今日の臨床サポート

胃アニサキス症

著者: 天野祐二 医療法人博仁会 浦和共済病院 消化器内科

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正済:2021/11/24
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 胃アニサキス症を疑う症例には、上部消化管内視鏡検査および内視鏡的虫体摘出術が推奨される(推奨度2)。
  1. 急性胃アニサキス症の内視鏡所見は非常に多彩である。NBI内視鏡観察も刺入虫体の視認性を向上させる(推奨度2)。
  1. 胃アニサキス症で出現する蕁麻疹は再感染例に多い。一般にサバ蕁麻疹はアニサキス幼虫が原因である(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
天野祐二 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 新しい酸分泌抑制薬の適応および使用法について追加した。
  1. 保険診療上の情報の追加を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 胃アニサキス症とは、多くの海産魚類に寄生するAnisakis属またはAnisakis亜科に属するPseudoterranova属の幼虫が、経口的に侵入し胃壁へ刺入することにより発生する寄生虫疾患である。
  1. アニサキス症を引き起こす種は主にAnisakis simplex(アニサキスⅠ型)、Anisakis physeteris(アニサキスⅡ型)およびPseudoterranova Decipiensの3種である。アニサキス症の原因として最も多いのはアニサキスⅠ型幼虫で、Ⅰ型はさらにAnisakis pegreffiiAnisakis simplex sensu strictoおよびAnisakis simplex Cの3種類に分類されている。
  1. サバの体内には、日本海産ではAnisakis pegreffiiが、太平洋産ではAnisakis simplex sensu strictoが多いが、国内のアニサキス感染者100名より摘出した虫体の99%が後者であった。内臓から筋肉部位(刺身の部分)へのアニサキスの移行率は、Anisakis simplex sensu strictoのほうがAnisakis pegreffiiと比較して100倍以上高いことが高感染率の原因といわれている。
  1. 待機宿主といわれるサバ、イカ、イワシ、アジ、サケ、カツオ、タラなどに寄生したアニサキス第3期幼虫の生食により、多くは4~6時間後に発症する。
  1. 2018年の特に4~5月にはカツオによる発症が急増しており、今後しばらく待機宿主としてカツオにも注視すべきといわれている。
  1. 胃アニサキス症は、虫体が胃壁に刺入することによって生じる急性アレルギー反応が原因である。
  1. 胃アニサキス症はluminal typeまたは緩和型、invasive typeまたは激症型に病型分類される。一般に後者は即時型過敏反応による消化管の攣縮を伴うもので、あらかじめアニサキス抗原で感作されているか、再感染の場合である。一方、激症型の症状としては、悪心・嘔吐と上腹部痛が主体であり、放置すると数日間続く。
  1. 国際登録されているAnisakis simplexの9種類のアレルゲン(Ani s 1~9)のうち、主なものはAni s 1とAni s 7であり、それぞれに対するIgE抗体の検索はアニサキス感染症診断に有用である(保険適応はない)[1][2]。しかしながら、Ani s 1は胃アニサキス症に特異的であるのに対して、Ani s 7はアニサキス感作後の蕁麻疹に特異的であるという違いを持つ[3]
  1. 近年では、海産魚類生食という食文化の流行もあって、特に急性胃アニサキス症はきわめて多い。内視鏡治療で簡単に治癒することもあって、本例が届出報告されることは少なくなったが[4]、国立感染症研究所によると、近年の症例数は年間7,000例強と試算されている。
問診・診察のポイント  
  1. 症状が出現した直近の食事内容をよく聞き、該当する待機宿主の生食がなかったどうか確認する。

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文献 

著者: Yukihiro Kobayashi, Shoichiro Ishizaki, Yuji Nagashima, Kazuo Shiomi
雑誌名: Parasitol Int. 2008 Sep;57(3):314-9. doi: 10.1016/j.parint.2008.01.005. Epub 2008 Feb 15.
Abstract/Text Third stage larvae of the nematode Anisakis simplex often infect marine fish and invertebrates. When the larvae are ingested orally via seafood, they can cause IgE-mediated allergic reactions as well as anisakiasis. Of the known A. simplex allergens, Ani s 1 (Kunitz/bovine pancreatic trypsin inhibitor family protein) has been demonstrated to be a major allergen, being expected to be a useful tool for diagnosis of A. simplex allergy. For a diagnostic purpose, sufficient amounts of either natural Ani s 1 (nAni s 1) or recombinant Ani s 1 (rAni s 1) with an IgE-binding capacity should be stably supplied whenever needed. In this study, therefore, we first developed a simple and rapid purification method for Ani s 1 that is based on affinity chromatography using anti-Ani s 1 antibodies as ligands. The method was shown to produce nAni s 1 with a higher yield than the previously reported methods. Then, an attempt was made to express rAni s 1 in Escherichia coli as a His-tagged protein. rAni s 1 obtained as an inclusion body was solubilized in a solvent containing denaturing and reducing reagents and purified by nickel-chelate chromatography. Refolding of rAni s 1 was accomplished by dialysis in the presence of arginine, followed by that in the absence of arginine. Fluorescence ELISA and inhibition ELISA data revealed that rAni s 1 is IgE reactive enough to be used as a diagnostic tool.

