慢性膵炎の診断 ―画像診断と機能検査の併用による―

近年，各種膵疾患に対する検査法の発達には目を見張るものがあるが，実際の運用にあたっては各検査法の適応，限界，組合わせおよび実施する順序等に迷うことが少なくない。本研究では，最近我々が経験した慢性膵炎Ⅰ群116例の診断過程を振り返ることにより，慢性膵炎の診断における理想的な検査法の組合わせとそれぞれの役割を検討し，同時に診断名のみならず病態と病期が容易に理解できる表現方法を提案した。画像診断法，膵外分泌機能検査法（EX），膵内分泌機能検査法（EN）を比較検討し，以下の結果を得た。①画像診断法は必須である。②内視鏡的逆行性膵胆管造影（ERCP）を軸とした腹部超音波検査（US）あるいは腹部CTスキャン（CT）の組合わせは欠くことができない。③EXもまた必須の検査法である。④ENは慢性膵炎の診断に必要不可欠ではないが，治療方針を決めるうえで重要である。⑤純粋膵液（PPJ）の生化学的検査と組織化学的検査は膵炎の診断と病態生理の解明に重要である。⑥PPJ中の細胞診は慢性膵炎に合併した膵癌の検索に有用である。⑦以下に示すような診断の記載方法を提案した。"Calcified chronic pancreatitis, alcoholic, diffuse,　ERCP-3, US-2, CT-3, EX-2, EN-1, Lf(＋)"。

Endoscopic retrograde cholangiopancreatography (ERCP), ultrasonography (US), computed tomography (CT), exocrine pancreatic function test (EX), endocrine pancreatic function test (EN), and analysis of pure pancreatic juice (PPJ) are currently available for the investigation of pancreatic diseases. The purpose of the present study is to evaluate the roles and preferable combinations of these tests in the diagnosis of chronic pancreatitis and then to propose a way to describe the results of the tests along with diagnosis for a better understanding of the disease process. Comparative studies of imaging, EX and EN led to the following conclusions. 1) imaging procedures (ERCP, US and CT) are mandatory, partly because they were frequently the test that showed diagnostic changes and partly because they often gave key information for operative treatment. Among the imaging procedures, ERCP combined with US and/or CT is mandatory because these combinations alone can reveal detailes of structural changes attendant on chronic pancreatitis. 2) EX is also mandatory, because it was occasionally the only test that showed diagnostic changes and partly because it often gave important information for medical treatment. 3) EN is also important, not because it was indispensable for detecting chronic pancreatitis, but because it often gave important information for medical treatment. For btter understanding of the disease process as well as diagnosis, we propose, as suggested by Seligson, that the test used for the establishment of the diagnosis and the degree as well as extent of abnormalities. An example is "Calcified chronic pancreatitis, alcoholic, diffuse, ERCP-3, US-2, CT-3, EX-2, EN-1, Lf(+)". This attitude will lead to a more rational approach to both diagnosis and treatment.