今日の臨床サポート

虫垂炎(小児科)

著者: 黒澤照喜 帝京大学医学部附属溝口病院 小児科

監修: 渡辺博 帝京大学老人保健センター

著者校正/監修レビュー済:2021/07/21
参考ガイドライン:
  1. 日本小児救急医学会(https://minds.jcqhc.or.jp/n/med/4/med0431/G0001192):エビデンスに基づいた子どもの腹部救急診療ガイドライン2017 第Ⅱ部 小児急性虫垂炎ガイドライン
患者向け説明資料

概要・推奨   

  1. 虫垂炎を疑う患者には、丁寧な診察、超音波やCTなどの画像検査を、必要に応じて繰り返し行う必要がある。特に小児患者では早期に穿孔を起こすことが多く、保護者への説明が不可欠である(推奨度1)。
  1. 乳幼児や精神発達遅滞の児では典型的な右下腹部痛を呈さないことがあり、慎重な診察が要求される(推奨度1)。
  1. 穿孔しておらず血流が保たれている虫垂炎は待機的手術、あるいは保存的治療を選択することがある(推奨度2)。
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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:
黒澤照喜 : 特に申告事項無し[2021年]
監修:渡辺博 : 特に申告事項無し[2021年]

改訂のポイント:
  1.  定期レビューを行い、微修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 虫垂炎とは、虫垂の閉塞により感染が起こった病態である。小児の重症腹痛疾患のなかで最もよく認められ、全体の1-8%を占める[1]
  1. わが国での人口1万人に対する年平均虫垂切除数は、5歳未満では男女とも0.6人、5~9歳では男児6.9人、女児4.9人と増加し、10~14歳では男性13.2人、女性8.5人と最も高くなる。5歳以降では、男児の発生頻度が高い傾向にある[2]
  1. 右下腹部(McBurney点)を最強とする疼痛・圧痛などが典型的だが、心窩部痛などから始まることも多い。発熱、嘔吐、下痢、便秘、食思不振などもみられる。特に乳幼児では特徴的な症状がみられないことも多い。
  1. 虫垂炎が進行すると壁を穿破して腹膜炎を来すことがある。小児は成人と比べて虫垂穿孔が起こりやすく(15.9~34.8%)、なかでも幼児期の穿孔率は学童期と比べて高率である[3][2]
  1. 腹膜炎から敗血症性ショックを来すと死亡することもある(0.5~1%)。
  1. 超音波・腹部CTなどの画像検査、血液検査を施行する。
  1. 抗菌薬などを投与する内科的な方法、切除を行う外科的な方法、および抗菌薬投与後の待機的な切除(interval appendectomy)が行われ、患者の状態・施設の方針・経験などによって決まる。
 
  1. 虫垂炎の起因菌は大腸菌などが多いとされており、それに合わせた抗菌薬を選択する(推奨度2)[4]
  1. 起因菌は通常の腸管内細菌で、主に好気性および嫌気性グラム陰性桿菌による。最も一般的なものは大腸菌、腸球菌、緑膿菌などである。
  1. 追記:虫垂培養および腹水培養から起因菌が推測される。後者はより正確だが陽性率は必ずしも高くない。
    抗菌薬のプロトコールは施設ごとに決まっていることが多く、今後、再検討し種類の統一・減少が行われることが望ましい[5]
問診・診察のポイント  
  1. 虫垂炎は典型的には右下腹部痛、悪心嘔吐、発熱が認められるとされるが、小児患者、特に乳幼児では症状が典型的でないことも多い。

