今日の臨床サポート

下血・血便

著者: 砂田圭二郎 自治医科大学 消化器内科学部門

著者: 山本博徳 自治医科大学 消化器内科学部門

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:2020/01/24
参考ガイドライン:
消化性潰瘍診療ガイドライン2015
小腸内視鏡診療ガイドライン
患者向け説明資料

概要・推奨   

  1. 出血源の鑑別診断として常に上部消化管疾患を考慮することが勧められる(推奨度1)
  1. 下血・血便の診断に際しては、出血部位の同定および腹部の状態を知るため、緊急時には腹部造影CTをまず行うことが勧められる(推奨度1)
  1. 下血(黒色便)のときは、上部消化管疾患を想起し、緊急上部消化管内視鏡を行うことが勧められる(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:
砂田圭二郎 : 特に申告事項無し[2021年]
山本博徳 : 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. 定期レビューを行い、消化性潰瘍診療ガイドラインの内容を取り入れた。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 下血・血便とは、消化管からの出血が肛門より排出されることである。“下血”は消化管出血による肛門からの血液排出の総称として用いられる場合もあるが、狭義には上部消化管出血による黒色便を指す。一方“血便”は下部消化管出血による赤色便を指す。
  1. 消化管出血(顕出血)がある場合、排泄される便の色は黒色調から赤色調となる。
  1. 血液が消化管内に長く滞留すると、血液中のヘモグロビンが胃液や他の消化液、腸内細菌などにより変性を受け血液が黒色に変色する。
  1. 欧米では、血液の混じった黒色便排出をmelenaと呼び、赤色便の排出をhematocheziaと呼んでいる。
  1. melenaには下血、hematocheziaには血便という邦訳が用いられており、下血(狭義)は、黒色便排出を指す用語である。
  1. ただし、本来の意味から離れて黒色便と血便の総称として下血(広義)が用いられることもある。
  1. なお、タール便(tarry stool)は黒色便のなかに包括されるが、便中の水分が吸収され少なくなった状態で光沢のある真っ黒いネバネバしたコールタールに似た外観を特徴とする。
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文献 

著者: Gottumukkala S Raju, Lauren Gerson, Ananya Das, Blair Lewis, American Gastroenterological Association
雑誌名: Gastroenterology. 2007 Nov;133(5):1697-717. doi: 10.1053/j.gastro.2007.06.007.
Abstract/Text This literature review and the recommendations therein were prepared for the AGA Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on March 12, 2007, and by the AGA Institute Governing Board on May 19, 2007.