PMID 18374626  Parasitol Int. 2008 Sep;57(3):314-9. doi: 10.1016/j.par・・・
著者: A M Anadón, F Romarís, M Escalante, E Rodríguez, T Gárate, C Cuéllar, F M Ubeira
雑誌名: Clin Exp Immunol. 2009 Jun;156(3):471-8. doi: 10.1111/j.1365-2249.2009.03919.x.
Abstract/Text Ani s 7 is currently the most important excretory/secretory (ES) Anisakis simplex allergen, as it is the only one recognized by 100% of infected patients. The allergenicity of this molecule is due mainly to the presence of a novel CX(17-25)CX(9-22)CX(8)CX(6) tandem repeat motif not seen in any previously reported protein. In this study we used this allergen as a model to investigate how ES allergens are recognized during Anisakis infections, and the usefulness of a recombinant fragment of Ani s 7 allergen (t-Ani s 7) as a marker of true Anisakis infections. The possible antigenic relationship between native Ani s 7 (nAni s 7) from Anisakis and Pseudoterranova decipens antigens was also investigated. Our results demonstrate that nAni s 7 is secreted and recognized by the immune system of rats only when the larvae are alive (i.e. during the acute phase of infection), and that this molecule is not present in, or is antigenically different from, Pseudoterranova allergens. The t-Ani s 7 polypeptide is a useful target for differentiating immunoglobulin E antibodies induced by true Anisakis infections from those induced by other antigens that may cross-react with Anisakis allergens, including P. decipiens. The results also support the hypothesis that the Ani s 7 major allergen does not participate in maintaining the antigenic stimulus during chronic infections.

PMID 19438600  Clin Exp Immunol. 2009 Jun;156(3):471-8. doi: 10.1111/j・・・
著者: C Cuéllar, A Daschner, A Valls, C De Frutos, V Fernández-Fígares, A M Anadón, E Rodríguez, T Gárate, M Rodero, F M Ubeira
雑誌名: Arch Dermatol Res. 2012 May;304(4):283-8. doi: 10.1007/s00403-012-1206-8. Epub 2012 Jan 15.
Abstract/Text Diagnosis in gastro-allergic anisakiasis (GAA) is straightforward, when clinical history is combined with further allergological evaluation of specific IgE by means of skin prick test and serum specific IgE. In Anisakis simplex sensitisation associated chronic urticaria (CU+), clinical evaluation of possible previous parasitism is difficult, and positive serum specific IgE could be due to cross-reactivity or other unknown factors. In this study, we evaluated the association between IgE seropositivity to the recombinant allergens Ani s 1 and Ani s 7 and several A. simplex-associated allergic disorders. Twenty-eight patients with GAA and 40 patients with CU+ were studied and their IgE responses were compared with a control group composed of patients with chronic urticaria not sensitized to A. simplex (CU-) according to the skin prick test, as well as a group of 15 healthy subjects not referring urticaria or currently A. simplex associated symptoms. 82.1% of GAA patients and 42.5% of CU+ patients were positive for Ani s 1 (P < 0.001), while the Ani s 7 allergen was recognized by 92.9 and 92.5% of sera from patients with GAA and CU+, respectively. The combined positivity obtained for both allergens reached 100% in GAA, and 95% in CU+. IgE determinations to Ani s 1 and Ani s 7 allergens are useful to diagnose the Anisakis infections and to differentiate among several A. simplex-associated allergic disorders. The IgE responses to Ani s 1 are mainly associated with GAA, while this molecule cannot be considered a major allergen in CU+ patients.

