今日の臨床サポート

虚血性大腸炎

著者: 大川清孝 大阪市立十三市民病院 消化器内科

監修: 上村直実 国立国際医療研究センター 国府台病院

著者校正/監修レビュー済:2021/11/02
参考ガイドライン:
  1. アメリカ消化器病学会(AGA):ACG clinical guideline: epidemiology, risk factors, patterns of presentation, diagnosis, and management of colon ischemia(CI). Am J Gastroenterol 2015;110:18-44. PMID: 25559486(大腸虚血のガイドライン)
患者向け説明資料

概要・推奨   

  1. 虚血性大腸炎とは可逆性の一過性型と狭窄型を指し、不可逆性の壊死型を含めないのが現在の考え方である。しかし、臨床的には重症の虚血性大腸炎と壊死型虚血性大腸炎の鑑別は難しいことがある。
  1. 虚血性大腸炎の治療には統計学的に示されたエビデンスはない。
  1. 腹膜刺激症状を示さない壊死型虚血性大腸炎がある。
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(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
大川清孝 : 特に申告事項無し[2021年]
監修:上村直実 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 1963年に、Boleyらが大腸栄養血管の可逆性閉塞に基づく一過性の腸管虚血性病変を、初めて1つの疾患単位として提唱した[1]。1966年にMarstonらは症例の集積と解析から、この疾患を虚血性大腸炎と呼称し、臨床経過から一過性型、狭窄型、壊死型に分類した[2]。しかし、Marstonは1977年には、壊死型を除外し、「主幹動脈に明らかな閉塞がなく、しかし虚血の証拠を証明し難い腸管粘膜血流障害によって引き起こされた可逆性の病変」という疾患概念に変更した[3]。そして壊死型を急性腸管不全の範疇に入れるとした。わが国では飯田らの定義のように、後者の定義が用いられることが多いが、海外では、前者の定義が用いられることが多い。わが国でも壊死型虚血性大腸炎という言葉が使われることも多く、未だに定義の混乱がみられる。
  1. 虚血性大腸炎とは、動脈硬化や腸管内圧の亢進による腸管の虚血により生ずる粘膜傷害である。本症の病因は不明であるが、血圧低下、動脈硬化などの血管側因子と腸管内圧亢進などの腸管側因子がからみあい、腸粘膜あるいは腸管壁の血流低下を引き起こして虚血状態を作ると推定されている。
  1. 突発する血便に対する緊急内視鏡により診断されるなかで最も多い病気で、common diseaseである。
  1. 欧米での頻度は1,000人の入院患者中1人とされているが、軽症例が多いため実際の頻度は不明である。
  1. 予後は病気の重症度に依存しており、壊死型以外は予後がよい。
  1. 欧米とわが国では臨床像が異なるため、注意が必要である。欧米では軽症例が少なく、重症例が多い。
問診・診察のポイント  
  1. 腹痛、血便、下痢が多い症状であるが、これらの順番を詳細に聞くことが重要である[4]
  1. 突然に強い下腹部痛が出現し、その後下痢を来し徐々に血性下痢となっていくのが典型的パターンである。

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文献 

著者: S J BOLEY, S SCHWARTZ, J LASH, V STERNHILL
雑誌名: Surg Gynecol Obstet. 1963 Jan;116:53-60.
Abstract/Text
PMID 13968597  Surg Gynecol Obstet. 1963 Jan;116:53-60.
著者: A Marston, M T Pheils, M L Thomas, B C Morson
雑誌名: Gut. 1966 Feb;7(1):1-15.
Abstract/Text
PMID 5906128  Gut. 1966 Feb;7(1):1-15.
著者: I E Koutroubakis, A Sfiridaki, A Theodoropoulou, E A Kouroumalis
雑誌名: Gastroenterology. 2001 Sep;121(3):561-5.
Abstract/Text BACKGROUND & AIMS: Hypercoagulable states may play an important role in the pathogenesis of colon ischemia. Aim of this study was to assess this hypothesis investigating the role of acquired and hereditary thrombotic risk factors in patients with definite diagnosis of colon ischemia.
METHODS: We compared the frequency of antiphospholipid antibodies, protein C, protein S, and antithrombin deficiencies, factor V Leiden, prothrombin gene mutation G20210GA, and methylenetetrahydrofolate reductase C677T in 36 patients (23 men, 13 women; mean age, 64.8 years) with colon ischemia, 18 patients with diverticulitis, and 52 healthy controls.
RESULTS: The prevalence of antiphospholipid antibodies was significantly higher in patients with colon ischemia compared with inflammatory and healthy controls (19.4% vs. 0% and 1.9%). Among genetic factors, only factor V Leiden was significantly associated with colon ischemia (22.2% vs. 0% and 3.8%). A combination of thrombophilic disorders was found in 25% of the cases. Overall, one or several prothrombotic abnormalities were present in 26 patients (72%).
CONCLUSIONS: A comprehensive thrombophilic screening in colon ischemia reveals a congenital or acquired thrombophilic state in 72% of patients. Hereditary and acquired thrombotic risk factors may play an important role in the disease pathogenesis.

