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症例は86歳の女性で,心房細動に対しアスピリン100mg/日を内服していた.腹痛,下痢・嘔吐を認め受診.腹膜刺激症状と腹部単純X線検査で著明な小腸ガス像を認めた.発症3時間後のCTで肝臓のair density area,門脈内ガス像(portal venous gas;以下,PVG),腸管壁内気腫・壁浮腫像を認め,腸管壊死を疑い手術を施行した.中等量の血性腹水が存在し,Treiz靭帯より120cmの小腸より壊死部と灰白色の虚血腸管を認めた.上腸間膜動脈(superior mesenteric artery;以下,SMA)閉塞症による小腸壊死と診断し,小腸大量切除・回盲部切除を行った.病理組織学的に小腸の著明な出血壊死が見られ,粘膜層の凝固壊死および出血が認められた.腹水培養で細菌は同定されず,第25病日に内科転科となった.発症後3時間でPVGを呈したSMA閉塞症の報告は他に1例のみであり,貴重である.本疾患は予後不良であり,腸管壊死を疑う場合,早期の開腹術が予後改善につながると考えられた.
An 86-year-old woman seen for abdominal pain and taking aspirin daily for atrial fibrillation was found on physical examination to have muscular guarding, and erect abdominal X-ray showed a large amount of gas in the small intestine. Three hours after onset, computed tomography (CT) showed hepatic portal venous gas (PVG) with branching and a small amount of air in the small intestinal wall. Her general condition worsened, necessitating emergency surgery under a diagnosis of panperitonitis due to intestinal necrosis. Moderate amounts of bloody ascites and marked edema and necrosis of the small intestine and an ischemic gray portion were seen. Pathological findings showed hemorrhagic necrosis throughout the entire small intestine and necrosis with blood coagulation in the mucosal layer consistent with superior mesenteric artery (SMA) occlusion. The postoperative course was fair. This is, to our knowledge, the second report of SMA occlusion associated with PVG detected less than three hours after onset. Surgical treatment should thus be considered in SMA occlusion with PVG at an early stage once intestinal necrosis is suspected.
