今日の臨床サポート

腹部膨満・腹部腫瘤

著者: 荒武寿樹1) 東京北部病院

著者: 亀岡信悟2) 牛久愛和総合病院

監修: 杉原健一 東京医科歯科大学大学院

著者校正済:2022/09/14
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 腹部膨満・腹部腫瘤は腹腔内臓器の器質的病変に由来するものと機能的病態に起因するものがある。
  1. 器質的病変は画像診断が有用である。
  1. 機能的病態はそれぞれのガイドラインに沿った症状の把握が重要である。
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  1. IBSの有病率はおおよそ10%であり、経年的に増加しているとは言えない[1]
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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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
荒武寿樹 : 未申告[2022年]
亀岡信悟 : 特に申告事項無し[2022年]
監修:杉原健一 : 講演料(大鵬薬品工業)[2022年]

改訂のポイント:
  1. 定期レビューを行い、機能性消化管疾患・肝硬変についてガイドラインに沿う図表の追加、日本人の癌データを更新、腹部膨満を来す一部症例の追加を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 腹部膨満(感)は『お腹が張る』という自覚症状のあることをいう。一方、他覚的に、臥位で臍部や腹部の一部が剣状突起と恥骨を結ぶ線より突出している場合を腹部膨隆という。
  1. 過敏性腸症候群(IBS)などでは腹部膨満は必ずしも腹部膨隆を伴わないことがある。
  1. 腹部腫瘤は腹壁・腹腔内臓器に生じたしこりである。
  1. 腹部膨満の原因は、①腸管内ガス・液体の過剰な貯留、②腸管外腹腔内の異常な気体・液体貯留、③腹腔内臓器の腫大・腫瘤、④肥満、⑤妊娠――などがある。
  1. 腹部腫瘤は③の一部に相当するが、腹部膨満という自覚症状はなく、健診時診察や超音波検査、CTなどでみつかることもある。腹壁や腹腔内各臓器の腫大・腫瘍、ヘルニアなどがある。
 
  1. 腹部膨満・膨隆についての病態生理、診断、治療についてのレビュー
  1. まとめ:腹部膨満は年齢・性別にかかわらずよくみられる症状である。膨満感はほぼすべての過敏性腸症候群患者においてみられ、その他の機能性・器質的疾患でもみられる。
    膨満は有効な治療が少なく、必ずしも効果のない場合もあり、しばしば患者を苦しめ臨床家をも悩ませる。膨満と膨隆という言葉は同じように使われるが、これらの症状は異なった病態を含んでいる。両者はいまだ完全には解明されていない。ここでは病態、診断、治療について総説する。
  1. 追記:腹部膨満・腹部膨隆についての総説で有用な文献と思われる[2]
 
腸管ガスの成因

主に摂取された飲食物から腸管ガスは出来る。大量の二酸化炭素が消化の副産物として小腸に産生されるが多くは吸収される。水素と二酸化炭素のほとんどが大腸で産生されるがその多くは再吸収される。メタン産生菌が水素を消費してメタンチオールと硫化水素を出す。

出典

img1:  Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?
 
 Gastroenterol Hepatol (N Y). 2011 Nov;7(・・・
 
  1. 腹部膨満患者ではIBSも念頭に置くことが勧められる(推奨度2)
  1. まとめ:Lacyらによれば腹部膨満(感)の頻度は全米人口中15~30%であり、過敏性腸症候群(IBS)患者では66~90%にある[2]
    また、わが国における一般生活者におけるROMA III基準に合致するIBS患者の頻度は13.1%との報告がある。
  1. 代表事例:Miwaらによる20~79歳までの一般生活者15,000名を対象としたインターネットによるアンケート調査において、ROMA III基準に合致するIBS患者は13.1%であった[3]
    またOkumuraらによると、一般内科受診5,183名中、腹部症状は14.8%(818名)にあり、そのなかで機能性消化管障害患者は39.1%(320名)を占めた[4]
  1. 結論:機能性消化管障害は有病率が比較的高い疾患である。
問診・診察のポイント  
  1. 問診ではまず、症状発現時からの経時的変化、随伴症状の有無(腹痛、発熱、嘔吐など)が重要である。次に、既往歴(手術や外傷、悪性腫瘍など)、併存疾患(糖尿病、神経・筋疾患、精神疾患など)、現在使用している治療薬、食欲や体重変化、排便・排尿の状態、便・尿の性状、月経・不正出血、妊娠の有無などが大切である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

Brian E Lacy, Scott L Gabbard, Michael D Crowell
Pathophysiology, evaluation, and treatment of bloating: hope, hype, or hot air?
Gastroenterol Hepatol (N Y). 2011 Nov;7(11):729-39.
Abstract/Text Abdominal bloating is commonly reported by men and women of all ages. Bloating occurs in nearly all patients with irritable bowel syndrome, and it also occurs in patients with other functional and organic disorders. Bloating is frequently disturbing to patients and frustrating to clinicians, as effective treatments are limited and are not universally successful. Although the terms bloating and abdominal distention are often used interchangeably, these symptoms likely involve different pathophysiologic processes, both of which are still not completely understood. The goal of this paper is to review the pathophysiology, evaluation, and treatment of bloating and abdominal distention.