PMID 22249742  Arch Dermatol Res. 2012 May;304(4):283-8. doi: 10.1007/・・・
著者: Azusa Umehara, Yasushi Kawakami, Jun Araki, Akihiko Uchida
雑誌名: Parasitol Int. 2007 Sep;56(3):211-5. doi: 10.1016/j.parint.2007.02.005. Epub 2007 Mar 6.
Abstract/Text Anisakis simplex complex presently comprises three sibling species, A. simplex sensu stricto, A. pegreffii and A. simplex C. A. simplex is a common parasite in fishes and cephalopods and capable of causing anisakiasis in humans. Therefore, identification of sibling species of A. simplex was important for human health. In this study, one hundred Anisakis type I larvae isolated from eighty five patients with anisakiasis in Hokkaido and Kyushu in Japan were analyzed by adapting the new molecular method that can identify the sibling species of A. simplex complex. Based on the restriction fragment length polymorphism (RFLP) pattern of ITS regions including 5.8 subunit rRNA gene, we identified two sibling species, A. simplex s. str. and A. pegreffii. However, the infection rate of A. simplex s. str. was significantly higher than that of A. pegreffii. Eighty four (98.8%) out of the eighty five patients were infected with A. simplex s. str. On the contrary, one patients (1.2%) in Kyushu infected with A. pegreffii. This study provided basic information about human infection with A. simplex complex. Furthermore, we suggested that A. simplex s. str. is the most important etiological agent in Japan.

PMID 17428725  Parasitol Int. 2007 Sep;56(3):211-5. doi: 10.1016/j.par・・・
著者: Hiroshi Yasuda
雑誌名: Nihon Rinsho. 2010 Jun;68 Suppl 6:300-2.
Abstract/Text
PMID 20942063  Nihon Rinsho. 2010 Jun;68 Suppl 6:300-2.
著者: S Kasuya, K Koga
雑誌名: Arerugi. 1992 Feb;41(2 Pt 1):106-10.
Abstract/Text Anisakis larvae which parasitize sea fishes sometimes cause not only anisakiasis but also such allergic reactions as mackerel-induced urticaria. We prepared AlaSTAT by using excretory/secretory antigens from Anisakis larvae to detect specific IgE in various patients groups. The AlaSTAT positive rate was 87.5% in gastric anisakiasis patients who were endoscopically diagnosed, while it was 66.7% in patients who had acute abdominal pain but no larva detected. Ascariasis in the common bile duct was 0%. The positive rate in mackerel-induced urticaria patients was 75.0%, while it was 8.3% and 10.0% in patients with urticaria of unknown origin and normal controls, respectively. Based on these data, the detection of specific IgE using AlaSTAT is useful in elucidating the cause of urticaria or acute abdominal pain, such as Anisakis.

PMID 1567281  Arerugi. 1992 Feb;41(2 Pt 1):106-10.
著者: S Kasuya, H Hamano, S Izumi
雑誌名: Lancet. 1990 Mar 17;335(8690):665.
Abstract/Text
PMID 1969043  Lancet. 1990 Mar 17;335(8690):665.
著者: Kiyoshi Shikino, Masatomi Ikusaka
雑誌名: Intern Med. 2019 Jul 15;58(14):2121. doi: 10.2169/internalmedicine.2428-18. Epub 2019 Mar 28.
Abstract/Text
PMID 30918192  Intern Med. 2019 Jul 15;58(14):2121. doi: 10.2169/inter・・・
著者: T Machi, S Okino, Y Saito, Y Horita, T Taguchi, T Nakazawa, Y Nakamura, H Hirai, H Miyamori, S Kitagawa
雑誌名: Intern Med. 1997 Jan;36(1):28-30.
Abstract/Text We treated two cases of gastric anisakiasis presenting with severe chest pain. In both cases, there was a history of prior ingestion of raw saltwater fish. After endoscopic removal of larvae, the chest pain disappeared and never recurred. Other diseases causing chest pain were ruled out by symptoms, signs, blood tests, electrocardiography, chest radiograph, and ultrasonic examination of the heart and abdomen. Thus the chest pain was considered to be caused by gastric anisakiasis. Gastric anisakiasis should be included in the differential diagnosis of acute chest pain.

