今日の臨床サポート

急性腹症

著者: 角田茂1) 京都大学 消化管外科

著者: 坂井義治2) 日本赤十字社 大阪赤十字病院 消化器外科

監修: 杉原健一 東京医科歯科大学大学院

著者校正/監修レビュー済:2021/07/07
患者向け説明資料

概要・推奨   

  1. 分画を含めた全血球計算値(CBC)は外科的な評価に重要であり、急性腹症全例に行うべきである(推奨度1)。
  1. 重篤な急性腹症には腹部造影CTが勧められる(推奨度1)。
  1. 妊娠可能な女性の急性腹症では妊娠検査を行う(推奨度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。
※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:
角田茂 : 特に申告事項無し[2021年]
坂井義治 : 特に申告事項無し[2021年]
監修:杉原健一 : 講演料(大鵬薬品)[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)

病態・疫学・診察

疫学情報・病態・注意事項  
ポイント:
  1. 急性腹症は最近もしくは突然発症した腹痛と定義され、通常は1週間以内の急性発症で手術などの迅速な対応が必要な腹部疾患であり、新たに出現した痛みの場合とともに慢性疼痛の増悪も含まれる疾患概念である。
  1. 腹腔内の異常に起因する場合と、腹腔外に原因のある場合がある。
  1. 救急外来における受診動機の5~10%を占める。確定診断が困難なことも多く、35~41%の患者は救急外来での確定診断に至らずに入院となる。確定診断に至らない腹痛のおよそ8割は、2週間以内に軽減・消失する。
  1. 高齢者の急性腹症は、1/2~2/3が入院加療を要し、約1/3の症例は外科的介入を要する。若年者に比し死亡率は6~8倍である。
  1. 高齢者や糖尿病患者などは、重症であっても、典型的な症状を呈さないことがあり注意が必要である。
  1. 主な急性腹症の比較:<図表>
問診・診察のポイント  
問診:
  1. 意識状態・バイタルサインの評価:
  1. 例:ぐったりした傾眠傾向を認める場合は、敗血症を想起する。

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文献 

著者: Chaan S Ng, Christopher J E Watson, Christopher R Palmer, Teik Choon See, Nigel A Beharry, Barbara A Housden, J Andrew Bradley, Adrian K Dixon
雑誌名: BMJ. 2002 Dec 14;325(7377):1387.
Abstract/Text OBJECTIVES: To evaluate the impact of early abdominopelvic computed tomography in patients with acute abdominal pain of unknown cause on length of hospital stay and accuracy of diagnosis.
DESIGN: Randomised, prospective controlled trial.
SETTING: Teaching hospital in England.
PARTICIPANTS: 120 patients admitted with acute abdominal pain for which no immediate surgical intervention or computed tomography was indicated.
INTERVENTION: 55 participants were prospectively randomised to early computed tomography (within 24 hours of admission) and 65 to standard practice (radiological investigations as indicated).
MAIN OUTCOME MEASURES: Length of hospital stay, accuracy of diagnosis, and, owing to a possible effect on inpatient mortality, deaths during the study.
RESULTS: Early computed tomography reduced the length of hospital stay by 1.1 days (geometric mean 5.3 days (range 1 to 31) v 6.4 days (1 to 60)), but the difference was non-significant (95% confidence interval, 8% shorter stay to 56% longer stay, P=0.17). Early computed tomography missed significantly fewer serious diagnoses. Seven inpatients in the standard practice arm died. Only 50% (59 of 118) of diagnoses on admission were correct at follow up at 6 months, but this improved to 76% (90) of diagnoses after 24 hours.
CONCLUSIONS: Early abdominopelvic computed tomography for acute abdominal pain may reduce mortality and length of hospital stay. It can also identify unforeseen conditions and potentially serious complications.

PMID 12480851  BMJ. 2002 Dec 14;325(7377):1387.
著者: E Sala, C J E Watson, C Beadsmoore, T Groot-Wassink, T R Fanshawe, J C Smith, A Bradley, C R Palmer, A Shaw, A K Dixon
雑誌名: Clin Radiol. 2007 Oct;62(10):961-9. doi: 10.1016/j.crad.2007.01.030. Epub 2007 Jul 2.
Abstract/Text AIM: To compare the effect of an initial early computed tomography (CT) examination versus standard practice (SP) on the length of hospital stay, diagnostic accuracy, and mortality of adults presenting with acute abdominal pain.
MATERIALS AND METHODS: Two hundred and five adults presenting with acute abdominal pain were randomized to undergo an early CT examination or current SP, which comprised supine abdominal and erect chest radiography. One hundred and ninety-eight patients (99 in each arm) were included in the analysis. The primary endpoint was the duration of inpatient stay; secondary endpoints were diagnostic certainty and mortality.
RESULTS: There was no significant difference in the length of hospital stay between the two arms (p=0.20). At randomization 36% (35 of 96) of CT patients and 49% (48 of 98) of SP patients were correctly diagnosed; 24h after randomization the correct diagnosis had been established in 84% of CT patients and 73% of SP patients. This refinement in diagnostic certainty was significantly better in the CT group (p<0.001). There was no difference in mortality between the two trial arms (p=0.31).
CONCLUSION: Early abdominal CT in patients with acute abdominal pain improves diagnostic certainty, but does not reduce the length of hospital stay and 6 month mortality.

