemistry, glucose and D-xylose tolerance tests, fecal fat and urinalysis, failed to reveal any abnormality. Routine GI roentgenography and hypotonic duoclenography disclosed a presence of a stricture at the second portion of the duodenum. Celiac arteriography showed hypervascularity, a complex of tortuous and irregular arterioles, at the area of the pancreas head. On the axial transverse tomography, coupled with the pneumoretroperitoneum, no gas was detected at the dorsal surface of the pancreas. Pancreozymin secretin test showed a decreased bicarbonate output in the duodenal juice. Although an inflammatory process, mainly involving the pancreas, was suggested by the above findings, malignancy could not be excluded. Therefore, an exploratory laparatomy was performed and it was found that numerous lymph nodes including the subpyloric, pre-pancreatic, biliary and mesenteric were enlarged and that there were tumor-like indurations at the body and tail of the pancreas. But the stomach, duodenum, liver and biliary trart were found intact. The histologic diagnosis of tuberculous lymphadenitis was established. The patient responded quite satisfactorily to the treatment for tuberculosis. Several recent reports dealing with similar cases were reviewed and a possible pathogenesis of the tuberculous peritoneal lymphaclenitis was discussed.