今日の臨床サポート

腹痛(小児科)

著者: 神保圭佑 順天堂大学小児科

著者: 大塚宜一 順天堂大学小児科

監修: 五十嵐隆 国立成育医療研究センター

著者校正/監修レビュー済:2021/09/08
患者向け説明資料

概要・推奨   

  1. 小児急性腹痛症の最大の原因は便秘症である。
  1. 急性腹痛症に対する診断前の不用意な鎮痛は現時点で推奨されない(推奨度3)。
  1. 慢性腹痛症は小児・学童の9~15%に合併する非常に多い主訴だが、大部分が機能性消化管障害である。
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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:
神保圭佑 : 特に申告事項無し[2021年]
大塚宜一 : 特に申告事項無し[2021年]
監修:五十嵐隆 : 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、文章の簡素化と読みやすさに配慮した加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 腹痛は小児科外来ではよく遭遇する主訴だが鑑別診断が幅広く、病態を理解し適切に鑑別を進める必要がある。
  1. 急性腹痛の多くはウイルス性胃腸炎や便秘症などの比較的軽症な疾患によって引き起こされるが、急性腹症といわれる緊急に外科的な介入を要する重症疾患が含まれることに常に注意が必要である。
  1. 急性腹痛は腹部臓器以外に、胸部疾患や心因反応により発症することがある。
2~3週間を超えて持続する慢性腹痛に関しては、機能性疾患、器質的疾患、および心理社会的要因の関与について鑑別する必要がある。なお、一般に遷延性腹痛とは12週を超える腹痛のことを指す。
 
  1. 慢性腹痛は小児・学童の9~15%に合併する非常に多い主訴である。
  1. 一般人口中の慢性腹痛症の有病率については、この分野の古典であるApleyを含めて複数の研究がある[1]。近年の疫学についてはChitkaraのシステムレビューを参照されたい[2]
  1. 注意:いわゆる慢性腹痛とApleyの反復性腹痛(recurrent abdominal pain、RAP)の間には定義のギャップがある。海外のガイドラインではRAPという用語を使用しない動きがあり、近年の文献については対象症例に注意して研究デザインを検討する必要がある。ただし、わが国のガイドライン( >詳細情報 の「推薦図書」参照)ではRAPという用語を残している。
問診・診察のポイント  
  1. 急性腹痛の鑑別ポイントは、迅速に重症度評価を行い急性腹症を鑑別することである。一般・救急外来における症例の多くは感染性胃腸炎や便秘症などの軽症疾患だが、急性腹症はときに致死的な経過をたどることがあり注意を要する。また、まれではあるが、帰宅後に感染性胃腸炎を契機に腸重積症を発症することもあり、帰宅後の再診依頼には注意深い配慮が必要である。

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文献 

著者: Denesh K Chitkara, David J Rawat, Nicholas J Talley
雑誌名: Am J Gastroenterol. 2005 Aug;100(8):1868-75. doi: 10.1111/j.1572-0241.2005.41893.x.
Abstract/Text OBJECTIVE: Recurrent abdominal pain (RAP) of childhood is a common problem encountered by clinicians. The aim of this study was to systematically review published literature about the prevalence, incidence, natural history, and co-morbid conditions of childhood RAP in western countries.
METHODS: A computer-assisted search of MEDLINE, EMBASE, and Current Contents/Science Edition databases was performed. Study selection criteria included: (1) United States and European population and school-based samples of children; (2) diagnostic criteria of RAP; and (3) published in full manuscript form in English. Data were extracted, tabulated, and presented in descriptive form.
RESULT: The prevalence of RAP ranged from 0.3 to 19% (median 8.4; IQR 2.3-14.7). Published studies in children demonstrate a higher prevalence of RAP in females, with the highest prevalence of symptoms between 4 and 6 yr and early adolescence. Identified studies demonstrated associations between RAP and the child's familial and socioeconomic environment. In addition, childhood RAP was reported to be associated with psychological co-morbidity in childhood and adulthood. Population/school-based studies have not, however, established the incidence of this disorder, what features predict long-standing symptoms, or whether RAP is a risk factor for adult functional bowel disorders.
CONCLUSION: RAP is a common complaint of childhood with associated familial, psychological, and co-morbid conditions. Epidemiologic studies of RAP in children may offer information on the evolution of functional bowel disorders through the lifespan.