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文献 

著者: S J Scholer, K Pituch, D P Orr, R S Dittus
雑誌名: Pediatrics. 1996 Oct;98(4 Pt 1):680-5.
Abstract/Text OBJECTIVE: To determine the prevalence, associated symptoms, and clinical outcomes of children presenting for a nonscheduled visit with acute abdominal pain.
DESIGN: Historical cohort.
SETTING: Inner-city teaching hospital.
PARTICIPANTS: A total of 1141 consecutive children, ages 2 to 12, presenting for a nonscheduled visit (clinic or emergency department) with a complaint of nontraumatic abdominal pain of < or = 3 days' duration were identified through a manual chart review.
MEASUREMENTS: Collected data included: 1) demographic characteristics, 2) presenting signs and symptoms, 3) records from the hospital record for all children who returned within 10 days for follow-up, 4) test results, and 5) telephone follow-up. A clinical reviewer used the data to assign a final diagnosis to each patient.
RESULTS: The prevalence of children presenting with abdominal pain of < or = 3 days' duration was 5.1%. The most common associated symptoms were history of fever (64%), emesis (42.4%), decreased appetite (36.5%), cough (35.6%), headache (29.5%), and sore throat (27.0%). The six most prevalent final diagnoses, accounting for 84% of all final diagnoses, were upper respiratory infection and/or otitis (18.6%), pharyngitis (16.6%), viral syndrome (16.0%), abdominal pain of uncertain etiology (15.6%), gastroenteritis (10.9%), and acute febrile illness (7.8%). Approximately 1% of children required surgical intervention (10/12 for appendicitis). Approximately 7% of children returned within 10 days for reevaluation of their illness; on return, 11 had treatable medical diseases and 4 had diseases requiring surgical intervention.
CONCLUSIONS: An acute complaint of abdominal pain in children occurs in 5.1% of nonscheduled visits, is frequently accompanied by multiple complaints, and is usually attributed to a self-limited disease. Close follow-up will identify the 1% to 2% who proceed to have a more serious disease process. This epidemiologic data will aid clinic-based physicians who manage children with acute abdominal pain.

PMID 8885946  Pediatrics. 1996 Oct;98(4 Pt 1):680-5.
著者: Javed Alloo, Theodore Gerstle, Joel Shilyansky, Sigmund H Ein
雑誌名: Pediatr Surg Int. 2004 Jan;19(12):777-9. doi: 10.1007/s00383-002-0775-6. Epub 2004 Jan 16.
Abstract/Text Appendicitis is the most common surgical abdominal emergency in the pediatric population, but is rarely considered in children less than 3 years of age. The goal of this study was to identify the presenting symptoms and signs in this age group and examine their subsequent management and outcome. A 28-year experience of a single pediatric surgeon in academic practice was reviewed; 27 children less than 3 years old (mean 23 months) comprised 2.3% of all children with appendicitis in his series. The most common presenting symptoms were vomiting (27), fever (23), pain (21), anorexia (15), and diarrhea (11). The average duration of symptoms was 3 days, with 4 or more days in 9 children. Eighteen children were seen by a physician before the correct diagnosis was made; 14 were initially treated for an upper respiratory tract infection, otitis media, or a urinary tract infection. The most common presenting signs were abdominal tenderness (27), peritonitis (24), temperature 38.0 degrees C or more (21), abdominal distension (18), Leukocytosis (<12.0 x 10(3)/mm(3)) was found in 18, tenderness was localized to the right lower quadrant (RLQ) in 14 and was diffuse in 10. Abdominal radiographs demonstrated findings of a small-bowel obstruction (SBO) in 14 of 21 patients, a fecalith in 2, and a pneumoperitoneum in 1. Contrast enemas were performed in 6 children, 5 of whom had a phlegmon or an abscess. Perforated appendicitis was found in all 27 patients. An appendectomy was performed in 25 and a RLQ drain was placed in 18. Postoperative antibiotics were administered to 17 children for an average of 6 days. Two patients underwent interval appendectomies, 1 following treatment with IV antibiotics and 1 following surgical drainage. The average time to resume oral intake was 7 days and the average hospital stay was 21 (median 15) days. Sixteen patients had 22 complications, which included 6 wound infections, 4 abscesses, 4 wound dehiscences, 3 pneumonias, 2 SBOs, 2 incisional hernias, and 1 enterocutaneous fistula. Perforated appendicitis was found in all children less than 3 years old, resulting in very high morbidity (59% complications), which may be attributed to the 3-5-day delay in diagnosis. Although appendicitis is uncommon in this age group, it should be seriously considered in the differential diagnosis of children under the age of 3 years who present with the triad of abdominal pain, tenderness, and vomiting.

