b a 図1 入院時大腸内視鏡所見 a F2, Cw, RC + の直腸静脈瘤 b 門脈圧亢進症性腸症を認めた c b a 図 2 TIPS 時の造影 a SMV 造影では IMV への逆流 大矢印 と門脈本幹壁在血栓 小矢印 が認められる b 脾静脈造影では脾静脈は血栓性閉塞を示した c TIPS
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1 TIPS KEY WORDS: ectopic varices, transjugular intrahepatic portosystemic shunt, liver cirrhosis, portal hypertension Kanazawa H 1, Narahara Y 1, Fukuda K 1, Kondoh C 1, Harimoto H 1, Matsushita Y 1, Kidokoro H 1, Katakura R 1, Atsukawa M 1, Nakatsuka Y 1, Sakamoto C 1 : Ectopic varices and transjugular intrahepatic portosystemic shunt. JJPH 2009; 15: I Transjugular intrahepatic portosystemic shunt: TIPS 2 54 TIPS 1 TIPS 2 54 II F 2 Cw RC + Portal hypertensive colonopathy: PHC Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School, Sendagi, Bunkyou-ku, Tokyo, Japan Partial splenic artery embolization: PSE TIPS 6 13 WBC 2500/μl Hb 8.4 g/dl Plt /μl AST 28 IU/L ALT 12 IU/L LDH 218 IU/L ALP 297 IU/L γ GTP 91 IU/L T-Bil 1.1 mg/dl Creatinine 0.73 mg/dl Albumin 2.9 g/dl T-Cho 115 mg/ dl PT 65 M2 103 HBs HCV Child-Pugh 7 TIPS 6 16 TIPS Superior mesenteric vein: SMV 50 Inferior mesenteric vein: IMV SMV SMV IMV 2-a 2-b 8 mm Wallstent Porto-systemic pressure gradient: PSG 15 mmhg 7 mmhg SMV IMV 154
2 b a 図1 入院時大腸内視鏡所見 a F2, Cw, RC + の直腸静脈瘤 b 門脈圧亢進症性腸症を認めた c b a 図 2 TIPS 時の造影 a SMV 造影では IMV への逆流 大矢印 と門脈本幹壁在血栓 小矢印 が認められる b 脾静脈造影では脾静脈は血栓性閉塞を示した c TIPS 作成後の SMV 造影で は IMV への逆流は消失したが門脈血栓が残存している 流は消失した 図 2-c TIPS 後には下血はなく 7 月 4 脈圧の軽度上昇のため SMV 血流の一部が TIPS 前ほどで 日の大腸内視鏡検査では直腸静脈瘤および PHC の改善 はないものの IMV へ逆流を示していた この際の大腸内 図 3 を認め 7 月 9 日軽快退院した 視鏡検査では直腸静脈瘤および PHC は前回退院時と同様 退院後の経過 であり増悪は見られなかった 退院 1 カ月後の 8 月 4 日 便秘を契機としてⅢ度の肝 その後外来通院中であったが 平成 16 年 1 月 22 日ド 性脳症を生じ再入院となった 肝性脳症は一般的治療に プラ超音波検査にてシャント閉塞の疑いが持たれバルン より改善した 8 月 17 日に行った脾静脈造影では脾静脈 拡張術施行目的で 3 回目の入院となった TIPS 路へのガ および門脈本幹の血栓はほぼ消失していた 図 4-a し イドワイヤ挿入は容易であったが SMV からの造影では かし TIPS 内に輪状の狭窄を認め PSG は 12 mmhg へ上 シャントは閉塞し 門脈本幹の壁在血栓の再発 SMV 血 昇していた シャントの状態は良好であり肝性脳症が生 流の IMV への逆流を認めた 図 5-a PSG は 15 mmhg じたことを考慮しバルン拡張術は施行しなかった その を示した バルン拡張術 ウロキナーゼを用いた血栓溶 際の SMV 造影を図 4-b に示した シャント狭窄による門 解療法 血栓吸引治療を行ったのち 直径 8 mm の Spiral 日門亢会誌 2009; 15:
3 3 TIPS 3 a b 4 TIPS 2 a TIPS b SMV IMV Z-stent stent-in-stent TIPS SMV total shunt IMV 5-b Stent-in-stent PSG 6 mmhg 7 4 PHC TIPS 5 10 TIPS WBC 3200/μl Hb 13.9 g/dl Plt /μl AST 31 IU/L ALT 12 IU/L LDH 267 IU/L ALP 380 IU/L γ GTP 9 IU/L T-Bil 1.3 mg/dl Creatinine 0.98 mg/dl Albumin 3.2 g/dl T-Cho 147 mg/ dl PT 68 Child-Pugh 7 156
4 a b 5 TIPS 7 a SMV IMV b SMV total shunt IMV IMV TIPS IMV PHC TIPS 2 7 TIPS IMV TIPS IMV 5 10 TIPS TIPS III. TIPS 21 3 Pub-Med TIPS Child-Pugh A 18 B 47 C 35 PSG 19.5 mmhg TIPS 14 TIPS TIPS PSG 3 2, 3, PSG 12 mmhg PSG 12 mmhg 55 PSG 12 mmhg PSG TIPS
5 1 TIPS Kochar N Vidal V Nayar M Vangeli M Shibata D Haskal Child A/B/C 2/16/9 5/12/7 3/3/3 2/9/8 4/5/3 2/2/5 18/47/35 Child-Pugh mmhg Child-Pugh IV. TIPS TIPS 9 TIPS TIPS Balloon-occluded retrograde transvenous obliteration: B-RTO , 62 63, 64 B-RTO B-RTO 59 B-RTO TIPS 3 1 Norton ID, Andrews JC, Kamath PS: Management of ectopic varices. Hepatology 1998; 28: Kochar N, Tripathi D, McAvoy NC, et al: Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts. Aliment Pharmacol Ther 2008; 28: Vidal V, Joly L, Perreault P, et al: Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol 2006; 29: Nayar M, Saravanan R, Rowlands PC, et al: TIPSS in the treatment of ectopic variceal bleeding. Hepatogastroenterology 2006; 53: Vangeli M, Patch D, Terreni N, et al: Bleeding ectopic varices treatment with transjugular intrahepatic portosystemic shunt (TIPS) and embolisation. J Hepatol 2004; 41: Shibata D, Brophy DP, Gordon FD, et al: Transjugular intrahepatic portosystemic shunt for treatment of bleeding 158
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直腸静脈瘤に対するIVR
直腸静脈瘤に対する塞栓術 関西医科大学放射線科学講座 狩谷秀治 目次 1. 解剖 2. 病態 3. 治療 解剖 門脈圧亢進症により直腸静脈瘤が生じた場合の血行動態 Spl. V IMV 上直腸静脈 SMV Int. iliac V 中直腸静脈 下直腸静脈 直腸静脈瘤 正面像 下腸間膜静脈造影 側面像 病態 痔核 ( 直腸静脈瘤とは異なる ) 1) Vascular cushion( 動脈 静脈 動静脈交通枝からなる血管叢
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日本消化器病学会雑誌第102巻第8号
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Journal of Breast and Thyroid Sonology Journal of Breast and Thyroid Sonology Vol.3, No.3 July 2014 Original Article Clinical significance of classification of mixed-pattern tumor by breast ultrasound...
E Societe de Pathologie Infectieuse de Langue Francaise (, 1991) E Spanish Thoracic Society (1992) E American Thoracic Society (ATS : 1993. ü ù2001 ) E British Thoracic Society (1993, ü è2001 ) E Canadian