PMID 17983812  Gastroenterology. 2007 Nov;133(5):1697-717. doi: 10.105・・・
著者: Naoki Ohmiya, Tomonori Yano, Hironori Yamamoto, Daigo Arakawa, Masanao Nakamura, Wataru Honda, Akihiro Itoh, Yoshiki Hirooka, Yasumasa Niwa, Osamu Maeda, Takafumi Ando, Tsuneyoshi Yao, Toshiyuki Matsui, Mitsuo Iida, Shinji Tanaka, Tsutomu Chiba, Choitsu Sakamoto, Kentaro Sugano, Hidemi Goto
雑誌名: Gastrointest Endosc. 2007 Sep;66(3 Suppl):S72-7. doi: 10.1016/j.gie.2007.05.041.
Abstract/Text BACKGROUND: Double balloon endoscopy (DBE) and videocapsule endoscopy (VCE) have been useful in managing obscure GI bleeding (OGIB).
OBJECTIVE: This study evaluated the usefulness of DBE for diagnosis, treatment, and prognosis of OGIB and compared diagnostic yield between DBE and VCE in Japan.
METHODS: Detection rates of abnormalities and diagnostic yields between VCE and DBE were compared in 74 patients at 5 centers. Of 244 patients who underwent DBE at Nagoya University Hospital, 130 (53%) with OGIB were enrolled for investigation of therapeutic procedures.
SETTING: Seven Japanese medical centers.
PATIENTS: Of 1034 patients who underwent DBE between September 2000 and December 2005 at 7 medical centers, 479 (46%) with OGIB were enrolled.
RESULTS: Overall diagnostic yield of DBE for OGIB was 277 of 479 (58%). In patients with overt-ongoing bleeding, overt-previous bleeding of sporadic type, overt-previous bleeding of first attack only, occult bleeding with continuous positive fecal occult blood test (FOBT), or occult bleeding with 1 positive FOBT with iron deficiency anemia, diagnostic yield was 24 of 31 (77%), 179 of 310 (58%), 34 of 72 (47%), 24 of 35 (71%), and 56 of 93 (60%), respectively. Regarding positive findings in 277 patients, ulcers or erosions (53%) were the most frequent, followed by angiodysplasia (23%), tumors or polyps (22%), and diverticula (4%). Diagnoses in these patients were as follows: chronic inflammatory diseases (24%), vascular diseases (24%), tumor or polyps (21%), drug or radiation injury (7%), other small-bowel diseases (7%), upper GI diseases (9%), colorectal diseases (9%), and biliary disease (0.4%). Small-bowel diseases were confirmed in 226 patients (47%). Comparison of overall detection rate of abnormalities in the small bowel between VCE (65%) and DBE (53%) was not significantly different, nor was that of overall diagnostic yield between VCE (50%) and DBE (53%). Eight acute pancreatitis and 4 perforation episodes occurred with no mortalities at DBE. Of 130 patients at Nagoya University Hospital, 78 (60%) were diagnosed with small-bowel diseases and underwent treatments as follows: medication or observation only (n = 30), enteroscopic therapies (electrocoagulation in 21, clipping in 4, and polypectomy in 3), and surgery (n = 22). Small-bowel vascular diseases were more prone to rebleeding than small-bowel nonvascular diseases in patients without surgical treatment at a median follow-up of 423 days.
CONCLUSIONS: DBE was relatively safe and useful for diagnosis and treatment of OGIB. A spectrum of small-bowel diseases presenting with OGIB in Japan may be distinct from that in the Western world.

PMID 17709039  Gastrointest Endosc. 2007 Sep;66(3 Suppl):S72-7. doi: 1・・・
著者:
雑誌名: Gastrointest Endosc. 1990 Sep-Oct;36(5 Suppl):S62-5.
Abstract/Text
PMID 2242815  Gastrointest Endosc. 1990 Sep-Oct;36(5 Suppl):S62-5.
著者: R Sidhu, D S Sanders, A J Morris, M E McAlindon
雑誌名: Gut. 2008 Jan;57(1):125-36. doi: 10.1136/gut.2007.129999.
Abstract/Text
PMID 18094205  Gut. 2008 Jan;57(1):125-36. doi: 10.1136/gut.2007.12999・・・
著者: Marco Pennazio, Renato Santucci, Emanuele Rondonotti, Carla Abbiati, Gizela Beccari, Francesco P Rossini, Roberto De Franchis
雑誌名: Gastroenterology. 2004 Mar;126(3):643-53.
Abstract/Text BACKGROUND & AIMS: Capsule endoscopy (CE) is a promising diagnostic tool for the study of patients with obscure gastrointestinal bleeding. However, the diagnostic yield of this technique has not been adequately studied. We evaluated sensitivity and specificity of CE and the outcome after CE in patients with obscure gastrointestinal bleeding.
METHODS: One hundred consecutive patients (all with recent negative upper and lower endoscopy; 26 with ongoing overt bleeding [group A], 31 with previous overt bleeding [group B], and 43 with guaiac-positive stools and iron-deficiency anemia [group C]) underwent CE.
RESULTS: The yield of positive findings on CE was 92.3% in group A, 12.9% in group B, and 44.2% in group C (P < 0.0001, A vs. B, A vs. C). Angiodysplasia (29%) and Crohn's disease (6%) were the most common diagnoses. Sensitivity, specificity, and positive and negative predictive values of CE were 88.9%, 95%, 97%, and 82.6%, respectively. CE results led to treatments resolving the bleeding in 86.9% of patients undergoing the procedure while actively bleeding. Capsule retention because of unsuspected stenosis occurred in 5 patients and required surgery, which resolved the clinical problem, in 4 patients.
CONCLUSIONS: CE is an effective diagnostic tool for patients with obscure GI bleeding. The best candidates for the procedure are those with ongoing obscure-overt bleeding or with obscure-occult bleeding. If done early in the course of the workup, CE could shorten considerably the time to diagnosis, lead to definitive treatment in a relevant proportion of patients, and spare a number of alternative investigations with low diagnostic yield.

