図１〜図３で遊離ガス（△）と腹水（※）を認め，図９と図１０でMorison窩にも腹水がある（※）．図５の↑が胃角部の，図６〜図８の↑は前庭部後壁の潰瘍性病変で，図６〜図１０で軽度だが粘膜下浮腫を認め（▲），胃潰瘍穿孔である．ガストログラフィン造影で胃角部から後壁へ広がる潰瘍を認めた（図A：↑）が，造影剤の漏出を認めないため保存的に治療し症状は全快した．後日の2回の内視鏡検査による生検で良性潰瘍であることが確認された．

参考症例：43歳男性．3時間前急に上腹部痛が出現し来院．体温：36.4℃，臍部下から上腹部にかけて腹膜刺激症状を認めた．遊離ガスがあり（△），少量の腹水がある（※）．小弯側に浮腫性壁肥厚があり（▲），↑が胃角部から後壁に広がる潰瘍性病変．ガストログラフィン造影で後壁に潰瘍を認め（↑），大量の造影剤の遊離腹腔内への漏出を認めた（白矢印）にもかかわらず，2週間の保存的治療が奏功した．腹腔内への造影剤の漏出は手術の適応であり，保存的治療で治癒したのは例外的と言えよう．

文献考察１）：胃潰瘍穿孔の手術例77例，9％は胃癌であった．
Dig Surg. 2000;17(2):132-7.
Perforated gastric ulcer.
Wysocki A, Biesiada Z, Beben P, Budzynski A.

BACKGROUND/AIMS: Reports about perforated gastric ulcer are scarce and thus it is difficult to settle for a uniform model of operative management. The purpose of the study was to review our experience with perforated gastric ulcer and evaluate the results of gastric resection vs. oversewing of the perforation. METHODS: Within 36 years 77 patients with peritonitis caused by histologically confirmed perforated gastric ulcer were operated. Furthermore, in another 7 microscopic examination revealed that perforation occurred within the gastric cancer. There were twice as many male as female patients. RESULTS: Recently, the overall postoperative mortality (20. 8%) tended to decrease markedly. 32 patients (mean age 49.9 years) were submitted to gastric resection and this procedure was associated with 2.9% mortality. All 3 subjects in whom vagotomy, pyloroplasty and wedge resection of the ulcer had been performed survived. In 40 patients (mean age 61.5 years) only a suture of the ulcer was performed. This procedure was associated with high mortality (1/3 of patients died). Selection criteria included poor general medical status, age, comorbidities, and substantial progression of the inflammatory process. CONCLUSION: Authors believe that emergency gastrectomy is a safe procedure; however, it might be performed without excessive operative risk in only half of the patients.PMID: 10781975
追記：リスクファクターとして全身状態，年齢（60歳），基礎疾患と腹膜炎の程度を考慮するが，リスクファクターのない45％の症例に胃切除を行い，死亡率はただの2.9％であった．55％の症例では単純閉鎖術を施行し，死亡率は37％であった．9％は胃癌であった．

２）70歳以上の胃十二指腸潰瘍穿孔手術例130例（胃：50例，十二指腸：80例）．
Hepatogastroenterology. 2001 Jan-Feb;48(37):156-62.
The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age.
Tsugawa K, Koyanagi N, Hashizume M, Tomikawa M, Akahoshi K, Ayukawa K, Wada H, Tanoue K, Sugimachi K.

BACKGROUND/AIMS: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients. METHODOLOGY: From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment. RESULTS: A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P 追記：十二指腸潰瘍穿孔には単純閉鎖と迷走神経切離術を，胃潰瘍穿孔例ではrisk factor（術前にショック状態，発症から24時間以上経過している，合併症の高い基礎疾患）がなければ胃切除術を比較的安全に行える．