PMID 9058096  Intern Med. 1997 Jan;36(1):28-30.
著者: Domenico Taranto, Gabriella Sessa, Raffaella Tortora, Fabrizio Tremolaterra
雑誌名: Dig Liver Dis. 2011 Mar;43(3):e5. doi: 10.1016/j.dld.2010.02.007. Epub 2010 Mar 27.
Abstract/Text
PMID 20347620  Dig Liver Dis. 2011 Mar;43(3):e5. doi: 10.1016/j.dld.20・・・
著者: Naoto Mizumura, Satoshi Okumura, Hiroshi Tsuchihashi, Masao Ogawa, Masayasu Kawasaki
雑誌名: ACG Case Rep J. 2018;5:e65. doi: 10.14309/crj.2018.65. Epub 2018 Sep 12.
Abstract/Text A 50-year-old man presented with epigastric pain after eating raw mackerel. Abdominal computed tomography revealed submucosal edema of the gastric antrum and pelvic ileum. Gastroscopy revealed an Anisakis simplex in the gastric antrum. His epigastric pain resolved after endoscopic removal of the Anisakis; however, he developed right lower quadrant pain the following day. Abdominal computed tomography showed submucosal edema of the terminal ileum involving different ileal loops, which was not present on admission. The patient developed delayed intestinal anisakiasis. A serving of raw fish may contain more than one Anisakis. After gastric anisakiasis, a second Anisakis may cause intestinal anisakiasis.

PMID 30238019  ACG Case Rep J. 2018;5:e65. doi: 10.14309/crj.2018.65. ・・・
著者: K Sugimachi, K Inokuchi, T Ooiwa, T Fujino, Y Ishii
雑誌名: JAMA. 1985 Feb 15;253(7):1012-3.
Abstract/Text From 1969 to 1984, we treated 178 patients with acute gastric anisakiasis caused by gastric mucosal penetration of the Anisakis larvae. Because the larvae of Anisakis can always be observed by endoscopy and removed with biopsy forceps, early performance of endoscopy is highly recommended for patients in whom acute gastric anisakiasis is suspected and for those who have eaten raw fish within 12 hours before onset of the gastric symptoms. Endoscopic removal is essential to relieve the intolerable pain; after relief, the administration of antacids will repair the damaged gastric mucosa. Ulcer formation is rare.

PMID 4038525  JAMA. 1985 Feb 15;253(7):1012-3.
著者: S Kakizoe, H Kakizoe, K Kakizoe, Y Kakizoe, M Maruta, T Kakizoe, S Kakizoe
雑誌名: Am J Gastroenterol. 1995 May;90(5):761-3.
Abstract/Text OBJECTIVES: To identify the endoscopic findings and clinical manifestations of anisakiasis, we studied 87 cases of gastric anisakiasis.
METHODS: Patient information was analyzed by means of patient records. The interval between the day of intake of Anisakis and endoscopic examination was determined in 86 cases. Then the endoscopic findings of each interval were elucidated.
RESULTS: Moderate to severe gastric mucosal edema tends to occur within 1 or 2 days after Anisakis infection, accompanied by leukocytosis. As to the sites of penetration of Anisakis, 55% of cases were found in the greater curvature with severe mucosal edema. Among 87 cases, four patients experienced anisakiasis twice during the interval examined, and six patients had past histories of anisakiasis before the investigated interval.
CONCLUSIONS: Gastric anisakiasis may be caused by an allergic reaction to the Anisakis antigen. There is a classic relationship between clinical and endoscopic findings and the interval after Anisakis administration. Anisakis usually is found in the greater curvature.