PMID 16086724  Am J Gastroenterol. 2005 Aug;100(8):1868-75. doi: 10.11・・・
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: Lisa N Sharwood, Franz E Babl
雑誌名: Paediatr Anaesth. 2009 May;19(5):445-51. doi: 10.1111/j.1460-9592.2008.02807.x.
Abstract/Text INTRODUCTION: The question of whether opioid analgesia should be given in patients with undifferentiated acute abdominal pain has been characterized by concerns about its efficacy and that signs used to determine accurate diagnosis may be masked by the drug. The objective of this review is to critically analyze pertinent pediatric randomized controlled studies considering this issue.
METHODS: A comprehensive literature search was conducted via Medline in October 2007, using the terms 'abdominal pain', 'physical examination', 'analgesics', 'opioid' and 'appendicitis'. Other articles were identified using the bibliographies of papers found through Medline; alternate databases were searched but did not reveal additional studies.
RESULTS: A total of four trials were identified, and their validity and applicability were reviewed. In all studies, randomization to the analgesia group was associated with significant reduction in pain; one study showing no greater effect with opioid than placebo. All studies used a 10 cm Visual Analogue Scale to assess pain. All studies were only sufficiently powered to consider the primary outcome of opioid efficacy in abdominal pain vs placebo rather than diagnostic accuracy, although they all reported on diagnostic accuracy. Meta-analysis of results for efficacy and accuracy was not possible due to the heterogeneity of study populations.
CONCLUSIONS: A large, probably multi-centred trial is needed to answer with sufficient power the question of whether opioid analgesia impairs diagnostic accuracy in children with undifferentiated acute abdominal pain.

PMID 19453578  Paediatr Anaesth. 2009 May;19(5):445-51. doi: 10.1111/j・・・
著者: Vera Loening-Baucke, Alexander Swidsinski
雑誌名: J Pediatr. 2007 Dec;151(6):666-9. doi: 10.1016/j.jpeds.2007.05.006. Epub 2007 Jul 30.
Abstract/Text OBJECTIVE: To evaluate the causes of acute abdominal pain in a large academic pediatric primary care population.
STUDY DESIGN: The complete charts of 962 children, > or = 4 years old, who were seen for at least 1 health maintenance visit during a 6-month period, were reviewed retrospectively for complaints and cause of acute abdominal pain.
RESULTS: We found that 9% of the 962 children had a visit for acute abdominal pain, with significantly more girls (12%) than boys (5%) having this complaint. Acute and chronic constipation were the most frequent causes of acute abdominal pain, occurring in 48% of subjects. A surgical cause was present in 2% of subjects. The cause for the acute abdominal pain remained unknown in 19% of subjects. We did not find significant differences in diagnoses in the primary care clinics versus emergency department.
CONCLUSIONS: We found that constipation was the most common cause of acute abdominal pain in children.

PMID 18035149  J Pediatr. 2007 Dec;151(6):666-9. doi: 10.1016/j.jpeds.・・・
著者: Marc A Benninga, Christophe Faure, Paul E Hyman, Ian St James Roberts, Neil L Schechter, Samuel Nurko
雑誌名: Gastroenterology. 2016 Feb 15;. doi: 10.1053/j.gastro.2016.02.016. Epub 2016 Feb 15.
Abstract/Text In 2006, a consensus concerning functional gastrointestinal intestinal disorders (FGIDs) in infants and toddlers was described. At that time little evidence regarding epidemiology, pathophysiology, diagnostic work-up, treatment strategies and follow-up was available. Consequently the criteria for the clinical entities were more experience than evidence based. In the past decade, new insights have been gained in the different FGIDs in these age groups. Based on those, further revisions have been made to the criteria. The description of infant colic has been expanded to include criteria for the general pediatrician and specific criteria for researchers. The greatest change was the addition of a paragraph regarding the neurobiology of pain in infants and toddlers, including the understanding of the neurodevelopment of nociception and of the wide array of factors that may impact the pain experience.

Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 27144631  Gastroenterology. 2016 Feb 15;. doi: 10.1053/j.gastro.2・・・
著者: Jeffrey S Hyams, Carlo Di Lorenzo, Miguel Saps, Robert J Shulman, Annamaria Staiano, Miranda van Tilburg
雑誌名: Gastroenterology. 2016 Feb 15;. doi: 10.1053/j.gastro.2016.02.015. Epub 2016 Feb 15.
Abstract/Text Characterization of childhood and adolescent functional gastrointestinal disorders (FGIDs) has evolved during the two decade long Rome process now culminating in Rome IV. The era of diagnosing a FGID only when organic disease has been excluded is waning,as we now have evidence to support symptom-based diagnosis. In child/adolescent Rome IV we extend this concept by removing the dictum that there was "no evidence for organic disease" in all definitions and replacing it with "after appropriate medical evaluation the symptoms cannot be attributed to another medical condition". This change allows the clinician to perform selective or no testing to support a positive diagnosis of a FGID. We also point out that FGIDs can coexist with other medical conditions that themselves result in gastrointestinal symptoms (e.g., inflammatory bowel disease). In Rome IV functional nausea and functional vomiting are now described. Rome III "abdominal pain related functional gastrointestinal disorders" (AP-FGID) has been changed to functional abdominal pain disorders (FAPD) and we have derived a new term, "functional abdominal pain -not otherwise specified", to describe children who do not fit a specific disorder such as irritable bowel, functional dyspepsia, or abdominal migraine. Rome IV FGID definitions should enhance clarity for both clinicians and researchers.

Copyright © 2016 AGA Institute. Published by Elsevier Inc. All rights reserved.
PMID 27144632  Gastroenterology. 2016 Feb 15;. doi: 10.1053/j.gastro.2・・・

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