毛利 衣子¹, 内田 浩也¹, 東 貞之¹, 平田 拓也², 深谷 隆², 奥野 敏隆³, 高峰 義和³, 坂本 岳史⁴, 橋本 公夫⁵, 坂下 裕美⁶

Kinuko MOHRI¹, Hiroya UCHIDA¹, Sadayuki AZUMA¹, Takuya HIRATA², Takashi FUKAYA², Toshitaka OKUNO³, Yoshikazu TAKAMINE³, Takeshi SAKAMOTO⁴, Kimio HASHIMOTO⁵, Hiromi SAKASHITA⁶

¹西神戸医療センター臨床検査技術部, ²西神戸医療センター小児科, ³西神戸医療センター外科, ⁴西神戸医療センター内科, ⁵西神戸医療センター病理科, ⁶京都大学医学部附属病院病理部

¹Department of Clinical Laboratory, Nishi-Kobe Medical Center, ²Department of Pediatrics, Nishi-Kobe Medical Center, ³Department of Surgery, Nishi-Kobe Medical Center, ⁴Department of Internal Medicine, Nishi-Kobe Medical Center, ⁵Department of Pathology, Nishi-Kobe Medical Center, ⁶Laboratory of Anatomic Pathology, Kyoto University Hospital

キーワード : Doppler color flow imaging, Meckel’s diverticulum, mesodiverticular band, acute abdomen, ultrasonography

メッケル憩室壊死による小児急性腹症の1例を経験したので報告する. 症例は5歳の女児. 2003年11月11日15時ごろより腹痛が出現し, 続いて嘔吐も繰り返したため当院を受診した. 来院時, 心窩部に圧痛を認めたが腫瘤は触知しなかった. 血液検査では白血球数20,700 /μlと増多していたが, CRPその他に異常は認めなかった. 腹部単純X線検査にて, 下腹部に拡張した腸管のガス像を認めた. 腹部造影CT,腹部超音波検査にて小腸の拡張と, 臍部に腸管の一部と思われる嚢胞性病変を認めた. その壁は不整に肥厚し, 層構造は不明瞭で, 超音波カラードプラ法にて明らかな血流シグナルは捉えられなかった. 以上より, メッケル憩室壊死の疑いがあり, 絞扼性イレウスも否定できなかったため開腹術を施行した. 回盲弁より60 cm口側の小腸に, 壊死した憩室を認めた. 憩室頂部と腸間膜を結ぶ約7 cmの索状物を認め, ここに小腸が入り込んでいたが, 絞扼など通過障害はなかった. 病理組織学的所見では, 憩室は腸管壁の全層を有し, 大量の出血と壊死がみられた. 索状物には動静脈が存在し, うっ血と出血がみられた. Mesodiverticular bandを伴うメッケル憩室の出血梗塞壊死と診断した.

A 5-year-old girl was brought to the hospital because of abdominal pain and vomiting. She complained of epigastralgia, but no abdominal mass was palpable on physical examination. White blood cell count was 20700 /μl but other results of laboratorytest were within normal limits. Plain abdominal X-ray film showed an abnormal intestinal shadow in the lower abdomen; contrast enhanced CT scan and ultrasonography, dilation of the small intestine and a cystlike mass near the umbilicus. The cystlike mass seemed likely to be part of the small intestine and appeared as a thick, not clearly defined structure consisting of a single layer with an irregular wall. Doppler color flow imaging showed poor vascularization of the wall. We carried out an exploratory laparotomy after arriving at a diagnosis of either necrosis of Meckel’s diverticulum or strangulation of the small intestine. We detected necrotic Meckel’s diverticulum at 60 cm oral side from the ileocecal valve. It was a 7-cm long fibrous band connecting the tip of the diverticulum to the mesentery. No bowel obstruction was observed. Histopathologic examination showed that the diverticulum had retained all the layers of the ileum, and examination of the histologic section identified severe hemorrhage and necrosis in the full thickness of the resected diverticulum. Because the band showed the presence of an artery, vein, and fat tissue, it was characterized as a mesodiverticular band. Because no involvement of the small intestine was indicated, our diagnosis was hemorrhagic infarction of Meckel’s diverticulum with a mesodiverticular band.