PMID 14730382  Pediatr Surg Int. 2004 Jan;19(12):777-9. doi: 10.1007/s・・・
著者: R S Bennion, E J Baron, J E Thompson, J Downes, P Summanen, D A Talan, S M Finegold
雑誌名: Ann Surg. 1990 Feb;211(2):165-71.
Abstract/Text By using optimum sampling, transport, and culture techniques in patients with gangrenous or perforated appendicitis, we recovered than has previously been reported. Thirty patients older than 12 years with histologically documented gangrenous or perforated appendicitis had peritoneal fluid, appendiceal tissue, and abscess contents (if present) cultured. Appendiceal tissue was obtained so as to exclude the lumen. A total of 223 anaerobes and 82 aerobic or faculatative bacteria were recovered, an average of 10.2 different organisms per specimen. Twenty-one different genera and more than 40 species were encountered. Bacteroides fragilis group and Escherichia coli were isolated from almost all specimens. Within the B. fragilis group, eight species were represented. Other frequent isolates included Peptostreptococcus (80%), Pseudomonas (40% [P. aeruginosa, 23.3%, other Pseudomonas spp., 16.7%]), B. splanchnicus (40%), B. intermedius (36.7%), and Lactobacillus (36.7%). Interestingly a previously undescribed fastidious gram-negative anaerobic bacillus was isolated from nearly one half of all patients. This organism was found to have low DNA homology (by dot blot) with the known organisms most closely resembling it.

PMID 2405791  Ann Surg. 1990 Feb;211(2):165-71.
著者: Shawn D St Peter, Danny C Little, Casey M Calkins, J Patrick Murphy, Walter S Andrews, George W Holcomb, Ronald J Sharp, Charles L Snyder, Daniel J Ostlie
雑誌名: J Pediatr Surg. 2006 May;41(5):1020-4. doi: 10.1016/j.jpedsurg.2005.12.054.
Abstract/Text OBJECTIVE: Appendicitis is the most common abdominal emergency in children. When perforation is encountered, postoperative management is grounded upon the use of intravenous antibiotics. The 3-drug regimen of ampicillin, gentamicin, and clindamycin has long been the accepted standard by pediatric surgeons. Although effective and seemingly inexpensive, this regimen produces a cumbersome dosing schedule, which has inspired the search for a simpler regimen that does not compromise efficacy or expense. To this end, we have introduced a 2-drug regimen of ceftriaxone and Flagyl (Pharmacia Corporation, Chicago, Ill) with once-a-day dosing.
METHODS: A retrospective review was conducted of the most recent 250 patients treated at our institution with perforated appendicitis. Patients treated since the implementation of this 2-drug regimen were compared with the recent historical cohort treated with triple antibiotic coverage. Parameters analyzed between the 2 groups included temperature curves for the first 5 postoperative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment, and medication charges.
RESULTS: The 2-drug regimen was used in 57 patients (group 1) compared with 193 patients treated with triple antibiotic coverage (group 2). Maximum recorded temperature between the 2 groups was similar upon admission, but the mean maximum temperature in group 1 became significantly lower than group 2 from postoperative day 1 onward (P < .001). Postoperatively, an abscess developed in 8.8% of group 1 compared with 14.2% of group 2, which was not significantly different (P = .37). Mean length of stay was 6.8 days in group 1 and 7.8 days in group 2 (P = .03). Medication charges to the patient were 81.32 dollars per day in group 1 compared with 318.53 dollars per day in group 2, translating to 1186.05 dollars savings for 5 days.
CONCLUSIONS: Once-a-day dosing with ceftriaxone and Flagyl provides adequate antibiotic coverage for the postoperative management of perforated appendicitis in children. This regimen allows patients to more rapidly defervesce compared with traditional triple antibiotic coverage; moreover, this simple regimen provides substantial advantages for administration and expense.

PMID 16677904  J Pediatr Surg. 2006 May;41(5):1020-4. doi: 10.1016/j.j・・・
著者: Andrea S Doria, Rahim Moineddin, Christian J Kellenberger, Monica Epelman, Joseph Beyene, Suzanne Schuh, Paul S Babyn, Paul T Dick
雑誌名: Radiology. 2006 Oct;241(1):83-94. doi: 10.1148/radiol.2411050913. Epub 2006 Aug 23.
Abstract/Text PURPOSE: To perform a meta-analysis to evaluate the diagnostic performance of ultrasonography (US) and computed tomography (CT) for the diagnosis of appendicitis in pediatric and adult populations.
MATERIALS AND METHODS: Medical literature (from 1986 to 2004) was searched for articles on studies that used US, CT, or both as diagnostic tests for appendicitis in children (26 studies, 9356 patients) or adults (31 studies, 4341 patients). Prospective and retrospective studies were included if they separately reported the rate of true-positive, true-negative, false-positive, and false-negative diagnoses of appendicitis from US and CT findings compared with the positive and negative rates of appendicitis at surgery or follow-up. Clinical variables, technical factors, and test performance were extracted. Three readers assessed the quality of studies.
RESULTS: Pooled sensitivity and specificity for diagnosis of appendicitis in children were 88% (95% confidence interval [CI]: 86%, 90%) and 94% (95% CI: 92%, 95%), respectively, for US studies and 94% (95% CI: 92%, 97%) and 95% (95% CI: 94%, 97%), respectively, for CT studies. Pooled sensitivity and specificity for diagnosis in adults were 83% (95% CI: 78%, 87%) and 93% (95% CI: 90%, 96%), respectively, for US studies and 94% (95% CI: 92%, 95%) and 94% (95% CI: 94%, 96%), respectively, for CT studies.
CONCLUSION: From the diagnostic performance perspective, CT had a significantly higher sensitivity than did US in studies of children and adults; from the safety perspective, however, one should consider the radiation associated with CT, especially in children.

(c) RSNA, 2006.
PMID 16928974  Radiology. 2006 Oct;241(1):83-94. doi: 10.1148/radiol.2・・・
著者: J S Janik, S H Ein, B Shandling, J S Simpson, C A Stephens
雑誌名: J Pediatr Surg. 1980 Aug;15(4):574-6.
Abstract/Text Thirty-seven late presenting children with appendiceal mass were treated between 1965 and 1975 with i.v. fluids, alimentation according to the state of gastrointestinal function, and no antibiotics. They ranged in age from 18 mo to 16 yr and all had had symptoms for at least 5 days (mean 8.7), an abnormal WBC (mean 19.9), and a fixed palpable mass without rebound tenderness. Children were discharged when clinical findings resolved. All returned for interval appendectomy. Eighty-one percent (31 children) had clinical improvement within 5-22 days (mean 10.9). Nineteen percent (7 children) had recurrence or worsening of symptoms and required abscess drainage within 2-10 days after observation began. No child in either group received antibiotics nor did any die. Only one recurrence of symptoms after discharge was recorded before interval appendectomy. Pathologic specimens revealed fibrosis in 46%, subacute inflammation in 35%, and acute inflammation in 19%. Nonoperative management of the appendiceal mass without antibiotics in children is safe as long as diligent observation is maintained. Interval appendectomy can be performed as late as 20 wk after symptom resolution or drainage, however, over 50% of the interval appendectomy specimens reveal acute and subacute inflammation.

PMID 7411371  J Pediatr Surg. 1980 Aug;15(4):574-6.
著者: M R Price, G M Haase, K H Sartorelli, D P Meagher
雑誌名: J Pediatr Surg. 1996 Feb;31(2):291-4.
Abstract/Text Therapy for children with appendiceal abscess remains controversial. The authors present two such cases initially treated conservatively, without interval appendectomy, that later had recurrent appendicitis. An 8-year-old boy presented with fever, abdominal pain, and a right-lower-quadrant abscess (noted by ultrasonography). During laparotomy, the abscess was drained and the appendix was not found. He was lost to follow-up but returned 2 1/2 years later with perforated appendicitis. An appendectomy was performed, and image-guided drainage of a postoperative abscess was required. A 10-year-old girl presented with fever and right-lower-quadrant pain. Computed tomography showed a multiloculated mass. During laparotomy, the cecum was found to be densely adherent to the pelvic organs and bowel, so the surrounding abscess was drained. Interval appendectomy was refused. The patient returned 8 months later with recurrent acute appendicitis and an appendiceal abscess requiring appendectomy and drainage. Although initial drainage alone of appendiceal abscess is efficacious, the authors strongly advocate interval appendectomy as a critical component of the complete management of this entity.

PMID 8938362  J Pediatr Surg. 1996 Feb;31(2):291-4.
著者: Steven L Lee, Arezou Yaghoubian, Christian de Virgilio
雑誌名: J Surg Educ. 2011 Jan-Feb;68(1):6-9. doi: 10.1016/j.jsurg.2010.08.003. Epub 2010 Nov 5.
Abstract/Text OBJECTIVE: In this era of heightened emphasis on patient outcomes, it is important to document the effect of residents acting as the surgeon for a surgical procedure. This study compares the outcomes of appendicitis between teaching and nonteaching institutions.
DESIGN: A retrospective review from 1998 to 2007 was performed. The study outcomes were postoperative morbidity and length of hospitalization (LOH). Data were analyzed using Wilcoxon rank-sum test and χ(2) analysis.
SETTING: Two teaching institutions (each with its own General Surgery residency program) were compared with 10 nonteaching institutions.
RESULTS: A total of 1472 patients were treated at the teaching institutions (mean age = 9.8 years, male = 63%), and 6431 patients were treated at the nonteaching institutions (mean age = 10.8 years, male = 62%). The perforated appendicitis rate was 37% at the teaching institutions and 30% at the nonteaching institutions (p < 0.0001). For nonperforated appendicitis, a higher rate of laparoscopic appendectomy was found at the nonteaching institutions versus the teaching institutions (39% vs 52%, p < 0.0001). Otherwise, no difference was noted in the rate of wound infection, postoperative abscess drainage, or readmissions between the institutions. The LOH was also similar. For perforated appendicitis, a lower wound infection (5.2% vs 8.2%, p = 0.03) and readmission (5.6% vs 9.7%, p = 0.004) rate was found at the teaching institutions. No differences were discovered in the incidence of postoperative abscess drainage or LOH between teaching versus nonteaching hospitals. Perforated appendicitis was managed nonoperatively more commonly at the teaching institutions (7.4% vs 12.8%, p = 0.0001).
CONCLUSIONS: Postoperative morbidity was similar in children with nonperforated appendicitis and lower in children with perforated appendicitis at teaching institutions. LOH was similar between teaching and nonteaching institutions. Overall, the presence of surgical trainees had no adverse impact on the quality of care for children with appendicitis.

Copyright © 2011 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
PMID 21292208  J Surg Educ. 2011 Jan-Feb;68(1):6-9. doi: 10.1016/j.jsu・・・
著者: Roland E Andersson, Max G Petzold
雑誌名: Ann Surg. 2007 Nov;246(5):741-8. doi: 10.1097/SLA.0b013e31811f3f9f.
Abstract/Text OBJECTIVE: A systematic review of the nonsurgical treatment of patients with appendiceal abscess or phlegmon, with emphasis on the success rate, need for drainage of abscesses, risk of undetected serious disease, and need for interval appendectomy to prevent recurrence.
SUMMARY BACKGROUND DATA: Patients with appendiceal abscess or phlegmon are traditionally managed by nonsurgical treatment and interval appendectomy. This practice is controversial with proponents of immediate surgery and others questioning the need for interval appendectomy.
METHODS: A Medline search identified 61 studies published between January 1964 and December 2005 reporting on the results of nonsurgical treatment of appendiceal abscess or phlegmon. The results were pooled taking the potential clustering on the study-level into account. A meta-analysis of the morbidity after immediate surgery compared with that after nonsurgical treatment was performed.
RESULTS: Appendiceal abscess or phlegmon is found in 3.8% (95% confidence interval (CI), 2.6-4.9) of patients with appendicitis. Nonsurgical treatment fails in 7.2% (CI: 4.0-10.5). The need for drainage of an abscess is 19.7% (CI: 11.0-28.3). Immediate surgery is associated with a higher morbidity compared with nonsurgical treatment (odds ratio, 3.3; CI: 1.9-5.6; P < 0.001). After successful nonsurgical treatment, a malignant disease is detected in 1.2% (CI: 0.6-1.7) and an important benign disease in 0.7% (CI: 0.2-11.9) during follow-up. The risk of recurrence is 7.4% (CI: 3.7-11.1).
CONCLUSIONS: The results of this review of mainly retrospective studies support the practice of nonsurgical treatment without interval appendectomy in patients with appendiceal abscess or phlegmon.

PMID 17968164  Ann Surg. 2007 Nov;246(5):741-8. doi: 10.1097/SLA.0b013・・・

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