PMID 14988816  Gastroenterology. 2004 Mar;126(3):643-53.
著者: Elizabeth J Carey, Jonathan A Leighton, Russell I Heigh, Arthur D Shiff, Virender K Sharma, Janice K Post, David E Fleischer
雑誌名: Am J Gastroenterol. 2007 Jan;102(1):89-95. doi: 10.1111/j.1572-0241.2006.00941.x. Epub 2006 Nov 13.
Abstract/Text OBJECTIVES: Capsule endoscopy (CE) has revolutionized the evaluation of obscure gastrointestinal bleeding (OGIB) but published literature is limited to small series with heterogeneous indications. The aim of this study was to determine the findings and the diagnostic yield of CE in a large series of patients with overt and occult OGIB.
METHODS: Data on 260 patients who underwent CE for overt (N = 126) or occult (N = 134) OGIB were obtained by retrospective chart review and review of an internal database of CE patients and findings.
RESULTS: Visualization of the entire small bowel was achieved in 74%. The majority of exams (66%) were rated as having a good or excellent prep. Clinically significant positive findings occurred in 53%. The yield of CE in the obscure-overt group was greater than in the obscure-occult group (60%vs 46%, P= 0.03). Small bowel angioectasias were the most common finding, comprising over 60% of clinically significant lesions. The mean follow-up was 9.6 months, and there were significant reductions in hospitalizations, additional tests/procedures, and units of blood transfused after CE. Both before and after CE, patients in the overt group had more significant GI bleeding than patients in the occult group. Complications occurred in five (1.9%) cases: nonnatural excretion (four) and CE impaction at cricopharyngeus (one).
CONCLUSIONS: The yield of clinically important findings on CE in patients with OGIB is 53% and is greater in patients with obscure-overt than obscure-occult GI bleeding. Angioectasias account for the majority of significant lesions in both groups. Compared with pre-CE, patients had clinical improvement post-CE in medical interventions for OGIB. Complications of CE occur in less than 2% of cases.

PMID 17100969  Am J Gastroenterol. 2007 Jan;102(1):89-95. doi: 10.1111・・・
著者: Natsuhiko Kameda, Kazuhide Higuchi, Masatsugu Shiba, Hirohisa Machida, Hirotoshi Okazaki, Hirokazu Yamagami, Tetsuya Tanigawa, Kenji Watanabe, Toshio Watanabe, Kazunari Tominaga, Yasuhiro Fujiwara, Nobuhide Oshitani, Tetsuo Arakawa
雑誌名: J Gastroenterol. 2008;43(6):434-40. doi: 10.1007/s00535-008-2182-9. Epub 2008 Jul 4.
Abstract/Text BACKGROUND: Wireless capsule endoscopy (CE) and double-balloon enteroscopy (DBE) are new methods enabling diagnostic endoscopy of the entire small intestine. However, which of the two is superior is unclear. We therefore prospectively compared the clinical efficacy of CE and DBE.
METHODS: We prospectively examined 32 patients with obscure gastrointestinal bleeding. CE preceded DBE by 1-7 days, and all patients underwent DBE twice, by antegrade and retrograde approaches, to evaluate the entire small intestine. Physicians evaluating the results of CE and DBE were blind to the results of the other method. We evaluated diagnosis, diagnostic yield of the two methods, and clinical outcomes.
RESULTS: CE revealed abnormal findings in 29 (90.6%) of 32 patients. CE definitively or probably detected the sources of bleeding in 23 (71.9%) of the 32 patients, including angioectasias (eight), erosions (seven), ulcers (five), tumor (one), and hemorrhagic polyps (two). DBE definitely or probably detected the sources of bleeding in 21 (65.6%) of the 32 patients, including angioectasias (seven), erosions (four), ulcers (five), tumor (one), hemorrhagic polyps (two) and diverticula (two). CE yielded more abnormal findings than DBE (CE 90.6%, DBE 65.6%) (P = 0.032), although there were no significant differences in diagnostic yield between the methods. We were able to perform additional treatment or biopsy with DBE in 13 patients, including coagulation therapy (ten), endoscopic mucosal resection (one), biopsy (seven), and extraction of retained CE (two).
CONCLUSIONS: Our results demonstrate the superiority of CE in detecting abnormal lesions, and the superiority of DBE in endoscopic management.