PMID 22298969
H Miwa
Life style in persons with functional gastrointestinal disorders--large-scale internet survey of lifestyle in Japan.
Neurogastroenterol Motil. 2012 May;24(5):464-71, e217. doi: 10.1111/j.1365-2982.2011.01872.x. Epub 2012 Jan 31.
Abstract/Text BACKGROUND: Care of patients with functional gastrointestinal disorders (FGIDs) commonly includes offering guidance on diet, exercise, and other lifestyle factors, but there is little information available on the actual lifestyles of FGID sufferers.
METHODS: An internet questionnaire survey of 15,000 adult members of the general public in Japan who were screened for functional dyspepsia (FD) and irritable bowel syndrome (IBS) using the Rome III adult FGID questionnaire was conducted.
KEY RESULTS: The prevalence of FD and IBS was 6.5% and 14.0%, respectively, and 3.0% of the subjects met the criteria for both FD and IBS. The prevalence of both FD and IBS was higher in women than in men. The lifestyles of 2,547 subjects who met the Rome III criteria for FD, IBS, or both were compared with the lifestyles of 1,000 control subjects who did not meet the criteria for FD or the criteria for IBS. Compared to the control subjects, a significantly lower percentage of subjects with FD, IBS, or both exercised frequently, and a significantly higher percentage thought that their sleep was insufficient, ate meals irregularly, did not have an appetite, did not like meat, thought that their vegetable consumption was insufficient, felt stress in their daily lives, and regarded themselves as being highly susceptible to stress.
CONCLUSIONS & INFERENCES: Persons with FGIDs are affected by impairment of sleep, eating habits, diet, exercise and other lifestyle factors, and feel excessive stress. This suggests that offering lifestyle guidance to FGID patients may be useful.

© 2012 Blackwell Publishing Ltd.
PMID 22292849
Toshikatsu Okumura, Sachie Tanno, Masumi Ohhira, Satoshi Tanno
Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan.
J Gastroenterol. 2010 Feb;45(2):187-94. doi: 10.1007/s00535-009-0168-x. Epub 2009 Dec 8.
Abstract/Text BACKGROUND: Since little is known about the prevalence of patients with functional gastrointestinal disorders (FGID), this study was performed to clarify the prevalence of FGID, especially functional dyspepsia (FD), in new patients of an outpatient clinic with primary care physicians in Japan.
METHODS: We analyzed consecutive outpatients (n = 5183) who first visited the Department of General Medicine, Asahikawa Medical College Hospital, between April 2004 and March 2009.
RESULTS: Out of 5813 patients, 818 (14.1%) visited because of abdominal symptoms. Final diagnoses of the 818 patients were FGID (n = 320, 39.1%), organic gastrointestinal diseases (n = 237, 28.9%), organic non-GI disease (n = 135, 16.5%), and others (n = 126, 15.4%). The 320 patients with FGID had FD (n = 170), irritable bowel syndrome (IBS) (n = 68), and other FGIDs (n = 88). The rate of FGID or FD in all patients was 5.5% or 2.9%, respectively. Among outpatients (n = 381) who complained of upper abdominal symptoms, approximately 45% had FD. There was no gender difference in the frequency of FGID, FD, or IBS in all ages of patients. A lower incidence of FD was shown in female patients over 70 years old and a higher incidence of IBS in male patients under 29 years old.
DISCUSSION: These results suggest that the prevalence of FGID, especially FD, is very high in an outpatient clinic with primary care physicians in Japan.

PMID 19997854
Alexandra Antonucci, Lucia Fronzoni, Laura Cogliandro, Rosanna-F Cogliandro, Carla Caputo, Roberto De Giorgio, Francesca Pallotti, Giovanni Barbara, Roberto Corinaldesi, Vincenzo Stanghellini
Chronic intestinal pseudo-obstruction.
World J Gastroenterol. 2008 May 21;14(19):2953-61.
Abstract/Text Chronic intestinal pseudo-obstruction (CIPO) is a severe digestive syndrome characterized by derangement of gut propulsive motility which resembles mechanical obstruction, in the absence of any obstructive process. Although uncommon in clinical practice, this syndrome represents one of the main causes of intestinal failure and is characterized by high morbidity and mortality. It may be idiopathic or secondary to a variety of diseases. Most cases are sporadic, even though familial forms with either dominant or recessive autosomal inheritance have been described. Based on histological features intestinal pseudo-obstruction can be classified into three main categories: neuropathies, mesenchymopathies, and myopathies, according on the predominant involvement of enteric neurones, interstitial cells of Cajal or smooth muscle cells, respectively. Treatment of intestinal pseudo-obstruction involves nutritional, pharmacological and surgical therapies, but it is often unsatisfactory and the long-term outcome is generally poor in the majority of cases.