PMID 11522740  Gastroenterology. 2001 Sep;121(3):561-5.
著者: Angeliki Theodoropoulou, Aekaterini Sfiridaki, Pantelis Oustamanolakis, Emanouel Vardas, Aekaterini Livadiotaki, Aekaterini Boumpaki, Gregorios Paspatis, Ioannis E Koutroubakis
雑誌名: Clin Gastroenterol Hepatol. 2008 Aug;6(8):907-11. doi: 10.1016/j.cgh.2008.03.010. Epub 2008 Jun 4.
Abstract/Text BACKGROUND & AIMS: Although ischemic colitis (IC) usually occurs in old people with concomitant illnesses, an increasing frequency of this disease among young people has been reported. Inherited risk factors have been suggested to play an important role in the pathogenesis of IC. The aim of this study was to investigate the prevalence and possible role of mutations associated with cardiovascular morbidity in young patients with IC.
METHODS: Patients younger than 55 years old with nonocclusive colon ischemia who were conservatively treated were included in the study. The diagnosis of definite IC was based on established clinical, endoscopic, and histologic criteria. Twelve polymorphisms of thrombophilic and vasoactive genes were evaluated in a group of 19 young patients with IC compared with 52 matched healthy controls (HC) by using commercially available kit.
RESULTS: The frequency of the 506 Q allele of the factor V (FV) 506 RQ (Leiden) mutation was significantly higher in patients with IC than in HC (P = .005). The allele frequency of the mutant 4G allele of plasminogen activator inhibitor (PAI) polymorphism was significantly higher in patients with IC compared with HC (P = .006). The frequencies of the genotypes and mutant alleles of the other 10 polymorphisms were not statistically different in the 2 groups (P > .05).
CONCLUSIONS: Our results suggest that FV R506Q and PAI-1 gene polymorphisms might be associated with the development of IC in young patients without other serious illness. Genetic predisposition might play an important role in the pathogenesis of IC in young patients.

PMID 18524690  Clin Gastroenterol Hepatol. 2008 Aug;6(8):907-11. doi: ・・・
著者: Lawrence J Brandt, Paul Feuerstadt, George F Longstreth, Scott J Boley, American College of Gastroenterology
雑誌名: Am J Gastroenterol. 2015 Jan;110(1):18-44; quiz 45. doi: 10.1038/ajg.2014.395. Epub 2014 Dec 23.
Abstract/Text
PMID 25559486  Am J Gastroenterol. 2015 Jan;110(1):18-44; quiz 45. doi・・・
著者: S O'Neill, S Yalamarthi
雑誌名: Colorectal Dis. 2012 Nov;14(11):e751-63. doi: 10.1111/j.1463-1318.2012.03171.x.
Abstract/Text AIM: The study reviews the literature related to ischaemic colitis (IC) to establish an evidence base for its management and to identify factors predicting severity and mortality.
METHOD: A systematic review of the English language literature was conducted according to recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE, Embase and Cochrane Library databases were searched using the keyword search 'ischaemic colitis OR colon ischaemia OR colonic ischaemia OR management ischaemic colitis'. IC is often misdiagnosed so only studies where the diagnosis was supported by histopathology in every case were included. Critical appraisal was performed of included studies using predefined quality assessment checklists and narrative data synthesis.
RESULTS: In all, 2610 publications were identified. Of these, eight retrospective case series and three case controlled studies describing 1049 patients were included. Medical management was used in 80.3% patients of whom 6.2% died. Surgery was required in 19.6% of whom 39.3% died. The overall mortality of IC was 12.7%. Lack of rectal bleeding, peritonism and renal dysfunction were commonly quoted predictors of severity; however, right sided IC appeared to be the most significant predictor of outcome.
CONCLUSION: Most patients with IC can be managed conservatively. Right sided IC may be the most significant predictor of severity.

© 2012 The Authors. Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
PMID 22776101  Colorectal Dis. 2012 Nov;14(11):e751-63. doi: 10.1111/j・・・
著者: John Sotiriadis, Lawrence J Brandt, Daniel S Behin, William N Southern
雑誌名: Am J Gastroenterol. 2007 Oct;102(10):2247-52. doi: 10.1111/j.1572-0241.2007.01341.x. Epub 2007 Jun 11.
Abstract/Text BACKGROUND: In general, ischemic colitis has a very good prognosis, but there is concern that when ischemia affects the right side of the colon in an isolated fashion, the prognosis may not be so favorable.
OBJECTIVE: The aim of this study was to compare the clinical features and outcomes of ischemia isolated to the right side of the colon with those of ischemia involving other areas of the colon.
METHODS: A retrospective study was undertaken of patients with colon ischemia hospitalized at the Moses and Weiler Divisions of the Montefiore Medical Center during the interval 1998-2005. Patients were identified using computerized searches of ICD-9 codes for colon ischemia and were divided into two groups: those with isolated right colon ischemia (IRCI) and those with colon ischemia not involving the right colon in an isolated fashion (non-IRCI). Only patients with biopsy-proven ischemic colitis were entered into our study.
RESULTS: A total of 273 cases of biopsy-proven ischemic colitis were identified, of which 71 (26.0%) were isolated to the right side. Of these IRCI cases, 59.2% had an unfavorable outcome compared with 17.3% of cases of non-ICRI: 54.9% of IRCI patients required surgery compared with 10.9% of non-IRCI patients; mortality in patients with IRCI was 22.5% compared with 11.9% in patients with non-IRCI.
CONCLUSIONS: A total of 273 cases of biopsy-proven ischemic colitis were identified of which 71 (26.0%) involved only the right side. Patients with IRCI had a worse outcome than those with colon ischemia involving other colon regions, including a fivefold need for surgery and a twofold mortality.

PMID 17561968  Am J Gastroenterol. 2007 Oct;102(10):2247-52. doi: 10.1・・・
著者: Lawrence J Brandt, Paul Feuerstadt, Matthew C Blaszka
雑誌名: Am J Gastroenterol. 2010 Oct;105(10):2245-52; quiz 2253. doi: 10.1038/ajg.2010.217. Epub 2010 Jun 8.
Abstract/Text OBJECTIVES: Previous reports on the anatomic portions of colon involved in cases of supposed ischemic colitis (IC) have been limited by the absence of confirmation of the true nature of the disease. This is the first anatomic study to define the patterns of colon involvement in which only cases with biopsy-proven or -compatible IC and in which the entire colon had been visualized at surgery or at colonoscopy were included. The aims of this study were to re-examine patterns of colonic involvement in IC using only cases in which the diagnosis was biopsy proven or compatible, and to examine the clinical features and outcomes with regard to the segments of colon involved.
METHODS: A retrospective study was undertaken of patients with IC who were hospitalized at Montefiore Medical Center from 1998 to 2009. Patients were identified using computerized searches of ICD-9 (International Classification of Diseases, ninth revision) codes for colon ischemia, and patterns of colon involvement were then tabulated and categorized into five major groups: right colon, transverse colon, left colon, distal colon, and pancolon involvement. Patterns were classified based on the most proximal location of injury. Major anatomic patterns were then subcategorized into more specific segments of involvement. Only biopsy-proven or -compatible cases of IC in which the entire colon had been visualized at surgery or at colonoscopy were used in this study.
RESULTS: A total of 313 cases of biopsy-proven or -compatible IC were identified. Patterns and frequencies of involvement were: right colon, 25.2%; transverse colon, 10.2%; left colon, 32.6%; distal colon, 24.6%; and pancolon, 7.3%. Compared with all other patterns of IC, the right colon pattern was more likely to be associated with coronary artery disease (39.2 vs. 21.4%) or end-stage kidney disease requiring dialysis (20.3 vs. 7.7%), a longer hospitalization (median stay, 10 vs. 6 days), a greater need for surgery (44.3 vs. 11.5%), and the highest mortality rate (20.3 vs. 9%). Patients with a left colon pattern were less likely to be operated upon, and had a shorter length of stay than any other pattern of IC. Hyperthyroidism, stroke, and chronic obstructive pulmonary disease (COPD) were statistically significant independent predictors of mortality.
CONCLUSIONS: IC is typically a segmental disease, flanked by normal colon on either side of the affected area. Comorbid disease associations and severity of disease as reflected by length of hospitalization, need for surgery, and mortality vary with the segment involved. IC isolated to the right side of the colon is a more severe disease than IC affecting any other segment of colon.

PMID 20531399  Am J Gastroenterol. 2010 Oct;105(10):2245-52; quiz 2253・・・
著者: R Díaz Nieto, M Varcada, O A Ogunbiyi, M C Winslet
雑誌名: Colorectal Dis. 2011 Jul;13(7):744-7. doi: 10.1111/j.1463-1318.2010.02272.x. Epub 2010 Mar 30.
Abstract/Text AIM: Ischaemic colitis is uncommon. Aetiological factors include abdominal aortic surgery, drugs (especially inotropics) or rheumatoid diseases, such as Takayasu's or Buerger's diseases. However, there is often no triggering factor, and it may be part of multifactorial cardiac, respiratory, renal or metabolic failure.
METHOD: A systematic review of the current literature on the management of ischaemic colitis was carried out.
RESULTS: Ten retrospective trials (841 patients) were included. No randomized controlled or prospective trial of the management of ischaemic colitis was found.
CONCLUSION: There is very little evidence base for the management of this condition.

© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.
PMID 20374265  Colorectal Dis. 2011 Jul;13(7):744-7. doi: 10.1111/j.14・・・
著者: S J Sarnoff, J Fine
雑誌名: Ann Surg. 1945 Jan;121(1):74-82.
Abstract/Text
PMID 17858552  Ann Surg. 1945 Jan;121(1):74-82.
著者: E J PATH, J N McCLURE
雑誌名: Ann Surg. 1950 Feb;131(2):159-70, illust.
Abstract/Text
PMID 15402790  Ann Surg. 1950 Feb;131(2):159-70, illust.
著者: I COHN, C E FLOYD, C F DRESDEN, G H BORNSIDE
雑誌名: Ann Surg. 1962 Oct;156:692-702.
Abstract/Text
PMID 14022133  Ann Surg. 1962 Oct;156:692-702.
著者: Seiichiro Abe, Tetsuji Takayama, Hidetoshi Ohta, Rishu Takimoto, Tetsuro Okamoto, Yasushi Sato, Tomomi Nikaido, Kouhei Takizawa, Tomoyuki Abe, Yoshiro Niitsu
雑誌名: Gastrointest Endosc. 2004 Jul;60(1):148-51.
Abstract/Text
PMID 15229451  Gastrointest Endosc. 2004 Jul;60(1):148-51.
著者: Jenó Solt, Agnes Hertelendi, Károly Szilágyi
雑誌名: Orv Hetil. 2002 Aug 4;143(31):1835-40.
Abstract/Text AIM: Benign stenosis of the lower gastrointestinal tract usually develops, due to complication of a surgical intervention or sometimes because of other inflammatory bowel processes. Their reoperation is technically difficult and risky. Therefore the authors use a balloon catheter dilatation in the treatment of lower gastrointestinal tract stenosis since 1985.
METHODS: First a guide wire is passed colonoscopically, then under X-ray control a double lumen balloon catheter, or directly through the channel of the endoscope a single or double lumen balloon catheter is introduced into the stenosis, which is then gradually dilated to 12-25 mm diameter. The applied pressure is 1.5-3 atm. Result of the dilatation can be judged from the decreased indentation of the balloon, and from increased diameter of stenosis at colonoscopic, or sometimes colonographic follow up.
RESULTS: Between January of 1985 and July of 2001 they performed 123 dilatation on 52 patients. The causes of stenoses were in 40 cases postoperative stenosis, in 5 Crohn disease, in 2 ulcerative colitis, in 1 ischemic stenosis, and in 3 scar of the anus. From all stenosis cases 4 were localised to the anus, 40 to the rectum, 7 to the colon, and 1 to the terminal ileum. Due to the dilatation the average diameter of the stenosis was increased from 7.2 (1-14) mm to 19.7 (14-25) mm. Following the dilatation in 42 patients out of 52 the colonoscope was passed through the stenosis. Colostomies were closed in 11 cases out of 17. In 4 patients the subileus state ceased, and all of our 3 patients colo-cutan fistula healed rapidly. 16 out of 52 patients re-operation was proposed. One patient had fever as complication which was treated with antibiotics.
CONCLUSIONS: Dilatation of benign stenosis of the lower gastrointestinal tract with balloon catheter is an effective method, which in most of the cases (69%) will stop the obstructive symptoms and in the long run therefore surgery can be avoided.

PMID 12187577  Orv Hetil. 2002 Aug 4;143(31):1835-40.
著者: Jayaprakash Sreenarasimhaiah
雑誌名: BMJ. 2003 Jun 21;326(7403):1372-6. doi: 10.1136/bmj.326.7403.1372.
Abstract/Text
PMID 12816826  BMJ. 2003 Jun 21;326(7403):1372-6. doi: 10.1136/bmj.326・・・

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