図１と図２で前腹壁直下に遊離ガスを認め（白矢印），図１，図４〜図１０に腹水がある（※）ので消化管穿孔の可能性は極めて高い．図１２の直腸１から逆行性に結腸を追跡すると，数字順に進展し図３の下行結腸２８となる．結腸の走行がはっきりすれば図８〜図１０の△は腸管外の糞便と判断される．Ｓ状結腸と下行結腸に多数の憩室（↑）を認め，図７の24〜図９の22で壁肥厚を示しているのでＳ状結腸憩室炎の穿孔と診断する．手術でＳ状結腸に2ｃｍ大の穿孔（図A：▲）を，骨盤腔には糞便と腹膜炎を認め，Hartmann手術を施行した．病理：穿孔部近傍に多数の憩室を認め，憩室炎の穿孔として矛盾しない．

参考症例（特発性Ｓ状結腸穿孔）：67歳男性．6時間前に上腹部痛が急に出現し，軽快しないため来院した．体温：37.0℃，臍左側に圧痛，反跳痛と筋性防御を認めた．
図１で遊離ガス（白矢印）と腹水（※）があり，消化管穿孔の可能性が極めて高い．図８〜図１３でも腹水（※）を認めるが，図１１と図１２の散在するガス像↑はニボーを形成しないので腸管内容物と解釈すべきで，骨盤腔内消化管の穿孔を強く示唆する．直腸から下行結腸は数字順に走行する．図５の8〜図３の10のＳ状結腸は粘膜下浮腫を示しており（▲），穿孔の責任病変と解釈する．手術でＳ状結腸中央部での穿孔を認めた．病理：原因不明のＳ状結腸壊死と穿孔．

文献考察：日本人の大腸憩室症は右側型：67％，左側型：9％，両側型：24％→10年後には右側型：46％，左側型：6%，両側型：46%と両側型が増加し，憩室の数は右側で2倍に，両側型で2倍に，左側型では5倍に増える．
Dis Colon Rectum. 2005 Nov;48(11):2111-6.
An analysis of the development of colonic diverticulosis in the Japanese.
Takano M, Yamada K, Sato K.

PURPOSE: There are quite different characteristics between colonic diverticulosis in the West and that in Asia, including Japan. These differences include the predominance of a few diverticula over others, right-sidedness, young generation, male, and few complications. In Japan, colonic diverticulosis started increasing in the 1970s. This study was performed to obtain exact evidence of diverticular development in contemporary Japanese by observing changes in diverticula in the same individuals examined over a period of ten or more years. METHODS: This study included 82 subjects (56 (68 percent) males and 26 (32 percent) females) who underwent barium enema examinations repeatedly for more than ten years from 1982 to 2000. The diverticula were categorized according to their location in the colon: right, left, or bilateral. They were also categorized by whether they appeared individually, were scattered with two to nine diverticula, or were numerous with ten or more diverticula. RESULTS: At the beginning of observation, the most frequent location was the right side (55; 67 percent), followed by bilateral (20; 24 percent) and the left side (7; 9 percent). Ten or more years later, the number on the right side had decreased to 39 (48 percent). The number of bilateral diverticula had increased to 38 (46 percent), and the number on the left had barely changed, to 5 (6 percent). The number of diverticula increased from 253 to 604 (239 percent) in the right and from 380 to 929 (244 percent) in the bilateral. The initially very small number in the left increased from 9 to 48 (533 percent). The data show marked increases in the right and bilateral diverticula, and also the spread from the right side to the left side. CONCLUSION: In contemporary Japanese, although the right predominated initially, diverticulosis showed a strong tendency to increase and spread from the right to the bilateral. The number of bilateral diverticula also tended to increase. The left did not change much.PMID: 16228844