右下腹部痛(Right Lower Quadrant Pain)シリーズ6 RESIDENT COURSE 解答 【症例 RR 28】

回腸Crohn病.Crohn’s disease of Ileum.






臍部(図3)を中心に右上から左下への斜線を境に,空腸は左側へ,回腸は右側へ位置する傾向が強いので,図3〜図9の▲は回腸と思われる.全周性にかなり強く造影されるが低濃度の部分も混在する.約6cm長の病変で,Crohn病,結核や悪性腫瘍を疑う.小腸造影では縦走潰瘍と狭窄を認めた(図A:△).5日後の手術では約40cm長の回腸が発赤,壁肥厚,腸間膜浮腫を呈し(図B),切除標本の粘膜面には縦走潰瘍を認めた(図C:↑).病理:Crohn病.







参考文献:Crohn病のCT
1)Radiographics. 2004 May-Jun;24(3):689-702.
Cross-sectional imaging in Crohn disease.
Furukawa A, Saotome T, Yamasaki M, Maeda K, Nitta N, Takahashi M, Tsujikawa T, Fujiyama Y, Murata K, Sakamoto T.

Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu Shiga 520-2192, Japan. akira@belle.shiga-med.ac.jp

The role of cross-sectional imaging in the diagnosis of Crohn disease has expanded with recent technologic advances in computed tomography (CT) and magnetic resonance (MR) imaging that allow rapid acquisition of high-resolution images of the intestines. To acquire images of diagnostic quality, administration of a fairly large amount of intraluminal contrast agent prior to examination and scanning with intravenous contrast material injection are necessary. Both CT and MR imaging are reported to have a sensitivity of over 95% for the detection of Crohn disease; however, they may not allow early diagnosis. Colonoscopy and conventional enteroclysis studies are indicated for patients with early-stage disease. At more advanced stages, CT and MR imaging can help identify and characterize pathologically altered bowel segments as well as extraluminal lesions (eg, fistulas, abscesses, fibrofatty proliferation, increased vascularity of the vasa recta, mesenteric lymphadenopathy). These modalities can also clearly depict inflammatory lesion activity and conditions that require elective gastrointestinal surgery, thereby aiding in treatment planning. In the clinical setting, CT is currently the imaging modality of choice at most institutions; however, it is expected that MR imaging will soon play a comparable role. CT or MR imaging should be included in a comprehensive evaluation of patients with Crohn disease, along with conventional imaging and clinical and laboratory tests. PMID: 15143222

2)Clin Radiol. 2003 Jan;58(1):68-74.
Bowel wall thickening in patients with Crohn's disease: CT patterns and correlation with inflammatory activity.
Choi D, Jin Lee S, Ah Cho Y, Lim HK, Hoon Kim S, Jae Lee W, Hoon Lim J, Park H, Rae Lee Y.

AIM: To assess CT patterns of bowel wall thickening in patients with Crohn's disease and to correlate these patterns with inflammatory activity. MATERIALS AND METHODS: We conducted a retrospective review of 58 helical abdominal CT scans of 53 patients with pathologically proven Crohn's disease. CT patterns of thickened bowel wall were divided into four types based on patterns of mural stratification and enhancement: type A, multilayered mural stratification; type B, two layers with strong mucosal enhancement and prominent low-density submucosa; type C, two layers without strong mucosal enhancement; and type D, homogeneous enhancement. We evaluated CT findings of the bowel and adjacent structures. We also reviewed pathologic features and clinical data to determine inflammatory activity. RESULTS: Fifty-five (95%) of 58 CT examinations showed bowel wall thickening. Of these 55 CT scans, type A pattern was found in 33 (60%), type B in 10 (18%), type C in five (9%), and type D in seven (13%). CT scans with type A showed significantly more wall thickening than those with either type C or type D. Histology revealed 43 cases with active disease and 12 with quiescent appearance. Thirty of 33 CT scans with type A and all 10 with type B were classified as acute disease, and three of five with type C and six of seven with type D as quiescent. CONCLUSION: In patients with Crohn's disease, CT patterns of bowel wall thickening correlated with inflammatory activity. Thickened bowel wall with layering enhancement is predictive of acute disease, and that of homogeneous enhancement suggests quiescence.PMID: 12565208
  【参照症例】   1. 下腹部痛シリーズ 9 【症例 LE 44】
2. 下腹部痛シリーズ 5 【症例 LE 23】

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