PMID 7733084  Am J Gastroenterol. 1995 May;90(5):761-3.
著者: M Yamazaki, K Hara, T Shinbo
雑誌名: Rinsho Hoshasen. 1978 Sep;23(9):919-24.
Abstract/Text
PMID 691802  Rinsho Hoshasen. 1978 Sep;23(9):919-24.
著者: K Fujisawa, T Matsumoto, R Yoshimura, S Ayabe, M Tominaga
雑誌名: Endoscopy. 2001 Sep;33(9):820. doi: 10.1055/s-2001-16517.
Abstract/Text
PMID 11558039  Endoscopy. 2001 Sep;33(9):820. doi: 10.1055/s-2001-1651・・・
著者: Yoshihiko Nakanishi, Shujiro Yazumi, Daisuke Ikeuchi, Akio Matsumoto, Hiromi Yamamura, Shinsuke Yoshizaki, Shinichi Mise, Norio Fukuyama, Chikao Shimamoto, Kenichi Katsu
雑誌名: Gastrointest Endosc. 2005 Jan;61(1):102.
Abstract/Text
PMID 15672065  Gastrointest Endosc. 2005 Jan;61(1):102.
著者: Ma Carmen Romero, Ma Concepción Navarro, Joaquina Martín-Sánchez, Adela Valero
雑誌名: Trop Med Int Health. 2014 Dec;19(12):1430-6. doi: 10.1111/tmi.12399. Epub 2014 Oct 20.
Abstract/Text OBJECTIVES: Therapy against anisakiasis requires invasive techniques to extract L3 , and an effective drug against this nematode is needed. The aim of this study was to determine the efficacy of peppermint essential oil (EO) and its main components against the parasite in comparison to albendazole, a drug currently prescribed to treat anisakiasis.
METHODS: We conducted in vitro experiments and studied an experimental model simulating the human infection in Wistar rats. We used polymerase chain reaction restriction fragment length polymorphism to identify A. simplex s.s. and A. pegreffii and determine any differences in their pathogenicity and susceptibility to the treatments.
RESULTS: The in vitro and in vivo experiments both showed that the larvicidal activity of peppermint EO, menthol, menthone and menthyl acetate is higher than that of albendazole. Large stomach lesions were observed in 46.7% of the albendazole-treated rats, whereas no gastrointestinal lesions were detected in those treated with peppermint EO, menthol, menthyl acetate or menthone.
CONCLUSIONS: In this animal model, treatment with peppermint EO or its main components was more effective than was treatment with albendazole. Lesions were more frequently produced by A. simplex s.s. larvae than by A. pegreffii larvae.

© 2014 John Wiley & Sons Ltd.
PMID 25330410  Trop Med Int Health. 2014 Dec;19(12):1430-6. doi: 10.11・・・
著者: Gotaro Kojima, Shinichiro Usuki, Ken Mizokami, Marianne Tanabe, Junji Machi
雑誌名: Am J Emerg Med. 2013 Sep;31(9):1422.e1-2. doi: 10.1016/j.ajem.2013.05.015. Epub 2013 Jun 18.
Abstract/Text Anisakiasis, a parasitic infection by larvae of the nematode Anisakis found in raw or undercooked saltwater fish, mostly involves stomach but rarely small intestine. We report a rare case of a 61-year-old man who presented with abdominal pain and developed small bowel obstruction caused by intestinal anisakiasis. Abdominal computed tomography revealed segmental edema of the intestinal wall with proximal dilatation. The patient underwent urgent laparotomy because strangulated small bowel obstruction was suspected. A localized portion of the intestine around jejunoileal junction was found to be erythematous, edematous, and hardened, which was resected. The resected specimen showed a linear whitish worm, Anisakis simplex, penetrating into the intestinal mucosa. It is often clinically challenging to consider intestinal anisakiasis in the differential diagnosis because of its nonspecific abdominal symptoms and findings. Although gastrointestinal anisakiasis is still rare in the United States, the incidence is expected to rise given the growing popularity of Japanese cuisine such as sushi or sashimi. Anisakiasis should be considered as one of the differential diagnoses in patients with nonspecific abdominal symptoms after consumption of raw or undercooked fish.

Copyright © 2013 Elsevier Inc. All rights reserved.
PMID 23786678  Am J Emerg Med. 2013 Sep;31(9):1422.e1-2. doi: 10.1016/・・・
著者: Nobukazu Yorimitsu, Atsushi Hiraoka, Hiroki Utsunomiya, Yusuke Imai, Haruka Tatsukawa, Nayu Tazuya, Hiroka Yamago, Yukou Shimizu, Satoshi Hidaka, Tetsuya Tanihira, Aki Hasebe, Yasunao Miyamoto, Tomoyuki Ninomiya, Masanori Abe, Yoichi Hiasa, Bunzo Matsuura, Morikazu Onji, Kojiro Michitaka
雑誌名: Intern Med. 2013;52(2):223-6. Epub 2013 Jan 15.
Abstract/Text A 67-year-old woman presented with periumbilical pain. Contrast-enhanced computed tomography findings indicated intussusception of the ascending colon without ischemia or necrosis, and we performed successful colonoscopy to treat the condition. Furthermore, an edematous area caused by anisakis was detected in the ascending colon and the anisakis was removed. The patient noted that she had eaten raw fish one day before the symptoms developed. Although colonic intussusception caused by anisakiasis is extremely rare, colonoscopy should be performed in colonic intussusception patients suspected of having anisakiasis in order to avoid invasive resection.

PMID 23318852  Intern Med. 2013;52(2):223-6. Epub 2013 Jan 15.

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契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから