今日の臨床サポート

腸音異常

著者: 本村和久 沖縄県立中部病院 総合診療科

監修: 大滝純司 東京医科大学 医学教育学分野 総合診療科

著者校正済:2022/02/16
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 腹痛があり、腸閉塞を疑う患者では、腸音の異常が診断に寄与するという限定的なエビデンスがある(推奨度2)
  1. 単独の身体所見として、腸音の異常の診断的意義を示すエビデンスはきわめて限られている。
  1. 腸音の異常だけで、診断根拠を得ることは困難である。
アカウントをお持ちの方はログイン
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧には
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。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※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、実際の保険適応の査定において保険適応及び保険適応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応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:
本村和久 : 特に申告事項無し[2022年]
監修:大滝純司 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、参考文献について加筆修正を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 腹部のあらゆる症状に対して、非侵襲的な検査である腸音の聴取は適応となり得る。
  1. 腹痛や消化器症状を有する患者の身体診察では必ず腸音を聴取する。腸音のほとんどは胃で発生する。次いで大腸、小腸の順となる[1]
  1. 腸音の異常の診断的意義は、腸閉塞(機械性イレウス)に限られ、病歴やその他の所見との総合的な判断となる[2]。教科書的には、特徴的な腸音異常は腸閉塞(機械性イレウス)での金属音(high pitched)、麻痺性イレウスでの腸蠕動音の低下である[3]
  1. 麻痺性イレウスのリスクが高い患者のモニタリングとして、腸音の変化を知ることは有用かもしれない[4]
  1. 腸音低下もしくは、消失の判断には、少なくとも2分の聴診が必要と教科書的にはいわれる[5][6]
問診・診察のポイント  
 
  1. 身体所見をとる順番は、視診、聴診、打診、触診の順番である[6]
  1. 腹部に物理的な刺激が加わると腸音の変化が起きる可能性がある[6]
  1. 腸閉塞(機械性イレウス)の診断において、視診での腹部膨隆、聴診での腸音の異常は有用である可能性がある[2]
 
  1. 腹痛があり、腸閉塞を疑う患者では、腸音の異常が診断に寄与するという限定的なエビデンスがある(推奨度2O)(参考文献:[2]
  1. 1,333人の急性腹痛患者の前向き研究では、急性小腸閉塞の診断で最も効果的な徴候は、以前の開腹術(相対危険度[RR]= 12.1)と疝痛発作(一定の痛みに対して)(RR = 2.4)であった。最も効果的な身体所見は、腹部の膨満(RR = 13.1)と異常な腸音(RR = 9.0)であった。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

J P Politzer, G Devroede, C Vasseur, J Gerard, R Thibault
The genesis of bowel sounds: influence of viscus and gastrointestinal content.
Gastroenterology. 1976 Aug;71(2):282-5.
Abstract/Text This study was undertaken to try to solve the controversy about the influence of gastrointestinal contents on the genesis of bowel sounds, and to probe the respective importance of the various abdominal viscera. Eleven healthy volunteers were intubated by mouth with a multiple-lumen tube. Bowel sounds were recorded for 10 min when the tube was in the stomach, the upper jejunum, and the cecum, while it was left intact in situ, or perfused with isotonic saline (15 ml per min), or with an equal (7.5 ml per min of each) mixture of isotonic saline and air. Using a previously developed method, a computer analysis was made of the recording without any human intervention during the treatment of data. An analysis of variance demonstrated that the effect of perfusion varied according to site, with 46% of counted sounds while the tube was in the stomach, 32% in the jejunum, and 22% in the colon (P less than 0.05). There were two types of sounds: some exceeded in amplitude a preset threshold, and thus were picked up by the computer, but their average absolute value for 20 msec remained inferior to another preset threshold. Their number was kept in memory (NS--sounds having an amplitude exceeding a threshold S1, expressed in number per 10 min). A second type of sounds also exceeded the present threshold but their average absolute value for 20 msec also exceeded another preset threshold. Their number (NE--sounds having an amplitude exceeding the thershold S1 but having also a 20-msec average amplitude above another threshold S2, expressed in number per 10 min) was also memorized. The latter group was composed of two types of sounds: some had a limited spectrum of low frequency (100 Hz) and were of high amplitude and short (congruent to 5 msec) duration (NE1); some others had a higher and more dispersed frequency centered around 300 Hz (NE2). Fifty per cent of high energy (NE) sounds appeared while the tube was in the stomach, 30% in the colon, and 20% in the jejunum (P less than 0.005). Short and high amplitude sounds (NE1) were counted more often (43%) when it was in the colon than in the stomach (38%) and the jejunum (19%) (P less than 0.025), and this was confirmed (P less than 0.005) by a study of the ratio of NE1/NE. On the contrary, higher frequency sounds (NE2) were present more often when the tube was in the stomach (59%) than in the jejunum (24%) and in the colon (17%) (P less than 0.005). There was no influence of the presence of the unperfused tube on the genesis of bowel sounds in different sites (P greater than 0.05). In the stomach and the colon perfusion of the air/saline mixture increased the number of sounds (P less than 0.025) and all types of sounds in the stomach (P less than 0.025), whereas in the jejunum it was the perfusion of saline which increased them (P less than 0.025). It is concluded that the stomach is the most active site of production of bowel sounds, followed by the colon and then the small bowel, that sounds differ in different sites, and that all this is influenced by viscus content.