PMID 17765461  Clin Radiol. 2007 Oct;62(10):961-9. doi: 10.1016/j.crad・・・
著者: Jaap Stoker, Adrienne van Randen, Wytze Laméris, Marja A Boermeester
雑誌名: Radiology. 2009 Oct;253(1):31-46. doi: 10.1148/radiol.2531090302.
Abstract/Text UNLABELLED: Acute abdominal pain may be caused by a myriad of diagnoses, including acute appendicitis, diverticulitis, and cholecystitis. Imaging plays an important role in the treatment management of patients because clinical evaluation results can be inaccurate. Performing computed tomography (CT) is most important because it facilitates an accurate and reproducible diagnosis in urgent conditions. Also, CT findings have been demonstrated to have a marked effect on the management of acute abdominal pain. The cost-effectiveness of CT in the setting of acute appendicitis was studied, and CT proved to be cost-effective. CT can therefore be considered the primary technique for the diagnosis of acute abdominal pain, except in patients clinically suspected of having acute cholecystitis. In these patients, ultrasonography (US) is the primary imaging technique of choice. When costs and ionizing radiation exposure are primary concerns, a possible strategy is to perform US as the initial technique in all patients with acute abdominal pain, with CT performed in all cases of nondiagnostic US. The use of conventional radiography has been surpassed; this examination has only a possible role in the setting of bowel obstruction. However, CT is more accurate and more informative in this setting as well. In cases of bowel perforation, CT is the most sensitive technique for depicting free intraperitoneal air and is valuable for determining the cause of the perforation. Imaging is less useful in cases of bowel ischemia, although some CT signs are highly specific. Magnetic resonance (MR) imaging is a promising alternative to CT in the evaluation of acute abdominal pain and does not involve the use of ionizing radiation exposure. However, data on the use of MR imaging for this indication are still sparse.
SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/content/253/1/31/suppl/DC1.

PMID 19789254  Radiology. 2009 Oct;253(1):31-46. doi: 10.1148/radiol.2・・・
著者: Wytze Laméris, Adrienne van Randen, H Wouter van Es, Johannes P M van Heesewijk, Bert van Ramshorst, Wim H Bouma, Wim ten Hove, Maarten S van Leeuwen, Esteban M van Keulen, Marcel G W Dijkgraaf, Patrick M M Bossuyt, Marja A Boermeester, Jaap Stoker, OPTIMA study group
雑誌名: BMJ. 2009 Jun 26;338:b2431. Epub 2009 Jun 26.
Abstract/Text OBJECTIVE: To identify an optimal imaging strategy for the accurate detection of urgent conditions in patients with acute abdominal pain.
DESIGN: Fully paired multicentre diagnostic accuracy study with prospective data collection.
SETTING: Emergency departments of two university hospitals and four large teaching hospitals in the Netherlands.
PARTICIPANTS: 1021 patients with non-traumatic abdominal pain of >2 hours' and <5 days' duration. Exclusion criteria were discharge from the emergency department with no imaging considered warranted by the treating physician, pregnancy, and haemorrhagic shock.
INTERVENTION: All patients had plain radiographs (upright chest and supine abdominal), ultrasonography, and computed tomography (CT) after clinical and laboratory examination. A panel of experienced physicians assigned a final diagnosis after six months and classified the condition as urgent or non-urgent.
MAIN OUTCOME MEASURES: Sensitivity and specificity for urgent conditions, percentage of missed cases and false positives, and exposure to radiation for single imaging strategies, conditional imaging strategies (CT after initial ultrasonography), and strategies driven by body mass index and age or by location of pain.
RESULTS: 661 (65%) patients had a final diagnosis classified as urgent. The initial clinical diagnosis resulted in many false positive urgent diagnoses, which were significantly reduced after ultrasonography or CT. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% (95% confidence interval 87% to 92%) for CT and 70% (67% to 74%) for ultrasonography (P<0.001). A conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% (46% to 52%) of patients would have CT. Alternative strategies guided by body mass index, age, or location of the pain would all result in a loss of sensitivity.
CONCLUSION: Although CT is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, using ultrasonography first and CT only in those with negative or inconclusive ultrasonography results in the best sensitivity and lowers exposure to radiation.

PMID 19561056  BMJ. 2009 Jun 26;338:b2431. Epub 2009 Jun 26.
著者: Jonathan Pearl, Raymond Price, William Richardson, Robert Fanelli, Society of American Gastrointestinal Endoscopic Surgeons
雑誌名: Surg Endosc. 2011 Nov;25(11):3479-92. doi: 10.1007/s00464-011-1927-3. Epub 2011 Sep 23.
Abstract/Text
PMID 21938570  Surg Endosc. 2011 Nov;25(11):3479-92. doi: 10.1007/s004・・・
著者: R G Dart, B Kaplan, K Varaklis
雑誌名: Ann Emerg Med. 1999 Mar;33(3):283-90.
Abstract/Text STUDY OBJECTIVE: To identify historical and physical examination findings that are predictive of ectopic pregnancy (EP) in pregnant patients with abdominal pain or bleeding.
METHODS: This study was conducted in an urban academic emergency department as a prospective observational study of consecutive patients from August 1, 1991, to August 31, 1992, who had abdominal pain or vaginal bleeding and a positive beta-human chorionic gonadotropin level. Patients were excluded if they had a diagnostic ultrasound during a previous visit, or if the uterine size was larger than 12 weeks by pelvic examination. Data were analyzed using chi2 with a P value less than. 05 identified as significant. Odds ratios were determined for significant variables. A classification and regression tree analysis was then performed using the predictive variables to derive a decision tree.
RESULTS: Four hundred forty-one patients were enrolled, 57 of whom (13%) had an EP. Factors by history that increased the risk of EP included pain that was described as moderate to severe, lateral, or sharp. Pain located in the midline decreased the risk of EP. A history of previous intrauterine device use, infertility, prior pelvic surgery, or tubal ligation were each found to be predictive. On physical examination, the presence of peritoneal signs, cervical motion tenderness, or lateral or bilateral abdominal or pelvic tenderness increased the risk of EP. A uterine size larger than 8 weeks by pelvic examination decreased the risk of EP. Combinations of predictive variables identified subsets of patients with either an increased or decreased frequency of EP, but in no case was a combination identified that would confirm or exclude this diagnosis with a high degree of certainty.
CONCLUSION: History and physical examination findings predictive of EP were identified. However, no constellation of findings could confirm or exclude this diagnosis with a high degree of reliability.

PMID 10036342  Ann Emerg Med. 1999 Mar;33(3):283-90.
著者: Max H Minnerop, Gregory Garra, Jasmine K Chohan, Regina M Troxell, Adam J Singer
雑誌名: Am J Emerg Med. 2011 Feb;29(2):212-5. doi: 10.1016/j.ajem.2009.10.017. Epub 2010 Mar 25.
Abstract/Text OBJECTIVES: Reliance upon patient assessment in excluding pregnancy is questionable. Physicians are encouraged to obtain pregnancy tests in all women of childbearing age. We affirmed the accuracy of women and their physicians in predicting pregnancy.
METHODS: This was a prospective, observational study performed in a suburban academic emergency department on adult women with an ordered pregnancy test. A standardized gynecologic history was obtained by trained research assistants. Subjects estimated their likelihood of pregnancy as impossible, possible, or definite. Emergency department physicians estimated the likelihood of pregnancy as high, moderate, or low. All women had either a serum or urine β-human chorionic antigen. The diagnostic characteristics of patient and physician predictions of pregnancy were calculated with 95% confidence intervals (CIs).
RESULTS: We enrolled 377 subjects. Median age was 29 (interquartile range, 22-37) years. Twelve percent of the women were pregnant. Women's estimates of pregnancy were as follows: impossible, 64.7%; possible, 22.5%; and definite, 12.7%. The pregnancy rates among women with estimates of impossible, possible, and definite were 0% (95% CI, 0%-1.5%), 4.7% (95% CI, 1.9%-11.5%), and 89.6% (95% CI, 77.8%-95.5%) (P < .001). Physicians' suspicions of pregnancy were high (13.7%), moderate (11.3%), and low (75.1%). The rate of pregnancy among low, moderate, and high physician suspicion groups were 0% (95% CI, 0%-1.4%), 9.5% (95% CI, 3.8%-22%), and 84.3% (95% CI, 72%-92%) (P < .001).
CONCLUSIONS: There were no pregnancies among women who estimated pregnancy as impossible or whose physicians thought that the likelihood of pregnancy was low. Routine pregnancy testing before radiological imaging and medication administration may not be required in adult women of childbearing age.

Copyright © 2011 Elsevier Inc. All rights reserved.
PMID 20825808  Am J Emerg Med. 2011 Feb;29(2):212-5. doi: 10.1016/j.aj・・・
著者: C L Stengel, D C Seaberg, B A MacLeod
雑誌名: Ann Emerg Med. 1994 Oct;24(4):697-700.
Abstract/Text STUDY OBJECTIVE: To determine the prevalence of unrecognized pregnancy in the emergency department and to ascertain if patient history can effectively detect unrecognized pregnancies.
DESIGN: Prospective study.
SETTING: Urban ED with annual census of 40,000.
PARTICIPANTS: One hundred ninety-one consecutive women meeting inclusion criteria.
INTERVENTIONS: All participants completed a menstrual/sexual history questionnaire and had a urine pregnancy test.
RESULTS: Overall, we found a 6.3% prevalence of unrecognized pregnancy. Women with abdominal/pelvic complaints had a 13% prevalence; those with other complaints had a 2.5% prevalence. Two historical risk factors, the patient's suspicion that she might be pregnant and an abnormal last menstrual period, had a statistically significant correlation with unrecognized pregnancy. A third risk factor, the presence of abdominal/pelvic complaints, nearly achieved statistical significance. These risk factors detected all unrecognized pregnancies with a sensitivity of 100% and a specificity of 54%.
CONCLUSION: The prevalence of unrecognized pregnancy in our ED was 6.3%. Historical risk factors detected all of them.

PMID 8092596  Ann Emerg Med. 1994 Oct;24(4):697-700.
著者: W Yamamoto, H Kono, M Maekawa, T Fukui
雑誌名: J Epidemiol. 1997 Mar;7(1):27-32.
Abstract/Text In order to evaluate the relationship between the patient-identified regions of abdominal pain and the disease diagnosis, a prospective study was conducted at General Medicine Outpatient Clinic, Saga Medical School Hospital. Four hundred eighty-nine outpatients complaining of abdominal pain at the first visit were classified into 10 groups according to the pain region complained of, i.e., whole abdominal, epigastric, right subcostal, left subcostal, right flank, left flank, periumbilical, right-lower, mid-lower, and left-lower, the clinic physicians and authors in joint-participation assigned the groups through studying the medical records. Comparisons were made in order to calculate sensitivity, specificity, and the positive and negative likelihood ratios between the pain regions and disease diagnoses. In general, the sensitivity of history-taking and physical examination is low, but specificity is, high in relation to epigastric pain and gastroduodenal diseases, right subcostal pain and hepatobiliary diseases, and mid lower pain and gynecological diseases (above 0.5). Comparative analysis between the pain regions complained of by the patient in the initial clinic visit and the medical diagnoses yielded clinically useful information as to the efficacy of medical history-taking and physical examination in the identification of abdominal diseases.

PMID 9127570  J Epidemiol. 1997 Mar;7(1):27-32.
著者: Sumant R Ranji, L Elizabeth Goldman, David L Simel, Kaveh G Shojania
雑誌名: JAMA. 2006 Oct 11;296(14):1764-74. doi: 10.1001/jama.296.14.1764.
Abstract/Text CONTEXT: Clinicians have traditionally withheld opiate analgesia from patients with acute abdominal pain until after evaluation by a surgeon, out of concern that analgesia may alter the physical findings and interfere with diagnosis.
OBJECTIVE: To determine the impact of opiate analgesics on the rational clinical examination and operative decision for patients with acute abdominal pain.
DATA SOURCES AND STUDY SELECTION: MEDLINE (through May 2006), EMBASE, and hand searches of article bibliographies to identify placebo-controlled randomized trials of opiate analgesia reporting changes in the history, physical examination findings, or diagnostic errors (those resulting in "management errors," defined as the performance of unnecessary surgery or failure to perform necessary surgery in a timely fashion).
DATA EXTRACTION: Two authors independently reviewed each study, abstracted data, and classified study quality. A third reviewer independently resolved discrepancies.
DATA SYNTHESIS: Studies both in adults (9 trials) and in children (3 trials) showed trends toward increased risks of altered findings on the abdominal examination due to opiate administration, with risk ratios for changes in the examination of 1.51 (95% confidence interval [CI], 0.85 to 2.69) and 2.11 (95% CI, 0.60 to 7.35), respectively. When the analysis was restricted to the 8 adult and pediatric trials that reported significantly greater analgesia for patients who received opiates compared with those who received placebo, the risk of physical examination changes became significant (risk ratio, 2.13; 95% CI, 1.14 to 3.98). These trials exhibited significant heterogeneity (I2 = 68.6%; P = .002), and only 2 trials distinguished clinically significant changes such as loss of peritoneal signs from all other changes; consequently, we analyzed risk of management errors as a marker for important changes in the physical examination. Opiate administration had no significant association with management errors (+0.3% absolute increase; 95% CI, -4.1% to +4.7%). The 3 pediatric trials showed a nonsignificant absolute decrease in management errors (-0.8%; 95% CI, -8.6% to +6.9%). Across adult and pediatric trials with adequate analgesia, opiate administration was associated with a nonsignificant absolute decrease in the risk of management errors (-0.2%; 95% CI, -4.0% to +3.6%).
CONCLUSIONS: Opiate administration may alter the physical examination findings, but these changes result in no significant increase in management errors. The existing literature does not rule out a small increase in errors, but this error rate reflects a conservative definition in which surgeries labeled as either delayed or unnecessary may have met appropriate standards of care. In published research reports, no patient experienced major morbidity or mortality attributable to opiate administration.

PMID 17032990  JAMA. 2006 Oct 11;296(14):1764-74. doi: 10.1001/jama.29・・・
著者: Jose Nazareno, Terry Ponich, Jamie Gregor
雑誌名: Can J Gastroenterol. 2005 Sep;19(9):561-5.
Abstract/Text OBJECTIVE: Abdominal wall pain (AWP) is a common yet often overlooked source of abdominal pain. Trigger point injections (TPI) into the abdominal wall have been tried in the past. Few studies have looked at the long-term outcome from these injections.
METHODS: A retrospective chart review was performed on 110 consecutive patients who received TPI for abdominal pain at the University of Western Ontario, London, Ontario. Outcomes from patients whose pain was due to AWP were determined. AWP was defined as fixed or localized pain and superficial or point tenderness (less than 2.5 cm diameter) or a positive Carnett sign (increased pain with tensing abdomen). The primary outcome was long-term efficacy of TPI. The number of diagnostic tests ordered to exclude AWP and the cost of investigating it were determined. Secondary analyses were done to determine if there were significant predictors of response to TPI.
RESULTS: Eighty-nine of 110 patients who received TPI met the criteria for AWP. In those who met the criteria for AWP, the average age was 42 years, 84% were female, and the average length of follow-up was 25 months. The primary outcome shows that, at follow-up, 77% had some or complete relief and 23% had no relief. An average of 4.3 diagnostic tests per patient were ordered to exclude other causes of abdominal pain. Secondary analyses show that meeting the criteria for AWP (P<0.0005), the absence of gastrointestinal symptoms (P<0.025), and an upper abdominal location of pain (P<0.025) were statistically significant predictors of a positive response to TPI.
CONCLUSIONS: This study demonstrates that TPI, in patients who meet criteria for AWP, are effective over the long term.

PMID 16151548  Can J Gastroenterol. 2005 Sep;19(9):561-5.
著者: J W Williams, D L Simel
雑誌名: JAMA. 1992 May 20;267(19):2645-8.
Abstract/Text
PMID 1573754  JAMA. 1992 May 20;267(19):2645-8.
著者: D H Bennett, L J Tambeur, W B Campbell
雑誌名: BMJ. 1994 May 21;308(6940):1336.
Abstract/Text
PMID 8019222  BMJ. 1994 May 21;308(6940):1336.
著者: Toshihiko Takada, Masatomi Ikusaka, Yoshiyuki Ohira, Kazutaka Noda, Tomoko Tsukamoto
雑誌名: Intern Med. 2011;50(3):213-7. Epub 2011 Feb 1.
Abstract/Text OBJECTIVE: Carnett's test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles. It is useful for differentiating abdominal wall pain from intra-abdominal pain. However, no study has reported its association with psychogenic abdominal pain. We evaluated its diagnostic usefulness in psychogenic abdominal pain.
METHODS: Two physicians performed Carnett's test on each patient, but only one received the medical history. The other physician only conducted the test. Based on the final diagnosis, patients were categorized into 3 groups: psychogenic pain, abdominal wall pain, or intra-abdominal pain. Each group was analyzed in association with the results of Carnett's test conducted by the blinded physician.
PATIENTS: A total of 130 outpatients with the chief complaint of abdominal pain who had abdominal tenderness.
RESULTS: There were 22 patients with psychogenic abdominal pain, 19 with abdominal wall pain and 62 with intra-abdominal pain. In patients with psychogenic pain or abdominal wall pain, Carnett's test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p<0.001, respectively). The positive likelihood ratio of Carnett's test for psychogenic abdominal pain was 2.91 (95% confidence interval [CI], 2.71-3.13), while the negative likelihood ratio was 0.19 (95% CI, 0.11-0.34). The corresponding values for abdominal wall pain were 2.62 (95% CI, 2.45-2.81) and 0.23 (95% CI, 0.13-0.41), respectively.
CONCLUSION: Carnett's test may be useful for ruling in and ruling out psychogenic abdominal pain in addition to distinguishing between abdominal wall pain and intra-abdominal pain.

PMID 21297322  Intern Med. 2011;50(3):213-7. Epub 2011 Feb 1.
著者: H Thomson, D M Francis
雑誌名: Lancet. 1977 Nov 19;2(8047):1053-4.
Abstract/Text 120 patients admitted as an emergency with localised abdominal pain were tested for abdominal-wall tenderness. Of the 24 patients with a positive test only 1 had a detectable intra-abdominal cause. In the remaining 23 no reason for the pain could be found.

PMID 72957  Lancet. 1977 Nov 19;2(8047):1053-4.
著者: Sun Ho Ahn, William W Mayo-Smith, Brian L Murphy, Steven E Reinert, John J Cronan
雑誌名: Radiology. 2002 Oct;225(1):159-64.
Abstract/Text PURPOSE: To compare the diagnostic yield of abdominal radiography with that of computed tomography (CT) in adult patients presenting to the emergency department with nontraumatic abdominal pain.
MATERIALS AND METHODS: Records of 1,000 consecutive patients presenting to the emergency department with acute abdominal pain from April to June 1998 were retrospectively reviewed. A total of 871 patients underwent abdominal radiography, and 188 underwent abdominal CT. The report interpretations of the abdominal radiographs and CT scans were divided into normal, nonspecific, and abnormal categories. Final discharge diagnoses were compared with the interpretations of the imaging examination results, and sensitivities and specificities of each modality were calculated and compared.
RESULTS: Interpretation of abdominal radiographs was nonspecific in 588 (68%) of 871 patients, normal in 200 (23%), and abnormal in 83 (10%). The highest sensitivity of abdominal radiography was 90% for intraabdominal foreign body and 49% for bowel obstruction. Abdominal radiography had 0% sensitivity for appendicitis, pyelonephritis, pancreatitis, and diverticulitis. Sensitivities of abdominal CT were highest for bowel obstruction and urolithiasis at 75% and 68%, respectively.
CONCLUSION: Abdominal radiographs are not sensitive in the evaluation of adult patients presenting to the emergency department with nontraumatic abdominal pain.

PMID 12355000  Radiology. 2002 Oct;225(1):159-64.
著者: J M Wagner, W P McKinney, J L Carpenter
雑誌名: JAMA. 1996 Nov 20;276(19):1589-94.
Abstract/Text Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.

PMID 8918857  JAMA. 1996 Nov 20;276(19):1589-94.
著者: Erik K Paulson, Matthew F Kalady, Theodore N Pappas
雑誌名: N Engl J Med. 2003 Jan 16;348(3):236-42. doi: 10.1056/NEJMcp013351.
Abstract/Text
PMID 12529465  N Engl J Med. 2003 Jan 16;348(3):236-42. doi: 10.1056/N・・・
著者: Keita Wada, Tadahiro Takada, Yoshifumi Kawarada, Yuji Nimura, Fumihiko Miura, Masahiro Yoshida, Toshihiko Mayumi, Steven Strasberg, Henry A Pitt, Thomas R Gadacz, Markus W Büchler, Jacques Belghiti, Eduardo de Santibanes, Dirk J Gouma, Horst Neuhaus, Christos Dervenis, Sheung-Tat Fan, Miin-Fu Chen, Chen-Guo Ker, Philippus C Bornman, Serafin C Hilvano, Sun-Whe Kim, Kui-Hin Liau, Myung-Hwan Kim
雑誌名: J Hepatobiliary Pancreat Surg. 2007;14(1):52-8. doi: 10.1007/s00534-006-1156-7. Epub 2007 Jan 30.
Abstract/Text Because acute cholangitis sometimes rapidly progresses to a severe form accompanied by organ dysfunction, caused by the systemic inflammatory response syndrome (SIRS) and/or sepsis, prompt diagnosis and severity assessment are necessary for appropriate management, including intensive care with organ support and urgent biliary drainage in addition to medical treatment. However, because there have been no standard criteria for the diagnosis and severity assessment of acute cholangitis, practical clinical guidelines have never been established. The aim of this part of the Tokyo Guidelines is to propose new criteria for the diagnosis and severity assessment of acute cholangitis based on a systematic review of the literature and the consensus of experts reached at the International Consensus Meeting held in Tokyo 2006. Acute cholangitis can be diagnosed if the clinical manifestations of Charcot's triad, i.e., fever and/or chills, abdominal pain (right upper quadrant or epigastric), and jaundice are present. When not all of the components of the triad are present, then a definite diagnosis can be made if laboratory data and imaging findings supporting the evidence of inflammation and biliary obstruction are obtained. The severity of acute cholangitis can be classified into three grades, mild (grade I), moderate (grade II), and severe (grade III), on the basis of two clinical factors, the onset of organ dysfunction and the response to the initial medical treatment. "Severe (grade III)" acute cholangitis is defined as acute cholangitis accompanied by at least one new-onset organ dysfunction. "Moderate (grade II)" acute cholangitis is defined as acute cholangitis that is unaccompanied by organ dysfunction, but that does not respond to the initial medical treatment, with the clinical manifestations and/or laboratory data not improved. "Mild (grade I)" acute cholangitis is defined as acute cholangitis that responds to the initial medical treatment, with the clinical findings improved.

PMID 17252297  J Hepatobiliary Pancreat Surg. 2007;14(1):52-8. doi: 10・・・
著者: Adrienne van Randen, Shandra Bipat, Aeilko H Zwinderman, Dirk T Ubbink, Jaap Stoker, Marja A Boermeester
雑誌名: Radiology. 2008 Oct;249(1):97-106. doi: 10.1148/radiol.2483071652. Epub 2008 Aug 5.
Abstract/Text PURPOSE: This study was a head-to-head comparison of graded compression ultrasonography (US) and computed tomography (CT) in helping diagnose acute appendicitis with an emphasis on diagnostic value at different disease prevalences, commonly occurring in various hospital settings.
MATERIALS AND METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched from January 1966 to February 2006. Prospective trials were selected if they (a) compared graded compression US and CT in the same patient population; (b) included more than 10 patients, otherwise, the study was considered a case report; (c) evaluated mainly adults or adolescents; (d) used surgery and/or clinical follow-up as reference standard; and (e) reported data to calculate 2 x 2 contingency tables for graded compression US and CT. Estimates of sensitivity, specificity, and positive and negative likelihood ratios (LRs) for US and CT were calculated. Posttest probabilities after CT and US were calculated for various clinically relevant prevalences.
RESULTS: Six studies were included, evaluating 671 patients (mean age range, 26-38 years); prevalence of acute appendicitis was 50% (range, 13%-77%). Positive LR was 9.29 (95% confidence interval [CI]: 6.9, 12.6) for CT and 4.50 (95% CI: 3.0, 6.7; P = .011) for US, yielding posttest probabilities for positive tests of 90% and 82%, respectively. Negative LR was 0.10 (95% CI: 0.06, 0.17) for CT and 0.27 (95% CI: 0.17, 0.43) for US (P = .013), resulting in posttest probabilities of 9% and 21%, respectively. Posttest probabilities for positive tests were markedly decreased at lower prevalences.
CONCLUSION: In head-to-head comparison studies of diagnostic imaging, CT had a better test performance than did graded compression US in diagnosing appendicitis. Ignoring the relationship between prevalence (pretest probability) and diagnostic value may lead to an inaccurate estimation of diagnostic performance.

(c) RSNA, 2008.
PMID 18682583  Radiology. 2008 Oct;249(1):97-106. doi: 10.1148/radiol.・・・
著者: Masahiko Hirota, Tadahiro Takada, Yoshifumi Kawarada, Yuji Nimura, Fumihiko Miura, Koichi Hirata, Toshihiko Mayumi, Masahiro Yoshida, Steven Strasberg, Henry Pitt, Thomas R Gadacz, Eduardo de Santibanes, Dirk J Gouma, Joseph S Solomkin, Jacques Belghiti, Horst Neuhaus, Markus W Büchler, Sheung-Tat Fan, Chen-Guo Ker, Robert T Padbury, Kui-Hin Liau, Serafin C Hilvano, Giulio Belli, John A Windsor, Christos Dervenis
雑誌名: J Hepatobiliary Pancreat Surg. 2007;14(1):78-82. doi: 10.1007/s00534-006-1159-4. Epub 2007 Jan 30.
Abstract/Text The aim of this article is to propose new criteria for the diagnosis and severity assessment of acute cholecystitis, based on a systematic review of the literature and a consensus of experts. A working group reviewed articles with regard to the diagnosis and treatment of acute cholecystitis and extracted the best current available evidence. In addition to the evidence and face-to-face discussions, domestic consensus meetings were held by the experts in order to assess the results. A provisional outcome statement regarding the diagnostic criteria and criteria for severity assessment was discussed and finalized during an International Consensus Meeting held in Tokyo 2006. Patients exhibiting one of the local signs of inflammation, such as Murphy's sign, or a mass, pain or tenderness in the right upper quadrant, as well as one of the systemic signs of inflammation, such as fever, elevated white blood cell count, and elevated C-reactive protein level, are diagnosed as having acute cholecystitis. Patients in whom suspected clinical findings are confirmed by diagnostic imaging are also diagnosed with acute cholecystitis. The severity of acute cholecystitis is classified into three grades, mild (grade I), moderate (grade II), and severe (grade III). Grade I (mild acute cholecystitis) is defined as acute cholecystitis in a patient with no organ dysfunction and limited disease in the gallbladder, making cholecystectomy a low-risk procedure. Grade II (moderate acute cholecystitis) is associated with no organ dysfunction but there is extensive disease in the gallbladder, resulting in difficulty in safely performing a cholecystectomy. Grade II disease is usually characterized by an elevated white blood cell count; a palpable, tender mass in the right upper abdominal quadrant; disease duration of more than 72 h; and imaging studies indicating significant inflammatory changes in the gallbladder. Grade III (severe acute cholecystitis) is defined as acute cholecystitis with organ dysfunction.

PMID 17252300  J Hepatobiliary Pancreat Surg. 2007;14(1):78-82. doi: 1・・・
著者: Robert L Trowbridge, Nicole K Rutkowski, Kaveh G Shojania
雑誌名: JAMA. 2003 Jan 1;289(1):80-6.
Abstract/Text CONTEXT: Although few patients with acute abdominal pain will prove to have cholecystitis, ruling in or ruling out acute cholecystitis consumes substantial diagnostic resources.
OBJECTIVE: To determine if aspects of the history and physical examination or basic laboratory testing clearly identify patients who require diagnostic imaging tests to rule in or rule out the diagnosis of acute cholecystitis.
DATA SOURCES: Electronic search of the Science Citation Index, Cochrane Library, and English-language articles from January 1966 through November 2000 indexed in MEDLINE. We also hand-searched Index Medicus for 1950-1965, and scanned references in identified articles and bibliographies of prominent textbooks of physical examination, surgery, and gastroenterology. To identify relevant articles appearing since the comprehensive search, we repeated the MEDLINE search in July 2002.
STUDY SELECTION: Included studies evaluated the role of the history, physical examination, and/or laboratory tests in adults with abdominal pain or suspected acute cholecystitis. Studies had to report data from a control group found not to have acute cholecystitis. Acceptable definitions of cholecystitis included surgery, pathologic examination, hepatic iminodiacetic acid scan or right upper quadrant ultrasound, or clinical course consistent with acute cholecystitis and no evidence for an alternate diagnosis. Studies of acalculous cholecystitis were included. Seventeen of 195 identified studies met the inclusion criteria.
DATA EXTRACTION: Two authors independently abstracted data from the 17 included studies. Disagreements were resolved by discussion and consensus with a third author.
DATA SYNTHESIS: No clinical or laboratory finding had a sufficiently high positive likelihood ratio (LR) or low negative LR to rule in or rule out the diagnosis of acute cholecystitis. Possible exceptions were the Murphy sign (positive LR, 2.8; 95% CI, 0.8-8.6) and right upper quadrant tenderness (negative LR, 0.4; 95% CI, 0.2-1.1), though the 95% CIs for both included 1.0. Available data on diagnostic confirmation rates at laparotomy and test characteristics of relevant radiological investigations suggest that the diagnostic impression of acute cholecystitis has a positive LR of 25 to 30. Unfortunately, the available literature does not identify the specific combinations of clinical and laboratory findings that presumably account for this diagnostic success.
CONCLUSIONS: No single clinical finding or laboratory test carries sufficient weight to establish or exclude cholecystitis without further testing (eg, right upper quadrant ultrasound). Combinations of certain symptoms, signs, and laboratory results likely have more useful LRs, and presumably inform the diagnostic impressions of experienced clinicians. Pending further research characterizing the pretest probabilities associated with different clinical presentations, the evaluation of patients with abdominal pain suggestive of cholecystitis will continue to rely heavily on the clinical gestalt and diagnostic imaging.

PMID 12503981  JAMA. 2003 Jan 1;289(1):80-6.
著者: S Hernández-Díaz, L A Rodríguez
雑誌名: Arch Intern Med. 2000 Jul 24;160(14):2093-9.
Abstract/Text BACKGROUND: In the last decades, studies have estimated the upper gastrointestinal tract bleeding/perforation (UGIB) risk associated with individual nonsteroidal anti-inflammatory drugs (NSAIDs). Later analyses have also included the effect of patterns of NSAID use, risk factors for UGIB, and modifiers of NSAID effect.
METHODS: Systematic review of case-control and cohort studies on serious gastrointestinal tract complications and nonaspirin NSAIDs published between 1990 and 1999 using MEDLINE. Eighteen original studies were selected according to predefined criteria. Two researchers extracted the data independently. Pooled relative risk estimates were calculated according to subject and exposure characteristics. Heterogeneity of effects was tested and reasons for heterogeneity were considered.
RESULTS: Advanced age, history of peptic ulcer disease, and being male were risk factors for UGIB. Nonsteroidal anti-inflammatory drug users with advanced age or a history of peptic ulcer had the highest absolute risks. The pooled relative risk of UGIB after exposure to NSAIDs was 3.8 (95% confidence interval, 3.6-4.1). The increased risk was maintained during treatment and returned to baseline once treatment was stopped. A clear dose response was observed. There was some variation in risk between individual NSAIDs, though these differences were markedly attenuated when comparable daily doses were considered.
CONCLUSIONS: The elderly and patients with a history of peptic ulcer could benefit the most from a reduction in NSAID gastrotoxicity. Whenever possible, physicians may wish to recommend lower doses to reduce the UGIB risk associated with all individual NSAIDs, especially in the subgroup of patients with the greatest background risk.

PMID 10904451  Arch Intern Med. 2000 Jul 24;160(14):2093-9.
著者: H Böhner, Q Yang, C Franke, P R Verreet, C Ohmann
雑誌名: Eur J Surg. 1998 Oct;164(10):777-84. doi: 10.1080/110241598750005435.
Abstract/Text OBJECTIVE: To assess the value of plain abdominal radiographs and of data from the medical history and physical examination in the diagnosis of acute abdominal pain in general and of bowel obstruction in particular.
DESIGN: Prospective study.
SETTING: 4 university and 2 community hospitals, Germany.
SUBJECTS: 1254 patients with acute abdominal pain lasting less than 7 days, and with no history of abdominal injury including surgery.
INTERVENTIONS: Standardised and structured medical history and physical examination, study of results of plain abdominal radiographs.
MAIN OUTCOME MEASURES: Positive predictive value and sensitivity of clinical variables and abdominal film with respect to the diagnosis at discharge.
RESULTS: 48 patients (3.8%) had bowel obstruction. 704 patients (56.1%) had plain abdominal films taken at the time of initial presentation. 111 studies (15.8%) showed important findings leading to diagnosis or immediate treatment, 455 (64.7%) showed unimportant or no findings. In 138 (19.6%) results of films were not reported. 16 of 45 single variables were of help in diagnosing bowel obstruction. The six with the highest sensitivity were distended abdomen, increased bowel sounds, history of constipation, previous abdominal surgery, age over 50, and vomiting. If only patients presenting with any two of these symptoms had had radiographs taken, 300 (42.6%) could have been avoided without loss in diagnostic accuracy.
CONCLUSION: A considerable number of plain abdominal films taken for patients with acute abdominal pain could be avoided by focusing on clinical variables relevant to the diagnosis of bowel obstruction.

PMID 9840308  Eur J Surg. 1998 Oct;164(10):777-84. doi: 10.1080/11024・・・
著者: Kimberly A Workowski, Stuart Berman, Centers for Disease Control and Prevention (CDC)
雑誌名: MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110.
Abstract/Text These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 18-30, 2009. The information in this report updates the 2006 Guidelines for Treatment of Sexually Transmitted Diseases (MMWR 2006;55[No. RR-11]). Included in these updated guidelines is new information regarding 1) the expanded diagnostic evaluation for cervicitis and trichomoniasis; 2) new treatment recommendations for bacterial vaginosis and genital warts; 3) the clinical efficacy of azithromycin for chlamydial infections in pregnancy; 4) the role of Mycoplasma genitalium and trichomoniasis in urethritis/cervicitis and treatment-related implications; 5) lymphogranuloma venereum proctocolitis among men who have sex with men; 6) the criteria for spinal fluid examination to evaluate for neurosyphilis; 7) the emergence of azithromycin-resistant Treponema pallidum; 8) the increasing prevalence of antimicrobial-resistant Neisseria gonorrhoeae; 9) the sexual transmission of hepatitis C; 10) diagnostic evaluation after sexual assault; and 11) STD prevention approaches.

PMID 21160459  MMWR Recomm Rep. 2010 Dec 17;59(RR-12):1-110.
著者: M Eskelinen, J Ikonen, P Lipponen
雑誌名: Eur Urol. 1998 Dec;34(6):467-73.
Abstract/Text OBJECTIVE: The accuracy of the clinical diagnosis of acute renal colic was studied in connection with the survey of acute abdominal pain by the Research Committee of the World Organization of Gastroenterology. The diagnostic efficiency of various clinical symptoms, signs and tests have not previously been analyzed in the diagnosis of acute renal colic, and therefore the study is of potential importance.
METHODS: 1,333 patients presenting with acute abdominal pain were included in the study. The clinical findings in each patient were recorded in detail, using a predefined structured data collection sheet, and the collected data were compared with the final diagnoses of the patients. Twenty-three clinical history variables, 14 clinical signs and 3 tests were evaluated in a single variable and multivariate analysis.
RESULTS: In multivariate logistic regression analysis, the most significant predictors of acute renal colic were urine, tenderness, renal tenderness, duration of pain and appetite. The sensitivity in detecting acute renal colic was 0.84, with a specificity of 0.99 and an efficiency of 0.98. To sum up the contributions of most significant diagnostic factors, a diagnostic score (DS) was built. This score incorporated independent variables, e.g. urine, tenderness, renal tenderness, duration of pain, appetite and sex. The DS reached a sensitivity of 0.89 in detecting acute renal colic, with a specificity of 0.99 and an efficiency of 0.99.
CONCLUSIONS: The results clearly show that acute abdominal pain with normal appetite, short duration of pain (10) are indicative of acute renal colic, and therefore, in this particular clinical question, careful history-taking and physical examination are of utmost importance. In our study, the DS system performed well considering the simple nature of its structure. However, to minimize the risk to the patient, we recommend that the DS is used only as an aid in decision-making when there is uncertainty as to the diagnosis of acute renal colic and the need for immediate treatment. In addition, the possibility of obstructive pyelonephritis in combination with renal colic should be considered clinically.

PMID 9831787  Eur Urol. 1998 Dec;34(6):467-73.
著者: P Bove, D Kaplan, N Dalrymple, A T Rosenfield, M Verga, K Anderson, R C Smith
雑誌名: J Urol. 1999 Sep;162(3 Pt 1):685-7.
Abstract/Text PURPOSE: Hematuria testing is routinely performed in patients with acute flank pain to screen for ureterolithiasis and to help determine the need for excretory urography. Unenhanced helical computerized tomography (CT) has recently been shown to be superior to excretory urography in diagnosing ureteral obstruction and can evaluate many other causes of flank pain. Given the speed, accuracy and safety of CT the value of hematuria testing for acute flank pain should be reexamined.
MATERIALS AND METHODS: We reviewed the medical records of 267 consecutive patients with acute flank pain referred for unenhanced helical CT. Microscopic and dipstick urinalysis data were obtained in 195 patients. Using helical CT as the gold standard, we calculated the sensitivity, specificity, predictive value and accuracy of hematuria for diagnosing ureterolithiasis.
RESULTS: Of the patients with ureterolithiasis 33% had 5 or less, 19% had 1 or less and 11% had no red blood cells (RBCs) per high power field. Of the patients without ureterolithiasis 24% had greater than 5 and 51% had greater than 1 RBC per high power field. Of the patients with ureterolithiasis 14% had a negative dipstick test and 1 RBC or less per high power field. There were 25 patients without ureterolithiasis who had CT abnormalities unrelated to the urinary tract, of whom 8 had greater than 1 RBC per high power field.
CONCLUSIONS: Absence of hematuria in the setting of acute flank pain cannot exclude a diagnosis of ureterolithiasis and should not obviate other diagnostic testing. Even when strongly positive on microscopy, hematuria has insufficient positive predictive value for diagnosing ureterolithiasis and may be misleading as other serious conditions resulting in acute flank pain may yield a positive test.

PMID 10458342  J Urol. 1999 Sep;162(3 Pt 1):685-7.
著者: Takashi Kobayashi, Koji Nishizawa, Kenji Mitsumori, Keiji Ogura
雑誌名: J Urol. 2003 Oct;170(4 Pt 1):1093-6. doi: 10.1097/01.ju.0000080709.11253.08.
Abstract/Text PURPOSE: Hematuria is absent in a significant proportion of patients with acute ureterolithiasis. We determined whether time from pain onset has any impact on the sensitivity of hematuria tests in the diagnosis of ureterolithiasis.
MATERIALS AND METHODS: We retrospectively reviewed the records of 537 patients with suspected acute unilateral renal colic during a 29-month period with regard to the interval between pain onset and urinalysis, including the dipstick test and microscopic red blood cell count as well as other clinical findings. Although ureterolithiasis was determined by plain x-ray and ultrasonography primarily, stone absence was diagnosed by computerized tomography.
RESULTS: Ureterolithiasis was diagnosed in 452 patients (84.2%). The dipstick test had higher sensitivity (0.780 vs 0.718) but it was equivalent on ROC analysis compared with microscopic examination (area under the curve 0.696 vs 0.694, p = 0.92). Hematuria test sensitivity was 0.95, 0.83, 0.65, 0.68, 0.77, 0.86 and 0.68 on days 0, 1, 2, 3, 4, 5 to 7 and 8 or more from pain onset, respectively (ANOVA p = 0.004). On logistic regression analysis including hydronephrosis grade, and stone size and location the interval between onset and urinalysis was the only independent factor affecting the incidence of negative hematuria in patients with ureterolithiasis (p = 0.03, 95% CI 0.89 to 0.99).
CONCLUSIONS: The interval between pain onset and urine collection has a significant impact on the diagnostic performance of hematuria tests. The incidence of negative hematuria is highest on the days 3 and 4.

PMID 14501699  J Urol. 2003 Oct;170(4 Pt 1):1093-6. doi: 10.1097/01.ju・・・

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