山下 都¹, 畠 二郎², 中武 恵子¹, 竹之内 陽子¹, 谷口 真由美¹, 小島 健次¹, 今村 祐志², 眞部 紀明², 楠 裕明², 春間 賢³

Miyako YAMASHITA¹, Jiro HATA², Keiko NAKATAKE¹, Yoko TAKENOUCHI¹, Mayumi TANIGUCHI¹, Kenji KOJIMA¹, Hiroshi IMAMURA², Noriaki MANABE², Hiroaki KUSUNOKI², Ken HARUMA³

¹川崎医科大学附属病院中央検査部, ²川崎医科大学附属病院検査診断学（内視鏡・超音波）, ³川崎医科大学附属病院内科学（食道胃腸）

¹Division of Clinical Laboratory, Kawasaki Medical School, ²Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, ³Department of Internal Medicine, Kawasaki Medical School

キーワード : primary duodenal cancer, extracorporeal ultrasound, hypercalcemia

症例は68歳，女性．嘔気のため他院で上部消化管内視鏡検査が施行されたが明らかな異常は認められなかった．次第に腎不全および高カルシウム血症を伴うようになり，当院を紹介受診．体外式超音波上，十二指腸は上腸間膜動脈と腹部大動脈の間よりやや肛門側の水平部から上行部にかけて約4cmの範囲で壁が全周性に肥厚し，その層構造は不明瞭であった．Levovist^®を用いたadvanced dynamic flow^TM（ADF）間歇送信による造影超音波では，壁内の血流は寡少であった．また，左腎に腎盂の拡張を認め腎盂尿管移行部付近で狭小化していた．さらに腎門部近傍の脂肪織は肥厚し縦横比の高いリンパ節が数個観察された．以上より広範囲に浸潤した原発性十二指腸癌が疑われ，姑息的手術を目的として開腹術となった．腫瘍は上腸間膜動静脈を巻き込んでおり切除困難で，小腸間膜には多数の播種を疑う結節を認めた．小腸間膜播種生検標本の病理組織学的所見から原発性十二指腸癌およびその播種性転移と診断された．患者は腎不全のため化学療法は困難であり，2ヵ月後に永眠された．通常の上部消化管内視鏡検査では十二指腸水平部や上行部を積極的に観察しないことも多く，本症例のように消化管疾患に由来すると思われる上腹部症状を有しながらも通常の上部消化管内視鏡検査で異常を認めない症例には，超音波を積極的に応用すべきであると思われた．

Duodenal cancer is relatively rare. Many patients are diagnosed at an advanced stage and the prognoses are generally poor because patients often complain of non-specific symptoms and endoscopic diagnosis of the distal part of the duodenum is often difficult. We report a case of primary duodenal cancer detected by abdominal ultrasonography (US). A 68-year-old Japanese woman was admitted to our hospital for further examination of nausea, renal failure, and hypercalcemia. No abnormality was found with ordinal gastroduodenal endoscopy performed by a nearby doctor. Abdominal US revealed diffuse wall thickening with blurred wall stratification in the distal 3rd and 4th position of the duodenum. Contrast US with Levovist^® showed the hypovascular nature of the tumor. Left hydroureter with surrounding fat tissue thickening including lymph node swelling suggested broad tumor invasion into the retroperitoneal space. Barium contrast studies as well as endoscopy also showed luminal narrowing of the duodenum, suggestive of duodenal cancer. On operation, the tumor was not resectable due to broad invasion and dissemination. Histopathological examination of the resected seeding nodule confirmed the diagnosis of primary duodenal cancer, and gastrojejunostomy was performed as a palliative therapy. The patient, in whom chemotherapy was difficult to carry out because of renal failure, died two months after the operation. In this case, US was useful for not only detection but also assessment of invasion of duodenal cancer.