PMID 939390
Abstract/Text BACKGROUND: The accuracy of clinical diagnosis of acute small-bowel studied in connection with the survey of acute abdominal pain by the Research Committee of the World Organization of Gastroenterology (OMGE). Criteria for inclusion and the diagnostic criteria of this prospective study were those set out by the OMGE Research Committee.
METHODS: The clinical findings in each patient were recorded in detail on a pre-defined structured data collection sheet, and the collected data were compared with the final diagnosis of patients.
RESULTS: The most efficient symptoms in the diagnosis of acute small-bowel obstruction were previous abdominal surgery (relative risk (RR) = 12.1) and type of pain (colic/intermittent versus steady) (RR = 2.4). The most efficient clinical tests were abdominal distension (yes versus no) (RR = 13.1) and bowel sounds (abnormal versus normal) (RR = 9.0). The sensitivity of the clinical decision was 0.75, with a specificity of 0.99 and an efficiency of 0.98. The computer-based diagnostic score reached a sensitivity of 0.87 with a specificity of 0.95 and an efficiency of 0.95.
CONCLUSIONS: Acute abdominal pain with distension, abnormal bowel sounds, and previous abdominal surgery are indicative of a small-bowel obstruction. A computer-based diagnostic score increases the sensitivity and usefulness index of the diagnosis of acute small-bowel obstruction in comparison with clinical decision alone.

PMID 7973431
Bing Li, Jian-Rong Wang, Yan-Lan Ma
Bowel sounds and monitoring gastrointestinal motility in critically ill patients.
Clin Nurse Spec. 2012 Jan-Feb;26(1):29-34. doi: 10.1097/NUR.0b013e31823bfab8.
Abstract/Text PURPOSE: The aims of this study were to determine whether bowel sounds auscultation is necessary in critically ill patients and to forecast the prospect of bowel sounds as a monitoring measurement in the intensive care unit (ICU).
BACKGROUND: It has been suggested recently that bowel sounds are not an objective indicator of bowel motility and that auscultation should be abandoned. This has led to confusion as to whether bowel sounds auscultation should be continued in the ICU.
DESCRIPTION OF THE PROJECT: A literature review of articles about bowel sounds and monitoring gastrointestinal motility in critically ill patients was conducted.
OUTCOME: At present, there are no more suitable indicators for bedside monitoring of bowel function and motility than bowel sounds. Although they lack objectivity, bowel sounds give a lot of useful information about gastrointestinal motility. The problems are how to improve practice and assessment standards and enhance the precision of auscultation devices.
CONCLUSION: Bowel sounds auscultation is necessary in the ICU. Effective application in critically ill patients requires reasonable practice and precise instrumentation.

Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
PMID 22146271
Yuqi Gu, Hyun Ja Lim, Michael A J Moser
How useful are bowel sounds in assessing the abdomen?
Dig Surg. 2010;27(5):422-6. doi: 10.1159/000319372. Epub 2010 Oct 15.
Abstract/Text BACKGROUND: The purpose of our study is to determine the accuracy of bowel sounds in the diagnosis of ileus and bowel obstruction.
METHODS: Healthy volunteers (n = 10) and patients with radiologically or laparotomy confirmed small bowel obstruction (n = 9) and ileus (n = 7) were enrolled. Two 30-second recordings from each subject were obtained using an electronic stethoscope. Study physicians (n = 20) were then presented with 43 recordings in blinded fashion and were asked whether each was from a normal subject or from a subject with bowel obstruction or ileus.
RESULTS: Physicians arrived at the correct diagnosis a median of 30 times out of 43 (69.8%). Intra-observer variation (κ = 0.72, agreement 81.3%) and intra-subject variation (κ = 0.63, agreement 78.7%) were very good. Bowel sounds from subjects with ileus and normal bowel sounds were correctly identified most of the time (84.5 and 78.1%, respectively). Bowel sounds from patients with obstruction were correctly identified only 42.1% of the time, but if a physician believed he or she was hearing a bowel obstruction, this had a strong positive predictive value (PPV, 72.7%).
CONCLUSION: Our results suggest that the auscultation of bowel sounds is useful, especially in detecting ileus. The diagnosis of obstruction had a high PPV.

