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 総合内科

監修: 大滝純司 東京医科大学 医学教育学 総合診療科

著者校正/監修レビュー済:2016/08/05
患者向け説明資料

概要・推奨   

所見のポイント:
  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診する。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。しかし、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。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。
 
緊急対応
  1. 病歴で、嘔吐・腹痛など腸閉塞を疑う所見があり、聴診で、金属音(high pitched)もしくは、腸蠕動音の低下がみられれば、血液検査、腹部立位単純X線写真、腹部エコー、腹部CTを考慮する。
 
専門医相談のタイミング:
  1. 腸閉塞では、常に開腹術の適応を考える必要があり、外科医との相談が必要である。
閲覧にはご契
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
  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
  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
  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
  1. 閲覧にはご契約が必要となります。閲覧にはご契
  1. 閲覧には
  1. 機械性イレウス(腸閉塞):原因としてヘルニア(鼠径・大腿)癒着性イレウス、腸重積、癌、捻転、異所性子宮内膜症などが考えられる
  1. 閲覧にはご契
  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
  1. 閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲
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
閲覧にはご契
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。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧には
  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
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:
本村和久 : 特に申告事項無し[2021年]
監修:大滝純司 : 特に申告事項無し[2021年]

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. 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]

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
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 

著者: J P Politzer, G Devroede, C Vasseur, J Gerard, R Thibault
雑誌名: 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  Gastroenterology. 1976 Aug;71(2):282-5.
著者: M Eskelinen, J Ikonen, P Lipponen
雑誌名: Scand J Gastroenterol. 1994 Aug;29(8):715-21.
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  Scand J Gastroenterol. 1994 Aug;29(8):715-21.
著者: Bing Li, Jian-Rong Wang, Yan-Lan Ma
雑誌名: 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  Clin Nurse Spec. 2012 Jan-Feb;26(1):29-34. doi: 10.1097・・・
著者: T Suzuki, H Uchida, K Watanabe, H Kashima
雑誌名: 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  J Clin Pharm Ther. 2007 Oct;32(5):525-7. doi: 10.1111/j・・・
著者: 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
雑誌名: 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  World J Emerg Surg. 2011 Jan 21;6:5. doi: 10.1186/1749-・・・
著者: G R Schmutz, A Benko, L Fournier, J M Peron, E Morel, L Chiche
雑誌名: 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  Eur Radiol. 1997;7(7):1054-8. doi: 10.1007/s00330005025・・・
著者: Christophe Trésallet, Nicolas Lebreton, Benoît Royer, Pierre Leyre, Gaelle Godiris-Petit, Fabrice Menegaux
雑誌名: 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  Dis Colon Rectum. 2009 Nov;52(11):1869-76. doi: 10.1007・・・
著者:
雑誌名: Ir Med J. 1975 May 10;68(9):232.
Abstract/Text
PMID 1132974  Ir Med J. 1975 May 10;68(9):232.
著者: L Laine
雑誌名: N Engl J Med. 1999 Jul 15;341(3):192-3. doi: 10.1056/NEJM199907153410309.
Abstract/Text
PMID 10403858  N Engl J Med. 1999 Jul 15;341(3):192-3. doi: 10.1056/NE・・・

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