Dieulafoy潰瘍の典型例と考えられる手術例―血管構築からみた検討

Exulceratio Simplex Dieulafoy, Report of a Case

要旨　特に前もって症状を認めず，突然の大量吐血で発症したDieulafoy潰瘍が，入院後，一時は保存的治療で治癒させることができるかと考えられたが，結局初回出血から6日目に再吐血を認めた．このときの出血は大量で血色素の低下も急激に進行し，輸血に対する反応も弱かったので緊急手術（胃全摘術）を行った．病理学的検索によれば，5.0×4.0mmの小さな浅いUl-Ⅱの潰瘍で，底部にはmedia厚70～120μmの太い動脈がsubmucosal layerに斜走し，先端は粘膜欠損部にて破綻を来していた．連続切片による血管構築を行ってDieulafoy潰瘍と判断した．なお，局所にはmicroaneurysmの所見はみられなかった．

　We here report a case of exulceratio simplex Dieulafoy in which massive hematemesis occurred suddenly without proceding symptoms. Conservative treatment performed immediately after admission was once effective giving us a hope that no surgical treatment would be required. Massive hematemesis, however, eventually recurred on the 6 th hospital day. Hemoglobin level declined rapidly this time with only poor response to blood transfusion.

　Accordingly emergency operation (total gastrectomy) was carried out. Pathological examination revealed a small shallow ulcer (Ul-II), measuring 5.0×4.0 mm in size. There was an arteriole with 70-120μm medial wall thickness running diagonally in the submucosal layer of the ulcer bottom. This arteriole was ruptured just at the mucosal deficit of the ulcer. Vascular reconstruction made by serial section formed the basis of the diagnosis, Dieulafoy's ulcer. Microaneurysm, however, was not found in the lesion.