胆管結石を合併した十二指腸乳頭部腺腫の1例―良悪性境界病変

An Adenoma of the Papilla of Vater with a Common Bile Duct Stone: A borderline lesion between malignancy and benignity

　十二指腸乳頭部に良性腺腫がみられることは稀であり，現在まで11例が報告されているにすぎない^4)～6)．また，十二指腸腺腫は前癌病変でありうる可能性も諸家により示唆されている^7)～10)．

　われわれは最近，急性腎不全を合併した胆道感染症疑診例が，大量下血を併発したため，緊急胃切除術をやむなく行ない，軽快した後，精査により総胆管結石および十二指腸乳頭部腫瘤が明らかとなり，根治手術を行ない全治しえた症例を経験した．本例の乳頭部腫瘤は組織学的にも良悪性の判定が非常に困難な症例であったので若干の考察を加え報告する．

　The patient, a 46-year-old man, was admitted complaining of pain in the right upper quadrant, jaundice and bloody stool with oliguria. Alkaline phosphatase, BUN and serum creatinine were remarkably eleavated. Under a diagnosis of cholangitis with acute renal failure he was observed with fluid and antibiotic therapy without hemodyalisis. Urinary output became progressively increased, but because of persistent and sever hematemesis with bloody stool, emergency operation was required. Gastrectomy revealed benign bloody ulcer. The postoperative course was uneventful and renal function returned to normal, but only alkaline phosphatase was still elevated. Hypotonic duodenography disclosed a tumor-like shadow in the second portion at a site corresponding to the papillary region. Duodenofiberscope showed the protruded mass with nodular surface at the region of the papilla of Vater. Atypical glandular structure was revealed by frozen section, but it was then impossible to classify it as cancer. Percutaneous transhepatic cholangiography demonstrated a stone in the terminal common bile duct. Two months after emergency laparotomy, an elective abdominal exploration, pancreaticoduodenectomy, was performed under a suspicion of malignancy. There was a choleterin stone in the common bile duct too. Resected specimen showed an enlarged and nodulated tumor of the papilla of Vater, 2.5×2.5×2.2 cm in size. Histologically this tumor was mainly composed of proliferated atypical glands with a number of Paneth's cells, enterochromaffine cells and goblet cells. However, we also observed partially glands with remarkable cellular and structural atypism. From these points, this tumor was an adenoma of the papilla of Vater, which was considered to be a borderline lesion between malignancy and benignity. There have been few reports of an adenoma at the papilla of Vater with acommon bile duct stone.