A case of crohn’s disease with an internal fistula, diagnosed using computed tomography enteroclysis

CT enteroclysis(CTE)とは,水や等張性緩下剤等(Niflec^[○!R],Elental^[○!R]等)の陰性造影剤を小腸チューブから注入し,全小腸を十分に拡張させた後Dynamic CTを撮影して小腸病変の診断を行う検査法である.海外ではクローン病に対する報告が多数なされており,腸管の炎症,狭窄や瘻孔に対して高い確率での検出が可能とされている.症例は30歳代男性.2006年に小腸大腸型クローン病と診断され,5-アミノサリチルサン(5-ASA)製剤内服と成分栄養剤で加療されていた.2008年,臀部痛が出現し,近医の造影CTで仙骨前面に膿瘍を認めたが保存的加療にて症状は軽快し,以後の受診歴はない.2009年4月,鮮血便を頻回に認め,上部・下部消化管内視鏡検査では出血源が同定されなかったことから小腸出血が疑われた.出血は絶食のみで自然止血したが,出血源の同定目的で当院へ転院となった.陰性造影剤としてNiflec^[○!R]を用いてCTEを施行したところ,回腸の壁肥厚,狭窄および直腸との内瘻の形成が疑われ手術適応と判断し,当院外科で手術が行われた.術中所見でCTEにて検出された回腸直腸瘻が実際に確認された.従来クローン病における内瘻の診断には小腸X線造影検査が用いられてきたが,瘻孔を明確に描出するのは難しく,術中所見ではじめて瘻孔形成部位が確定することも少なくなかった.本症例では内瘻の存在および局在の同定にCTEが安全に実施でき,手術適応を判断する上で有用であったことから,文献的考察を加えて報告する.

Computed tomography enteroclysis (CTE) is used for diagnosing lesions in the small intestine. In this technique, dynamic computed tomography is performed after a neutral enteric contrast material is infused through an enteroclysis catheter. Numerous overseas studies have been performed on Crohn’ s disease (CD), which is characterized by a high incidence of intestinal tract inflammation, strictures, and fistulae. We report the case of a man who was affected with Crohn disease. He was in his 30’s and frequently experienced bleeding during defecation. We initially performed gastroscopy and colonoscopy. The results of these procedures led to a suspicion of small intestinal bleeding because the source of bleeding could not be identified. Subsequently, CTE was safely performed and showed intestinal wall thickening , ileal strictures, and an ileorectal fistula. On the basis of these findings, we decided that it was essential for the patient to undergo surgery. The ileorectal fistula diagnosed by CTE was in accordance with the intraoperative findings. The conventional small-bowel followthrough technique is usually used for diagnosing internal fistulae in CD； however, clear visualization is difficult with this technique. Therefore, as reported in previous studies, we think that CTE is a better technique than conventional small-bowel follow-through technique for detecting internal fistulae.

CT enteroclysis

陰性造影剤

クローン病

瘻孔

内瘻