PMID 18494042
S Buob, A N Johnston, C R L Webster
Portal hypertension: pathophysiology, diagnosis, and treatment.
J Vet Intern Med. 2011 Mar-Apr;25(2):169-86. doi: 10.1111/j.1939-1676.2011.00691.x.
Abstract/Text Portal hypertension (PH) is the result of increased vascular resistance in the portal circulation, increased portal venous blood flow, or both. In veterinary medicine, where portal pressure is seldom measured directly, the diagnosis of PH often is inferred from identification of associated complications including multiple acquired portosystemic shunts, ascites, and hepatic encephalopathy. Likewise, treatment of PH primarily is aimed at controlling these complications. The goal of this review is to provide an update on the pathophysiology, diagnosis, and treatment of PH. The review draws from information in the veterinary hepatology literature, reviews, and consensus statements in human hepatology and the literature on experimental models of PH.

Copyright © 2011 by the American College of Veterinary Internal Medicine.
PMID 21382073
Pere Ginès, Javier Fernández, François Durand, Faouzi Saliba
Management of critically-ill cirrhotic patients.
J Hepatol. 2012;56 Suppl 1:S13-24. doi: 10.1016/S0168-8278(12)60003-8.
Abstract/Text Cirrhotic patients are prone to develop life-threatening complications that require emergency care and ICU admission. They can present specific decompensations related to cirrhosis such as variceal bleeding and hepatorenal syndrome (HRS) or other critical events also observed in the general population such as severe sepsis or septic shock. Clinical management of all these entities requires a specific approach in cirrhosis. Cirrhotic patients have a hyperdynamic circulation with high cardiac output and low systemic vascular resistance in the absence of infection. Circulatory dysfunction increases the susceptibility of critically-ill cirrhotic patients to develop multiple organ failure and attenuates vascular reactivity to vasopressor drugs. HRS, a severe functional renal failure occurring in patients with advanced cirrhosis and ascites, is also secondary to this circulatory dysfunction that leads to an extreme renal vasoconstriction. Moreover, hypotensive cirrhotic patients require a carefully balanced replacement of volemia, since overtransfusion increases portal hypertension and the risk of variceal bleeding and undertransfusion causes tissue hypoperfusion which increases the risk of multiple organ failure. Cirrhotic patients are also at a high risk for development of other bleeding complications and are more susceptible to nosocomial infections. This extreme complexity of critically-ill cirrhotic patients requires a specific medical approach that should be known by general intensivists since it has a negative impact on patient prognosis. This review will focus on the diagnostic approach and treatment strategies currently recommended in the critical care management of patients with cirrhosis.

Copyright © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
PMID 22300462
Hiroyuki Kirikoshi, Satoru Saito, Masato Yoneda, Koji Fujita, Hironori Mawatari, Takashi Uchiyama, Takuma Higurashi, Kento Imajo, Takashi Sakaguchi, Kazuhiro Atsukawa, Aya Sawabe, Akira Kanesaki, Hirokazu Takahashi, Yasunobu Abe, Masahiko Inamori, Noritoshi Kobayashi, Kensuke Kubota, Norio Ueno, Atsushi Nakajima
Outcomes and factors influencing survival in cirrhotic cases with spontaneous rupture of hepatocellular carcinoma: a multicenter study.
BMC Gastroenterol. 2009 Apr 30;9:29. doi: 10.1186/1471-230X-9-29. Epub 2009 Apr 30.
Abstract/Text BACKGROUND: Spontaneous rupture is rare complication of hepatocellular carcinoma (HCC) with high mortality rate in cirrhotic cases. The aim of this study was to determine the factors influencing prognosis in cases of spontaneously ruptured HCC and to investigate the outcomes of the treatments employed, especially transcatheter arterial embolization (TAE).
METHODS: A retrospective multicenter study was conducted in 48 cirrhotic patients with spontaneous rupture of HCC. Conservative treatment was employed in 32 patients (ConT group) and TAE was performed in 16 patients (TAE group).
RESULTS: The median survival time (MST) in the ConT group was only 13.1 days and the survival rate was extremely poor: 59.4% at 7 days, 37.5% at 14 days, and 6.3% at 30 days. On the other hand, the MST in the TAE group was 244.8 days and the survival rate was 87.5% at 1 month, 56.3% at 3 months, 23.4% at 12 months, and 15.6% at 24 months. According to the results of univariate analyses, factors associated with poor hepatic function and poor suitability for TAE was important determinants of short-term death (less than 3 weeks) among the patients (p < 0.05). On the other hand, among the patients in whom initial TAE was successfully performed (n = 15), a multivariate analysis showed that a maximum tumor size not exceeding 7 cm was the only independent factor determining long-term survival (p = 0.0130).
CONCLUSION: Despite the inherent limitations of this retrospective study, TAE appears to be a useful treatment strategy for cirrhotic patients with spontaneous HCC rupture, as it yielded a longer survival period compared with conservative treatment in patients with ruptured HCC. Among the patients with ruptured HCC in whom initial TAE was successfully performed, the maximum tumor size was an important factor influencing survival.