Copyright © 2010 S. Karger AG, Basel.
PMID 20948217
Heather Baid
A critical review of auscultating bowel sounds.
Br J Nurs. 2009 Oct 8-21;18(18):1125-9.
Abstract/Text Auscultation (listening for bowel sounds) is part of an abdominal physical assessment and is performed to determine whether normal bowel sounds are present. This article evaluates the technique involved in listening for bowel sounds and the significance of both normal and abnormal auscultation findings. Review of the relevant literature reveals conflicting information and a lack of available research on the topic of auscultating bowel sounds. The clinical significance of auscultation findings when there is no evidence base to support the practice of listening for bowel sounds is explored by further analysis of the literature and reflection by the author on the teaching she received and her own personal practice.

PMID 19966732
T Suzuki, H Uchida, K Watanabe, H Kashima
Minimizing antipsychotic medication obviated the need for enema against severe constipation leading to paralytic ileus: a case report.
J Clin Pharm Ther. 2007 Oct;32(5):525-7. doi: 10.1111/j.1365-2710.2007.00843.x.
Abstract/Text OBJECTIVE: To report the usefulness of antipsychotic dose-reduction for avoiding paralytic ileus in a patient with chronic schizophrenia and comorbid dementia.
CASE SUMMARY: A 65-year-old in-patient developed severe paralytic ileus warranting a transfer to the general hospital. Constipation was very troublesome and he often needed enema to prevent intestinal obstruction. He had originally been treated with 24 mg of bromperidol, which was reduced to 4 mg, and other psychotropic treatments were simultaneously simplified. As a result, bowel habits improved and enema is now only rarely necessary. Constipation is a frequent adverse effect of antipsychotics and adjunctive psychotropics, which can be severe and may lead to life-threatening paralytic ileus. Dose-reduction obviated a necessity of enema against persistent constipation, while the patient's mental status remained under control. Assessment using the Naranjo probability scale revealed a definite causal relationship.
DISCUSSION: With an increasing number of elderly patients with schizophrenia, more cases of severe gastrointestinal motility problems from antipsychotic medication are to be expected. In this patient population dose-reduction of antipsychotics and simplification of concomitant psychotropics should be seriously considered.

PMID 17875120
Fausto Catena, Salomone Di Saverio, Michael D Kelly, Walter L Biffl, Luca Ansaloni, Vincenzo Mandalà, George C Velmahos, Massimo Sartelli, Gregorio Tugnoli, Massimo Lupo, Stefano Mandalà, Antonio D Pinna, Paul H Sugarbaker, Harry Van Goor, Ernest E Moore, Johannes Jeekel
Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery.
World J Emerg Surg. 2011 Jan 21;6:5. doi: 10.1186/1749-7922-6-5. Epub 2011 Jan 21.
Abstract/Text BACKGROUND: There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.
METHODS: A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.
RECOMMENDATIONS: In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

PMID 21255429
Hideo Yasunaga, Hiroaki Miyata, Hiromasa Horiguchi, Kazuaki Kuwabara, Hideki Hashimoto, Shinya Matsuda
Effect of the Japanese herbal kampo medicine dai-kenchu-to on postoperative adhesive small bowel obstruction requiring long-tube decompression: a propensity score analysis.
Evid Based Complement Alternat Med. 2011;2011:264289. doi: 10.1155/2011/264289. Epub 2011 Mar 31.
Abstract/Text Adhesive small bowel obstruction (ASBO) is an adverse consequence of abdominal surgery. Although the Kampo medicine Dai-kenchu-to is widely used in Japan for treatment of postoperative ASBO, rigorous clinical studies for its use have not been performed. In the present retrospective observational study using the Japanese diagnosis procedure combination inpatient database, we selected 288 propensity-score-matched patients with early postoperative ASBO following colorectal cancer surgery, who received long-tube decompression (LTD) with or without Dai-kenchu-to administration. The success rates of LTD were not significantly different between Dai-kenchu-to users and nonusers (84.7% versus 78.5%; P = .224), while Dai-kenchu-to users showed a shorter duration of LTD (8 versus 10 days; P = .012), shorter duration between long-tube insertion and discharge (23 versus 25 days; P = .018), and lower hospital charges ($23,086 versus $26,950; P = .018) compared with Dai-kenchu-to nonusers. In conclusion, the present study suggests that Dai-kenchu-to is effective for reducing the duration of LTD and saving costs.

