全画像で大量の遊離ガスがあり（△とG），図１３〜図１５でMorison窩に腹水がある（※）．図２〜図１２の肝右葉の腫瘤性病変（T）は内部構造が不整で転移性腫瘍の可能性が極めて高い．図４〜図１１の↑は深い潰瘍性病変と解釈し，図４〜図１０の胃粘膜（▲）は他部位の粘膜と比較し造影効果が強く，やや肥厚し，腫瘍性病変を示唆する．図５〜図１０の白矢印は腫大したリンパ節の可能性が高い．従って肝転移を伴う胃癌の穿孔を強く疑う．丸数字１２：十二指腸．手術で胃癌の穿孔が確認された（図A：↑が癌病変）．病変は肝左葉に穿通し癒着し，小弯側にはブドウの房状に一塊となり腫大した転移性リンパ節を認めた．

参考症例１（5mmスライス，胃癌穿孔）：70歳女性．数日前から時々上腹部痛があり，9時間前に急に増強した．体温：37.5℃，上腹部に圧痛と反跳痛があるが筋性防御は認めない．
図１〜図４の遊離ガス（G）と図９〜図１６の腹水（※）は消化管穿孔を強く示唆する．図１と図２の肝臓の病変（白矢印）は転移性腫瘍を，図１〜図５の△は腫大したリンパ節も転移を示唆する．図８〜図１４の▲は不整な造影効果を受ける壁肥厚を示し胃癌の可能性が高く，図８〜図１０の↑は潰瘍で，胃癌の穿孔と診断する．手術で胃前壁に5cm大の硬い腫瘤があり，そこでの穿孔，小弯側にリンパ節腫大，肝臓に転移と思われる数個の腫瘍性病変を認めた．大網充填術を行い，術中生検の病理検査で胃癌と診断された．

参考症例２（非穿孔性胃癌）：54歳女性．前日に発症した心窩部痛のため来院．↑，▲，△が癌病変．病理：adenocarcinoma，por2＞sig，深達度はse．

文献考察：胃癌穿孔集計155例．
Am J Gastroenterol. 1997 Mar;92(3):516-8.
Surgical results of perforated gastric carcinoma: an analysis of 155 Japanese patients.
Adachi Y, Mori M, Maehara Y, Matsumata T, Okudaira Y, Sugimachi K.

OBJECTIVES: Free perforation of gastric carcinoma accounts for less than 1% incidence of acute abdominal crisis in Japan, and this problem occurs much less frequently in Western countries. To clarify the characteristics of patients with perforated gastric carcinoma (PGC) and to investigate a treatment of choice, we reviewed the data of Japanese patients with PGC. METHODS: A total of 155 cases of PGC reported in the Japanese literature from 1985 to 1994, including one patient of our own experience, were studied. The clinicopathologic features, including tumor stage and patient survival, were analyzed. RESULTS: There were 27 stage I tumors (19%), 16 stage II tumors (12%), 42 stage III tumors (30%), and 55 stage IV tumors (39%). Emergency gastrectomy was done in 128 patients (83%), with the mortality and 5-yr survival rate was 7 and 40%, respectively. The survival of patients was influenced by the gross type of tumor, serosal invasion, lymph node metastasis, stage of the disease, and operative curability. The 5-yr survival rate of stage I and II patients was 76% and that of curatively treated patients was 74%. CONCLUSIONS: Recent Japanese results of emergency gastrectomy for PGC are satisfactory. Long-term survival is expected in curatively treated patients with stage I and II tumors.PMID: 9068483