PMID 19405938
Arlene B Chapman, Wenjing Wei
Imaging approaches to patients with polycystic kidney disease.
Semin Nephrol. 2011 May;31(3):237-44. doi: 10.1016/j.semnephrol.2011.05.003.
Abstract/Text Imaging is an important approach to diagnosis, monitoring, and predicting outcomes for patients with autosomal-dominant polycystic kidney disease. This article reviews three common clinical imaging techniques, ultrasonography, computed tomography, magnetic resonance imaging, and their role in the management of autosomal-dominant polycystic kidney disease. Ultrasonographic criteria for diagnosis in children and adults are reviewed. Total kidney volume, as measured by magnetic resonance imaging, is suggested as an important potential marker to determine disease progression and overall prognosis. Renal blood flow and a novel approach to interpreting noncystic renal parenchyma by computed tomography images are other innovative imaging approaches described.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 21784272
Bernd Kasper, Philipp Ströbel, Peter Hohenberger
Desmoid tumors: clinical features and treatment options for advanced disease.
Oncologist. 2011;16(5):682-93. doi: 10.1634/theoncologist.2010-0281. Epub 2011 Apr 8.
Abstract/Text Desmoid tumors describe a rare monoclonal, fibroblastic proliferation characterized by a variable and often unpredictable clinical course. Although histologically benign, desmoids are locally invasive and associated with a high local recurrence rate, but lack metastatic potential. On the molecular level, desmoids are characterized by mutations in the β-catenin gene, CTNNB1, or the adenomatous polyposis coli gene, APC. Proof of a CTNNB1 mutation may be useful when the pathological differential diagnosis is difficult and location might be predictive for disease recurrence. Many issues regarding the optimal treatment of patients with desmoids remain controversial; however, surgery is the therapeutic mainstay, except if mutilating and associated with considerable function loss. Postoperative radiotherapy reduces the local recurrence rate, in cases of involved surgical margins. Because of the heterogeneity of the biological behavior of desmoids, including long periods of stable disease or even spontaneous regression, treatment needs to be individualized to optimize local tumor control and preserve patients' quality of life. Therefore, the application of a multidisciplinary assessment with multimodality treatment forms the basis of care for these patients. Watchful waiting may be the most appropriate management in selected asymptomatic patients. Patients with desmoids located at the mesentery or in the head and neck region could present with life-threatening complications and often need more aggressive treatment. This review describes treatment options and management strategies for patients with desmoid tumors with a focus on advanced disease.

PMID 21478276
Amena Sadiya
Nutritional therapy for the management of diabetic gastroparesis: clinical review.
Diabetes Metab Syndr Obes. 2012;5:329-35. doi: 10.2147/DMSO.S31962. Epub 2012 Sep 7.
Abstract/Text Diabetic gastroparesis (DGP), or slow emptying of the stomach, is a well-established complication of diabetes mellitus and is typically considered to occur in individuals with long-standing type 1 and type 2 diabetes mellitus. Clinical consequences of DGP include induction of gastrointestinal (GI) symptoms (early satiety, abdominal distension, reflux, stomach spasm, postprandial nausea, vomiting), alteration in drug absorption, and destabilization of glycemic control (due to mismatched postprandial glycemic and insulin peaks). Effective nutritional management not only helps in alleviating the symptoms, but also in facilitating better glycemic control. Although there have been no evidence-based guidelines pertaining to the nutrition care process of the DGP, the current dietary recommendations are based on expert opinions or observational studies. The dietary management of gastroparesis needs to be tailored according to the severity of malnutrition and kind of upper GI symptom by changing the volume, consistency, frequency, fiber, fat, and carbohydrates in the meal. Small frequent meals, using more liquid calories, reducing high fat or high fiber, consuming bezoar forming foods, and adjusting meal carbohydrates based on medications or insulin helps in improving the upper GI symptoms and glycemic control. Enteral nutrition can be an option for patients who fail to stabilize their weight loss, or for those who cannot gain weight with oral feedings, while total parenteral nutrition is rarely necessary for the patient with gastroparesis.

PMID 23055757

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