PMID 18600387  J Gastroenterol. 2008;43(6):434-40. doi: 10.1007/s00535・・・
著者: M Nakamura, Y Niwa, N Ohmiya, R Miyahara, A Ohashi, A Itoh, Y Hirooka, H Goto
雑誌名: Endoscopy. 2006 Jan;38(1):59-66. doi: 10.1055/s-2005-870446.
Abstract/Text BACKGROUND AND STUDY AIMS: Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) have been introduced as modalities for examining the entire small bowel. The aim of the present study was to assess the clinical effects of CE and DBE to consider the roles of CE and DBE and the indications for the procedures in patients with suspected small-bowel bleeding.
PATIENTS AND METHODS: Between June 2004 and January 2005, 32 patients in whom a site of bleeding in the gastrointestinal tract had not been identified were enrolled in the study. Twenty-eight patients were examined with both methods. Bleeding sources were categorized as either A1 lesions (immediate hemostatic procedures required) or A2 lesions (close observation required). CE and DBE were evaluated with regard to whether or not they were capable of accessing the entire small bowel and provided a diagnosis, and the access and diagnostic rates were calculated.
RESULTS: On CE, 13 patients were diagnosed with A1 lesions and six with A2 lesions; on DBE, 11 had A1 lesions and one had an A2 lesion. The access rate for the entire small intestine on CE was 90.6 % (29 of 32), significantly higher than with DBE at 62.5 % (10 of 16; P < 0.05). The diagnostic rate on CE was 59.4 % (19 of 32), higher than with DBE at 42.9 % (12 of 28; P = 0.30), but not significantly different. Among patients with A1 lesions who were diagnosed with DBE, histological diagnoses were obtained in six of the 11, and three patients were treated.
CONCLUSIONS: In many suspected small-bowel bleeding cases, CE should be selected for the initial diagnosis and DBE for treatment or histopathological diagnosis after detection of the bleeding site on CE.

PMID 16429356  Endoscopy. 2006 Jan;38(1):59-66. doi: 10.1055/s-2005-87・・・
著者: William G Kuhle, Robert G Sheiman
雑誌名: Radiology. 2003 Sep;228(3):743-52. doi: 10.1148/radiol.2283020756.
Abstract/Text PURPOSE: To evaluate the feasibility of helical computed tomography (CT) as an imaging modality for depicting active colonic hemorrhage in a swine model.
MATERIALS AND METHODS: Controlled extravasation of contrast material-enhanced blood (CEB) from 140 to 180 HU and at varying rates (0.3-1.0 mL/min) was performed during a 30-second period by using a microcatheter system placed within the descending colon of 14 swine. CEB was immediately followed by extravasation of unopacified blood at the same location and rate during serial helical CT imaging of the extravasation site. Region-of-interest analysis allowed quantification of the dilution of extravasated CEB as a function of time that was then modeled mathematically based on iodine mass and volume balances. Nonlinear least squares analysis was performed to optimize fitting of the model to experimental data, with a maximum regression value (R2) of 1.0 indicating a perfect fit. This model enabled the computer simulation of CT imaging of multiple combinations of bleeding rates and CEB attenuation to determine the sensitivity of helical CT for depicting active colonic bleeding.
RESULTS: Sixteen swine examinations yielded 16 CEB dilution curves. An excellent fit of the model to each dilution curve was achieved, as indicated by a mean R2 value of 0.8402. Swine examinations alone showed that targeted CT could depict CEB as low as 111 HU extravasating at a rate of 0.3 mL/min. Simulations that were based on helical CT images with 5-mm collimation reconstructed every 3 mm and that used the model indicated bleeding rates below 0.4 mL/min are detectable, provided peak aortic enhancement reaches 100 HU.
CONCLUSION: Conservatively, helical CT has the potential to depict active colonic hemorrhage at rates of 0.5 mL/min or less.

PMID 12954894  Radiology. 2003 Sep;228(3):743-52. doi: 10.1148/radiol.・・・

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