胃と腸42巻12号

2007年11月発行

今月の主題 非ステロイド性抗炎症薬（NSAID）起因性消化管病変 主題

NSAID起因性小腸病変の臨床像と画像所見

著者： 田口宏樹¹ 山本博徳¹ 林芳和¹ 南信弘¹ 三浦義正¹ 新城雅行¹ 岩本美智子¹ 矢野智則¹ 宮田知彦¹ 砂田圭二郎¹ 菅野健太郎¹

所属機関： ¹自治医科大学内科学講座消化器内科部門

ページ範囲：P.1721 - P.1729

要旨　ダブルバルーン内視鏡にて観察したNSAIDsによる小腸病変の評価を行った．NSAIDsは小腸単独の潰瘍性病変を引き起こすことがあり，通常の上下部消化管内視鏡では原因を特定できない消化管出血の一因となりうる．また，NSAIDs長期投与患者において小腸膜様狭窄症という特徴的な狭窄を来すことがある．NSAID起因性小腸潰瘍性病変についてはNSAIDsの休薬が治療となる．また，NSAID起因性小腸膜様狭窄症に対しては，NSAIDs休薬とともにDBEによるバルーン拡張術を行うことが，これまで開腹術でしか対応できなかった，特に深部小腸の狭窄病変に対して有効な治療法であると考えられる．

参考文献

1) Appleyard M, Glukhovsky A, Swain P. Wireless-capsule diagnostic endoscopy for recurrent small-bowel bleeding. N Engl J Med 344:232-233, 2001

2) Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 53:216-220, 2001

3) Allison MC, Howatson AG, Torrance CJ, et al. Gastrointestinal damage associated with the use of nonsteroidal antiinflammatory drugs. N Engl J Med 327:749-754, 1992

4) Laurence M, Bjarni T, Asgeir T, et al. A quantitative analysis of NSAID-induced small bowel pathology by capsule enteroscopy. Gastroenterology 128:1172-1178, 2005

5)松本主之，飯田三雄，蔵原晃一，他．NSAID起因性下部消化管病変の臨床像―腸炎型と潰瘍型の対比．胃と腸 35:1147-1158, 2000

6) Hayashi Y, Yamamoto H, Kita H, et al. Non-steroidal anti-inflammatory drug-induced small bowel injuries identified by double-balloon endoscopy. World J Gastroenterol 31:4861-4864, 2005

7)林芳和，山本博徳，喜多宏人，他．知られざる小腸病変―これからの小腸診療．内科 96:619-624, 2005

8)八尾隆史，恒吉正澄．非ステロイド系消炎鎮痛剤(NSAIDs)起因性小腸膜様狭窄症の一例．病理と臨床 24:88-89, 2006

9) Kessler WF, Shires GT, Fahey TJ. Surgical complications of nonsteroidal antiinflammatory drug-induced small bowel ulceration. J Am Coll Surg 185:250-254, 1997

10) Israel LH, Koea JB, Stewart ID, et al. Nonsteroidal anti-Inflammatory drug-induced strictures of the colon:report of a case and review of the literature. Dis Colon Rectum 44:1362-1364, 2001

11) Lang J, Price AB, Levi AJ, et al. Diaphragm disease:pathology of disease of the small intestine induced by non-steroidal anti-inflammatory drugs. J Clin Pathol 41:516-526, 1988

12) Yousfi MM, De Petris G, Leighton JA, et al. Diaphragm disease after use of nonsteroidal anti-inflammatory agents:first report of diagnosis with capsule endoscopy. J Clin Gastroenterol 38:686-691, 2004

13) Onwudike M, Sundaresan M, Wood JJ, et al. Diaphragm disease of the small bowel―a case report and literature review. Dig Surg 19:410-413, 2002

14) Nosho K, Endo T, Yoda Y, et al. Diaphragm disease of small intestine diagnosed by double-balloon enteroscopy. Gastrointest Endosc 62:187-189, 2005

15) Manetas M, O'Loughlin C, Kelemen K, et al. Multiple small-bowel diaphragms:a cause of obscure GI bleeding diagnosed by capsule endoscopy. Gastrointest Endosc 60:848-851, 2004

16)近藤英介，林伸一，鈴木弘文，他．NSAIDの長期使用による多発性隔膜様小腸狭窄症(diaphragm disease)の1例．日本臨床外科学会雑誌 66:647-652, 2005

17) Kamata Y, Iwamoto M, Nara H, et al. A case of rheumatoid arthritis with protein losing enteropathy induced by multiple diaphragmatic strictures of the small intestine:successful treatment by bougieing under double-balloon enteroscopy. Gut 55:1372, 2006

18) Bjarnason I, Pricw AB, Zanelli G, et al. Clinicopathological features of non-steroidal anti-inflammatory drug-induced small intestinal stricture. Gastroenterology 94:1070-1074, 1988

19) Bjarnason I, Hayllar J, Macpherson AJ, et al. Side effects of nonsteroidal anti-inflammatory drugs on the small intestine in humans. Gastroenterology 104:1832-1847, 1993

20)國方友紀，田中晶子，加藤伸一，他．NSAID誘起小腸傷害の発生―粘膜防御能破錠における運動性変化の重要性．実験潰瘍 28:40-44, 2001

21) Tanaka A, Kunihata T, Konaka A, et al. Dual action of nitric oxide in pathogenesis of indomethacin-induced small intestinal ulceration in rats. J Physiol Pharmacol 50:405-417, 1999

22) Boughton-Smith NK, Evans SM, Laszlo F, et al. The induction of nitric oxide synthase and intestinal vascular permeability by endotoxin in the rat. Br J Pharmacol 110:1189-1195, 1993

23) Sigthorsson G, Simpson RJ, Walley M, et al. COX-1 and 2, intestinal integrity, and pathogenesis of nonsteroidal anti-inflammatory drug enteropathy in mice. Gastroenterology 122:1913-1923, 2002

24)田中晶子，長谷晶子，宮澤徹，他．NSAID誘起小腸傷害の発生におけるシクロオキシゲナーゼ(COX)-1及びCOX-2阻害の重要性．実験潰瘍 29:28-32, 2002

25) Rahme E, Bardou M, Dasgupta K, et al. Gastrointestinal effects of rofecoxib and celecoxib versus NSAIDs among patients on low dose aspirin. Gastroenterology 126(Suppl 2):A-1-2, 2004

26) Hawkey CJ, Karrasch JA, Szczepanski L, et al. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal anti-inflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management(OMNIUM)Study Group. N Engl J Med 338:727-734, 1998

27) Whittle BJ, Laszlo F, Evans SM, et al. Induction of nitric oxide synthase and microvascular injury in the rat jejunum provoked by indomethacin. Br J Pharmacol 116:2286-2290, 1995

28) Bjarnason I, Smethurst P, Fenn CG, et al. Misoprostol reduces indomethacin-induced changes in human small intestinal permeability. Dig Dis Sci 34:407-411, 1989

29) Watanabe T, Higuchi K, Yamato M, et al. Involvement of toll-like receptor 4 in indomethacin-induced small intestinal damage and prevention of damage by probiotic lacto bacillus casei. Gastroenterology 128(suppl 2):A-513, 2005