クローン病における尿路合併症の臨床的検討  [in Japanese] MANAGEMENT OF URINARY COMPLICATION IN CROHN'S DISEASE  [in Japanese]

(目的)クローン病患者における尿路合併症は比較的少ないが,その診断や治療に難渋することがある.現在,それに対する治療指針はいまだ確立されていない.今回,我々はクローン病患者における尿路合併症の頻度,診断,治療について報告する.(対象と症例)1994年1月から2002年5月の間,社会保険中央総合病院にクローン病で通院中の1,551人をretrospectiveに検討した.(結果)1,551例中75例(4.8%)に尿路合併症を認めた.内訳は尿路結石60例,消化管膀胱瘻14例,尿膜管膿瘍1例であった.尿路合併症の診断を受けた患者のうち実際に泌尿器科を受診したのは41例(55%)である.内訳は尿路結石26例(43%),消化管膀胱瘻14例(100%),尿膜管膿瘍1例(100%)であった.尿路結石に対しては20例に保存的治療,4例にESWL,2例にTULを行い,全ての症例で良好な結果を得た.消化管膀胱瘻は12例(86%)の症例で,保存的治療で腸管の炎症をコントロール後に瘻孔,炎症腸管の切除を行った.尿膜管膿瘍は尿膜管,責任腸管切除と膀胱部分切除を行った.(結論)尿管結石の治療は非クローン病患者と同様の治療方法を行うべきと思われた.消化管膀胱瘻は成分栄養等の保存的治療を先行させた後に外科的治療を行うことでQOLが早期に改善され,腸管切除も回避できる可能性が示唆された.

(Purpose) Although urinary complications of Crohn's disease are relatively rare, they often present diagnostic and therapeutic dilemmas. However, there is no established strategy for treating urinary complications of Crohn's disease. In the present clinical study, we describe the frequency of urinary complications of Crohn's disease, and discuss various approaches to their diagnosis and treatment. (Patients and methods) The subjects were 1, 551 patients who underwent medical treatment for Crohn's disease between January 1994 and May 2002 at Social Insurance Central General Hospital. The subjects were retrospectively evaluated. (Results) Urinary complications occuered in 75 of the 1, 551 patients (4.8%) : urolitiasis in 60 patients, urinary fistula in 14 patients, and urachal abscess (Enterourachocutaneous fitulas) in 1 patient. A total of 41 of the 75 patients with urinary complications (55%) consulted a practicing urologist : 26 patients with urolithiasis, 14 patients with urinary fistula and 1 patient with urachal abscess. 26 patients with urolithiasis received medical treatment : 20 patients underwent conservative therapy, 4 patients underwent ESWL, and 2 patients underwent TUL. In all 26 of those cases, the treatment was successful. Twelve of the 14 patients with urinary fistulas (86%) underwent resection of the inflamed intestine combined with reconstruction of the urinary tract. The 1 patient with urachal abscess underwent resection of the urachus and the inflamed intestine, and partial cystectomy. (Conclusion) All patients with urolithiasis should be treated the same way, whether or not they have Crohn's disease. In patients with Crohn's disease complicated by urinary fistula, surgery should be performed after preoperative medical therapy, as it improves the quality of life of such patients more rapidly than other approaches and may help avoid intestinal resection.