PMID 21584269
G R Schmutz, A Benko, L Fournier, J M Peron, E Morel, L Chiche
Small bowel obstruction: role and contribution of sonography.
Eur Radiol. 1997;7(7):1054-8. doi: 10.1007/s003300050251.
Abstract/Text The purpose of this study was to determine whether sonography provides additional clinical information in patients suspected of small bowel (SB) obstruction. During a period of 30 months, in a prospective setting, we evaluated with sonography 123 patients suspected of SB obstruction. Sonographic examinations of the entire abdomen were performed with state-of-the-art, real-time, grey-scale equipment. Fourteen patients were labelled 'gassy' and no added information was provided following abdominal ultrasound. Sonography confirmed the SB obstruction in 82 cases with 5 false positives, resulting in a specificity of 82.1 %. Sonographic examinations were negative in 27 cases with 4 false negatives and a sensitivity of 95 %. The accuracy was 91.7 % when the 'gassy' patients were excluded and 81.3 % overall. The aetiology of the ileus was detected by sonography in 13 cases of paralytic ileus (54.1 %) and in 57 cases of mechanical ileus (71.4 %). It is concluded that ultrasound, which is a non-invasive, portable and even bedside imaging procedure, appears accurate in confirming a SB obstruction and in determining the aetiology of SB obstruction.

PMID 9265673
Christophe Trésallet, Nicolas Lebreton, Benoît Royer, Pierre Leyre, Gaelle Godiris-Petit, Fabrice Menegaux
Improving the management of acute adhesive small bowel obstruction with CT-scan and water-soluble contrast medium: a prospective study.
Dis Colon Rectum. 2009 Nov;52(11):1869-76. doi: 10.1007/DCR.0b013e3181b35c06.
Abstract/Text PURPOSE: Adhesive small bowel obstruction is usually managed nonoperatively, but there is still debate over the optimal duration of nonoperative management and the factors that predict failure of medical treatment. The aim of this study was to evaluate an algorithm using CT-scans and Gastrografin in the management of small bowel obstruction.
METHODS: In a prospective study, each patient admitted for small bowel obstruction underwent a physical examination, a plain film, and a CT-scan evaluation. Patients underwent emergency surgical exploration when bowel ischemia was suspected. Other patients received oral Gastrografin, and a second plain abdominal radiograph was done after 12 hours. In patients with clinical improvement, the nasogastric tube was removed and an immediate liquid diet was resumed. Other patients were referred for surgery.
RESULTS: In total, 118 patients with 123 episodes of small bowel obstruction were included. Thirty-six (29%) required immediate surgery because they presented clinical characteristics of bowel ischemia (36/36; 100%) or a defect in vascularization of the small bowel on CT-scan (5/36; 14%). The 87 remaining patients were managed nonoperatively, of which 28 deteriorated and were referred for surgery. The 59 other patients showed clinical improvement.
CONCLUSION: This study demonstrated the diagnostic role of Gastrografin(R) in discriminating between partial and complete small bowel obstruction. CT-scans were disappointing in their ability to predict the necessity of emergent laparotomies. We therefore recommend the use of Gastrografin(R) in adhesive small bowel obstruction patients who do not have clinical evidence of bowel ischemia. CT-scans should not be routinely performed in the decision-making process except when clinical history, physical examination, and plain film are not conclusive for small bowel obstruction diagnosis.

PMID 19966635
A Hair, C Paterson, P J O'Dwyer
Diagnosis of a femoral hernia in the elective setting.
J R Coll Surg Edinb. 2001 Apr;46(2):117-8.
Abstract/Text UNLABELLED: A femoral hernia accounts for approximately 5-10% of all groin hernias in adults. Misdiagnosis in children, in whom the condition is rare, has been well recognised and documented. The aim of this study was to assess the accuracy of diagnosis in an adult population.
METHODS: An analysis of 379 patients with a groin hernia, presenting electively to a University Department of Surgery and entered into a prospective clinical trial.
RESULTS: A femoral hernia was confirmed at operation in 12 (3%) patients while a further 4 had a preoperative diagnosis of a femoral hernia. The correct diagnosis of a femoral hernia was made in only 3 cases by general practitioners and in only 6 by surgical staff of all grades.
CONCLUSION: These data suggest that medical staff of all grades may be poor at diagnosing a femoral hernia and a change in the way we are taught to differentiate between femoral and inguinal hernia needs to be considered.

PMID 11329740
L Laine
Management of acute colonic pseudo-obstruction.
N Engl J Med. 1999 Jul 15;341(3):192-3. doi: 10.1056/NEJM199907153410309.
Abstract/Text
PMID 10403858

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから