今日の臨床サポート

筋性防御

著者: 矢吹拓 国立病院機構栃木医療センター 内科

監修: 大滝純司 東京医科大学 医学教育学 総合診療科

著者校正済:2021/10/27
現在監修レビュー中
参考ガイドライン:
  1. 日本腹部救急医学会・日本プライマリ・ケア連合学会・日本医学放射線学会・日本産科婦人科学会・日本血管外科学会:急性腹症ガイドライン 2015The Practice Guidelines for Primary Care of Acute Abdomen 2015

概要・推奨   

  1. 急性腹症の原因で注意すべきは、①感染による腹膜炎(虫垂炎、胆嚢炎など)、②臓器(虫垂、上部下部消化管)穿孔、③臓器虚血(腸閉塞、動脈閉塞等)である。
  1. 筋性防御を呈するなど腹部症状の強い患者では、鎮痛薬投与が勧められる(推奨度1)。
  1. 腹膜炎を疑う患者では、腹部診察で筋強直、筋性防御、腹壁圧痛テストを確認することが勧められる(推奨度1)。
  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
  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
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:
矢吹拓 : 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]

改訂のポイント:
  1. 定期レビューを行い、推奨度や文章表現など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. 筋性防御(guarding)は、腹部触診時に腹筋の緊張によって抵抗が発生する身体所見である。随意的な抵抗と不随意的な抵抗がある。
  1. 随意的な抵抗は不安や緊張によるもので病的意義は乏しく、不随意的な抵抗は内臓疾患の炎症が腹壁まで及び腹膜炎を呈していることを裏づける身体所見である。
  1. 筋性防御は腹膜炎に対して比較的特異度が高く、陽性尤度比は2.6との報告がある[1]。所見が陽性の場合は、虫垂炎、 消化管穿孔 、胆嚢炎腸閉塞、婦人科疾患などの腹膜炎を来す疾患を念頭に、バイタル・全身状態に注意しつつ速やかに原因精査、治療を進めていく必要がある。
  1. まれではあるが、強い腹膜炎の結果、板状硬と表現されるような持続的な腹筋収縮を呈することがある。これを筋強直(rigidity)と呼び、やはり腹膜炎を示唆する所見である。
問診・診察のポイント  
  1. 筋性防御は腹膜炎の可能性を示唆する身体所見である。多くの患者は腹痛を訴えるため、問診は「痛み」について詳細に聴取する必要がある。

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: G B Markle
雑誌名: Am J Surg. 1973 Jun;125(6):721-2.
Abstract/Text
PMID 4710195  Am J Surg. 1973 Jun;125(6):721-2.
著者: D H Bennett, L J Tambeur, W B Campbell
雑誌名: BMJ. 1994 May 21;308(6940):1336.
Abstract/Text
PMID 8019222  BMJ. 1994 May 21;308(6940):1336.
著者: Alan Dugdale
雑誌名: Aust Fam Physician. 2008 Jan-Feb;37(1-2):8.
Abstract/Text
PMID 18303617  Aust Fam Physician. 2008 Jan-Feb;37(1-2):8.
著者: B J Brewer, G T Golden, D C Hitch, L E Rudolf, S L Wangensteen
雑誌名: Am J Surg. 1976 Feb;131(2):219-23.
Abstract/Text In the majority of patients in this series of 1,000, acute abdominal pain was due to conditions that required neither surgical intervention nor hospitalization. Eleven of the 1,000 patients had an early missed diagnosis in the emergency clinic for which a subsequent operation was needed, and twenty underwent an operation which subsequent diagnosis showed was not required. All false-negative evaluations occurred in patients with early appendicitis or small bowel obstruction. Most false-positive results were due to acute infections of the female genitourinary tract in patients operated on to exclude appendicitis or a tubo-ovarian abscess. The following factors help identify the high risk patient with an acute surgical abdomen: (1) pain for less than 48 hours; (2) pain followed by vomiting; (3) guarding and rebound tenderness on physical examination; (4) advanced age; (5) a prior surgical procedure. The presence of these features demands careful evaluation and a liberal policy of admission and observation. White blood cell counts, body temperature, and abnormal abdominal roentgenograms may add confirmatory evidence but are not particularly helpful as screening devices.

PMID 1251963  Am J Surg. 1976 Feb;131(2):219-23.
著者: J Golledge, A P Toms, I J Franklin, M W Scriven, R B Galland
雑誌名: Ann R Coll Surg Engl. 1996 Jan;78(1):11-4.
Abstract/Text The aim of this study was to evaluate the accuracy of different methods of demonstrating right iliac fossa peritonism in appendicitis. The methods used were cat's eye symptom (pain on going over a bump in the road), cough sign, right iliac fossa tenderness, percussion tenderness, rebound tenderness and guarding. A series of 100 consecutive patients with a median age of 25 years (range 4-81 years), presenting with right iliac fossa pain were studied prospectively; the male:female ratio was 39:61. In all, 58 patients underwent operation, 44 had appendicitis confirmed on histology. Fourteen patients had a normal appendix removed; 11 were women aged between 16 and 45 years. Cat's eye symptom and cough sign were sensitive indicators of appendicitis (sensitivity 0.80 and 0.82, respectively), but were not specific (specificity 0.52 and 0.50, respectively) and therefore inaccurate (accuracy 64%). Percussion tenderness was less sensitive (sensitivity 0.57) but more specific (specificity 0.86). Rebound tenderness proved to be sensitive (sensitivity 0.82), specific (specificity 0.89) and accurate (accuracy 86%). Thus, rebound tenderness had a positive predictive value of 86% compared with 56% and 57% for cough sign and cat's eye symptom, respectively. In the difficult diagnostic group of young women, the positive predictive value of rebound tenderness was 88% compared with 58% and 56% for cat's eye symptom and cough sign. Appendicitis remains a difficult diagnosis, particularly in young women. Rebound tenderness still has an important role to play in clinical assessment.

PMID 8659965  Ann R Coll Surg Engl. 1996 Jan;78(1):11-4.
著者: R E Andersson, A P Hugander, S H Ghazi, H Ravn, S K Offenbartl, P O Nyström, G P Olaison
雑誌名: World J Surg. 1999 Feb;23(2):133-40.
Abstract/Text The clinical diagnosis of appendicitis needs to be improved, as up to 40% of explorations for suspected appendicitis are unnecessary. The use of body temperature and laboratory examinations as diagnostic aids in the management of these patients is controversial. The diagnostic power of these variables compared to that of the disease history and clinical findings is not well studied. In this study we prospectively assessed and compared the diagnostic value of 21 elements of the history, clinical findings, body temperature, and laboratory examinations in 496 patients with suspected appendicitis. The diagnostic value of each variable was compared from the area under the receiver operating characteristic (ROC) curve and the likelihood ratios (LR). Logistic regression was used to analyze the diagnostic value of a combination of variables and to analyze independent relations. No single variable had sufficiently high discriminating or predicting power to be used as a true diagnostic test. The inflammatory variables (temperature, leukocyte and differential white blood cell (WBC) counts, C-reactive protein) had discriminating and predicting powers similar to those of the clinical findings (direct and rebound abdominal tenderness and guarding). Anorexia, nausea, and right-sided rectal tenderness had no diagnostic value. The leukocyte and differential WBC counts, C-reactive protein, rebound tenderness, guarding, and gender were independent predictors of appendicitis with a combined ROC area of 0. 93 for appendicitis. This showed that inflammatory variables contain important diagnostic information, especially with advanced appendicitis. They should therefore always be included in the diagnostic workup in patients with suspected appendicitis.

PMID 9880421  World J Surg. 1999 Feb;23(2):133-40.
著者: J Berry, R A Malt
雑誌名: Ann Surg. 1984 Nov;200(5):567-75.
Abstract/Text In an analysis of the first 72 cases treated after the formulation of the appendicitis syndrome in 1886 compared with the experience from 1929-1959 and with 307 randomly selected recent cases, the major therapeutic trend has been an emphasis on appendectomy before perforation and abscess formation occur. The rate of infection nonetheless remains approximately 17%. Although the overall mortality rate has declined from 26% overall (40% for surgery) to 0.8%, the current rate of perforation is 28%, with a diagnostic accuracy of 82%. Among 13,848 patients from several reports the perforation rate increases linearly with diagnostic accuracy; therefore, a balance must be sought. Delay awaiting a diagnosis is a major determinant of perforation, but diagnostic aids are of limited help. Clinical acuity and prudent decisiveness are the keys to proper action.

PMID 6385879  Ann Surg. 1984 Nov;200(5):567-75.
著者: J M Dixon, R A Elton, J B Rainey, D A Macleod
雑誌名: BMJ. 1991 Feb 16;302(6773):386-8.
Abstract/Text OBJECTIVE: To determine whether rectal examination provides any diagnostic information in patients admitted to hospital with pain in the right lower quadrant of the abdomen.
DESIGN: Casualty officer or surgical registrar recorded symptoms and signs on admission on detailed forms. Final diagnosis was noted on discharge from hospital.
SETTING: District general hospital.
PATIENTS: 1204 Consecutive patients admitted to hospital with pain in the right lower quadrant of the abdomen as their major complaint; 1028 had a rectal examination on admission.
MAIN OUTCOME MEASURES: Odds ratio for each symptom and sign related to final diagnosis. Results of multiple logistic regression analysis for acute appendicitis.
RESULTS: Right sided rectal tenderness, present in 309 of those examined, was more common in patients with acute appendicitis (odds ratio 1.34, p less than 0.05). This odds ratio was considerably less than that for other clinical signs--namely, tenderness in the right lower quadrant (odds ratio 5.09), rebound tenderness (3.34), guarding (3.07), and muscular rigidity in the abdomen (5.03). In the logistic regression analysis of patients with acute appendicitis, when allowance was made for the presence or absence of rebound tenderness, rectal tenderness on the right lost its significance. Six patients had masses palpable rectally, of which three were palpable on abdominal examination; the other three patients had acute appendicitis. No other unexpected diagnoses were established, and no useful additional diagnostic information was obtained by routine rectal examination.
CONCLUSION: If patients presenting with pain in the right lower quadrant of the abdomen are tested for rebound tenderness then rectal examination does not give any further diagnostic information.

PMID 2004144  BMJ. 1991 Feb 16;302(6773):386-8.
著者: M Y Alshehri, A Ibrahim, N Abuaisha, T Malatani, S Abu-Eshy, S Khairulla, K Bahamdan
雑誌名: East Afr Med J. 1995 Aug;72(8):504-6.
Abstract/Text This is a prospective study on 123 randomly selected patients admitted with the diagnosis of acute appendicitis. The value of rebound tenderness as a clinical diagnostic tool was statistically compared to those of some other physical signs; namely guarding, rigidity and Rovsing's sign. Rebound tenderness was found to carry the highest sensitivity (94.7%), negative predictive value (81.3%), reliability (49.1%), and association with histological diagnosis (P < 0.05). However, its specificity and positive predictive value was not significantly different from those of other physical signs. It is concluded that, in contradistinction to some previously published reports, our study emphasizes the role of rebound tenderness in the clinical diagnosis of acute appendicitis.

PMID 7588144  East Afr Med J. 1995 Aug;72(8):504-6.
著者: J R Staniland, J Ditchburn, F T De Dombal
雑誌名: Br Med J. 1972 Aug 12;3(5823):393-8.
Abstract/Text This paper presents the clinical features of 600 patients suffering from abdominal pain of acute onset and admitted to either the General Infirmary or St. James's Hospital, Leeds. The survey was initially retrospective, but later put on a prospective basis. Roughly two-thirds of these 600 patients presented a "typical" picture of the disease with which they presented, while the remaining third presented one or more atypical features. Since other prospective studies have indicated that the diagnostic accuracy of a group of clinicians in respect of the acute abdomen is roughly 65% it is tentatively suggested (a) that clinical diagnosis contains a large element of "pattern-matching," and (b) that such a policy can be expected to be ineffective in roughly one-third of all cases of acute abdominal pain.

PMID 4506871  Br Med J. 1972 Aug 12;3(5823):393-8.
著者: R J Nauta, C Magnant
雑誌名: Am J Surg. 1986 Jun;151(6):746-8.
Abstract/Text In-hospital observation of patients with abdominal pain in the right lower quadrant has been suggested as a means of improving diagnostic accuracy and of decreasing the incidence of negative laparotomy. An analysis of 97 patients brought to the operating room over a 12 month period in a university hospital suggests that patients with the classic pattern of migratory pain, rebound tenderness, and an increased number of metamyelocytes in the peripheral blood smear most likely require operation. Leukocytosis alone was not predictive of a surgically remediable disease, which suggests that a period of observation in patients with atypical patterns of pain and no peritoneal signs is a sound treatment plan.

PMID 3717506  Am J Surg. 1986 Jun;151(6):746-8.
著者: D W Gray, J M Dixon, G Seabrook, J Collin
雑誌名: Ann R Coll Surg Engl. 1988 Jul;70(4):233-4.
Abstract/Text Pain arising from the abdominal wall has been implicated as a cause of non-specific abdominal pain (NSAP), and the presence of abdominal wall tenderness (AWT) has been proposed as an accurate diagnostic test for NSAP. One hundred and fifty eight patients admitted to hospital with abdominal pain were tested for the presence of positive AWT. In 53 patients the final diagnosis was appendicitis and positive AWT was found in five. Thirty eight patients were found to have a variety of other recognised pathological diagnoses, none of whom had a positive AWT. In 67 patients a diagnosis of NSAP was made in the absence of other pathological diagnosis, 19 of whom had positive AWT, which was significantly different from the other diagnostic groups. This study confirms the presence of AWT in up to 28% of patients with NSAP, and suggests that testing for AWT is of value in patients with abdominal pain, although a positive AWT is not as accurate a predictor of NSAP as previously reported.

PMID 2970820  Ann R Coll Surg Engl. 1988 Jul;70(4):233-4.
著者: H Thomson, D M Francis
雑誌名: Lancet. 1977 Nov 19;2(8047):1053-4.
Abstract/Text 120 patients admitted as an emergency with localised abdominal pain were tested for abdominal-wall tenderness. Of the 24 patients with a positive test only 1 had a detectable intra-abdominal cause. In the remaining 23 no reason for the pain could be found.

PMID 72957  Lancet. 1977 Nov 19;2(8047):1053-4.
著者: Michael A Darracq
雑誌名: Am J Emerg Med. 2020 Dec;38(12):2759.e1-2759.e4. doi: 10.1016/j.ajem.2020.05.077. Epub 2020 May 27.
Abstract/Text BACKGROUND: Carnett's sign (CAR) and Closed Eye sign (CE) have been suggested for use in the emergency department setting in the management of abdominal pain. The present study sought to determine the sensitivity/specificity of CAR and CE for pathological CT findings as a primary outcome and for subsequent hospital admission or surgical intervention as secondary outcomes in a community emergency department setting.
METHODS: A convenience sample of adults (≥18 y) presenting with acute (<48 h) nontraumatic and non-postoperative abdominal pain determined by treating provider to warrant CT imaging were eligible for enrollment. Treating providers completed a datasheet describing physical examination findings prior to CT imaging.
RESULTS: 320 patients were enrolled. 245/320 (76.5%) of enrolled patients had findings on CT Imaging. CAR+ was recorded in 145 and CAR- in 175 patients. CE+ was in 187 and CAR- in 133 patients. Sensitivity and specificity of CAR- for hospital admission was 42.2% and 38.9% and for surgery-44.8% and 43.1%. Sensitivity and specificity of CE- for hospital admission was 28% and 51.6% and for surgery-25.9% and 55%. CAR+ patients were more likely to be admitted or undergo surgery as compared to CAR-. CE+ patients were more likely to be admitted or undergo surgery as compared to CAR-. There were no differences in frequency of pathological CT findings between CAR+ and CAR- or CE+ and CE- patients.
CONCLUSION: CAR and CE are neither sufficiently sensitive nor specific for use in the emergency department setting. CT findings were equally likely in CAR+ and CAR- patients. CT Findings were also equally likely in CE+ and CE- patients.

Copyright © 2020 Elsevier Inc. All rights reserved.
PMID 32507573  Am J Emerg Med. 2020 Dec;38(12):2759.e1-2759.e4. doi: 1・・・
著者: R J Guy, P Barker
雑誌名: Ann R Coll Surg Engl. 1996 May;78(3 ( Pt 1)):234-5.
Abstract/Text
PMID 8779523  Ann R Coll Surg Engl. 1996 May;78(3 ( Pt 1)):234-5.
著者: H Oguzturk, D Ozgur, M G Turtay, C Kayaalp, S Yilmaz, M Dogan, E Pamukcu
雑誌名: Eur Rev Med Pharmacol Sci. 2012 Dec;16(14):1983-8.
Abstract/Text OBJECTIVES: To examine the effects of early administration of analgesics in patients with acute abdominal pain on pain severity, abdominal findings and diagnostic accuracy.
METHODS: 210 patients with non-traumatic acute abdominal pain lasting less than 72 hours were enrolled to this trial. Patients were administrated by placebo, tramadol (1 mg/kg), or paracetamol (15 mg/kg) randomly after the first evaluation of pain severity scores (standard 100 mm visual analog scale) and abdominal findings (rebound, rigidity, tenderness). After 20 and 40 minutes of administrations, pain severity scores and abdominal findings were re-examined. Complete blood count, electrocardiography, plain abdominal x-ray, urine analysis and abdominal ultrasound were used for the initial diagnosis. The final diagnoses were decided after re-examinations, biochemical blood analysis, abdominal computed tomography in all patients and consultations or other diagnostic methods when necessary.
RESULTS: There were 70 patients in each group. Baseline pain severity scores and abdominal findings were similar at all groups. After 20 minutes, pain severity scores were decreased in tramadol and paracetamol groups compared with the placebo group as 55% and 45% vs 1% respectively (p < 0.001). After 40 minutes, decreases on pain severity scores were more significant at treatment groups, 67% and 60% vs 0 (p < 0.001). When compared to placebo tramadol and paracetamol increased the new onset or worsening nausea or vomiting. There was no difference on abdominal findings among the groups after 20 and 40 minutes examinations. Diagnostic accuracy of tramadol, paracetamol and placebo groups were 96%, 94% and 94% respectively.
CONCLUSIONS: Early administration of tramadol and paracetamol provided effective pain relief in patients with non-traumatic acute abdominal pain and those administrations did not interfere with diagnosis.

PMID 23242726  Eur Rev Med Pharmacol Sci. 2012 Dec;16(14):1983-8.
著者: G Savoia, F Coluzzi, C Di Maria, F Ambrosio, F Della Corte, R Oggioni, A Messina, A Costantini, C Launo, C Mattia, F Paoletti, C Lo Presti, L Bertini, A V Peduto, F De Iaco, F Schiraldi, F Bussani, L De Vito, G Giagnorio, F Marinangeli, S Coaccioli, C Aurilio, F Valenti, C Bonetti, A Piroli, A Paladini, A Ciccozzi, T Matarazzo, G Marraro, A Paolicchi, A Martino, E De Blasio, E Cerchiari, G Radeschi
雑誌名: Minerva Anestesiol. 2015 Feb;81(2):205-25. Epub 2014 May 22.
Abstract/Text BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment.
METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting.
RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness.
CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

PMID 24847740  Minerva Anestesiol. 2015 Feb;81(2):205-25. Epub 2014 Ma・・・
著者: C Falch, D Vicente, H Häberle, A Kirschniak, S Müller, A Nissan, B L D M Brücher
雑誌名: Eur J Pain. 2014 Aug;18(7):902-13. doi: 10.1002/j.1532-2149.2014.00456.x. Epub 2014 Jan 22.
Abstract/Text Appropriate pain therapy prior to diagnosis in patients with acute abdominal pain remains controversial. Several recent studies have demonstrated that pain therapy does not negatively influence either the diagnosis or subsequent treatment of these patients; however, current practice patterns continue to favour withholding pain medication prior to diagnosis and surgical treatment decision. A systematic review of PubMed, Web-of-Science and The-Cochrane-Library from 1929 to 2011 was carried out using the key words of 'acute', 'abdomen', 'pain', 'emergency' as well as different pain drugs in use, revealed 84 papers. The results of the literature review were incorporated into six sections to describe management of acute abdominal pain: (1) Physiology of Pain; (2) Common Aetiologies of Abdominal Pain; (3) Pre-diagnostic Analgesia; (4) Pain Therapy for Acute Abdominal Pain; (5) Analgesia for Acute Abdominal Pain in Special Patient Populations; and (6) Ethical and Medico-legal Considerations in Current Analgesia Practices. A comprehensive algorithm for analgesia for acute abdominal pain in the general adult population was developed. A review of the literature of common aetiologies and management of acute abdominal pain in the general adult population and special patient populations seen in the emergency room revealed that intravenous administration of paracetamol, dipyrone or piritramide are currently the analgesics of choice in this clinical setting. Combinations of non-opioids and opioids should be administered in patients with moderate, severe or extreme pain, adjusting the treatment on the basis of repeated pain assessment, which improves overall pain management.

© 2014 European Pain Federation - EFIC®
PMID 24449533  Eur J Pain. 2014 Aug;18(7):902-13. doi: 10.1002/j.1532-・・・
著者: Stephen H Thomas, William Silen, Farah Cheema, Andrew Reisner, Sohail Aman, Joshua N Goldstein, Alan M Kumar, Thomas O Stair
雑誌名: J Am Coll Surg. 2003 Jan;196(1):18-31.
Abstract/Text BACKGROUND: Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain.
STUDY DESIGN: The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses.
RESULTS: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings.
CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain.

Copyright 2003 by the American College of Surgeons
PMID 12517545  J Am Coll Surg. 2003 Jan;196(1):18-31.
著者: S Pace, T F Burke
雑誌名: Acad Emerg Med. 1996 Dec;3(12):1086-92.
Abstract/Text OBJECTIVE: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.
METHODS: Prospective, double-blind, placebo-controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60,000 visits. Patients > or = 18 years old who had abdominal pain for < or = 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.
RESULTS: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED; 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 +/- 2.8 cm, than it did for the NS group, 0.8 +/- 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 +/- 0.5 mL vs 1.8 +/- 0.4 mL (p < 0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.
CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

PMID 8959160  Acad Emerg Med. 1996 Dec;3(12):1086-92.
著者: E John Gallagher, David Esses, Conroy Lee, Michael Lahn, Polly E Bijur
雑誌名: Ann Emerg Med. 2006 Aug;48(2):150-60, 160.e1-4. doi: 10.1016/j.annemergmed.2005.11.020.
Abstract/Text STUDY OBJECTIVE: Administration of analgesia to patients with acute abdominal pain is controversial. We test the hypothesis that morphine given to emergency department (ED) patients with acute abdominal pain will reduce discomfort and improve clinically important diagnostic accuracy.
METHODS: Pain was measured with a standard 0- to 100-mm visual analog scale. ED patients with acute abdominal pain were randomized in a double-blind fashion to 0.1 mg/kg intravenous morphine or placebo. The primary endpoint was the difference between the 2 study arms in clinically important diagnostic accuracy. Clinically important diagnostic accuracy was defined a priori by its complement, clinically important diagnostic error, using 2 independent, blinded investigators to identify any discordance between the provisional and final diagnoses that might adversely affect the patient's health status. The provisional diagnosis was provided by an ED attending physician, who examined the patient only once, 15 minutes after administration of the study agent. The final diagnosis was obtained through follow-up at least 6 weeks after the index ED visit.
RESULTS: We randomized 160 patients, of whom 153 patients were available for analysis, 78 patients in the morphine group and 75 patients in the placebo group. Baseline features were similar in both groups, including initial median visual analog scale scores of 98 mm and 99 mm. The median decrease in visual analog scale score at 15 minutes was 33 mm in the morphine group and 2 mm in the placebo group. There were 11 instances of diagnostic discordance in each group, for a clinically important diagnostic accuracy of 86% (67/78) in the morphine group and 85% (64/75) in the placebo group. The difference in clinically important diagnostic accuracy between the 2 groups was 1% (95% confidence interval [CI] -11% to 12%). Analysis by efficacy and intention to treat yielded similar results. Kappa for interobserver concordance in classification of clinically important diagnostic accuracy was 0.94 (95% CI 0.79 to 1.00). No patients required naloxone.
CONCLUSION: Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our data are most consistent with the inference that morphine safely provides analgesia without impairing clinically important diagnostic accuracy.

PMID 16953529  Ann Emerg Med. 2006 Aug;48(2):150-60, 160.e1-4. doi: 10・・・
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: Carlos Manterola, Manuel Vial, Javier Moraga, Paula Astudillo
雑誌名: Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. doi: 10.1002/14651858.CD005660.pub3. Epub 2011 Jan 19.
Abstract/Text BACKGROUND: For decades, the indication of analgesia in patients with Acute Abdominal Pain (AAP) has been deferred until the definitive diagnosis has been made, for fear of masking symptoms, generating a change in the physical exploration or obstructing the diagnosis of a disease requiring surgical treatment. This strategy has been questioned by some studies that have shown that the use of analgesia in the initial evaluation of patients with AAP leads to a significant reduction in pain without affecting diagnostic accuracy.
OBJECTIVES: To determine whether the evidence available supports the use of opioid analgesics in the diagnostic process of patients with AAP.
SEARCH STRATEGY: Trials were identified through searches in Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library, issue 2, 2009), MEDLINE (1966 to 2009) and EMBASE (1980 to 2009). A randomised controlled trial (RCT) filter for a MEDLINE search was applied (with appropriate modification for an EMBASE search). Trials also were identified through "related articles". The search was not limited by language or publication status.
SELECTION CRITERIA: All published RCTs which included adult patients with AAP, without gender restriction, comparing any opioids analgesia regimen with the non-use of analgesic before any intervention and independent of the results.
DATA COLLECTION AND ANALYSIS: Two independent reviewers assessed the studies identified via the electronic search. Articles that were relevant and pertinent to the aims of the study were selected and their respective full-text versions were collected for subsequent blinded evaluation. The allocation concealment was considered in particular as an option to diminish the biases.The data collected from the studies were reviewed qualitatively and quantitatively using the Cochrane Collaboration statistical software RevMan 5.0. After performing the meta-analysis, the chi-squared test for heterogeneity was applied. In situations of significant clinical heterogeneity, statistical analyses were not applied to the pool of results. In situations of heterogeneity, the random effect model was used to perform the meta-analysis of the results. A sensitivity analysis was also applied based on the evaluation to the methodological quality of the primary studies.
MAIN RESULTS: Eight studies fulfilled the inclusion criteria. Differences with use of opioid analgesia were verified in variables: Change in the intensity of the pain, change in the patients comfort level.
AUTHORS' CONCLUSIONS: The use of opioid analgesics in the therapeutic diagnosis of patients with AAP does not increase the risk of diagnosis error or the risk of error in making decisions regarding treatment.

PMID 21249672  Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005660. d・・・
著者: J F Simeone, J A Brink, P R Mueller, C Compton, P F Hahn, S Saini, S G Silverman, G Tung, J T Ferrucci
雑誌名: AJR Am J Roentgenol. 1989 Feb;152(2):289-90. doi: 10.2214/ajr.152.2.289.
Abstract/Text The sonographic Murphy sign is defined as the presence of maximal tenderness elicited by direct pressure of the transducer over a sonographically localized gallbladder. The reported prevalence of this sign is more than 95% in patients with acute cholecystitis. In this series of 18 patients with pathologically proved gangrenous cholecystitis, the sonographic Murphy sign was positive in only six (33%). Clinical examination showed a positive Murphy sign in eight patients (44%), diffuse abdominal pain in nine patients (50%), and no pain in one patient (6%). Other sonographic findings included pericholecystic fluid (10), thickening of the gallbladder wall (10), and a dilated gallbladder (five). Our experience suggests that the absence of the Murphy sign increases the possibility of gangrenous cholecystitis in patients with abdominal pain and sonographic findings of cholecystitis.

PMID 2643262  AJR Am J Roentgenol. 1989 Feb;152(2):289-90. doi: 10.22・・・
著者: A Alvarado
雑誌名: Ann Emerg Med. 1986 May;15(5):557-64.
Abstract/Text We conducted a retrospective study of 305 patients hospitalized with abdominal pain suggestive of acute appendicitis. Signs, symptoms, and laboratory findings were analyzed for specificity, sensitivity, predictive value, and joint probability. The total joint probability, the sum of a true-positive and a true-negative result, was chosen as a diagnostic weight indicative of the accuracy of the test. Eight predictive factors were found to be useful in making the diagnosis of acute appendicitis. Their importance, according to their diagnostic weight, was determined as follows: localized tenderness in the right lower quadrant, leukocytosis, migration of pain, shift to the left, temperature elevation, nausea-vomiting, anorexia-acetone, and direct rebound pain. Based on this weight, we devised a practical diagnostic score that may help in interpreting the confusing picture of acute appendicitis.

PMID 3963537  Ann Emerg Med. 1986 May;15(5):557-64.
著者: M Kalan, D Talbot, W J Cunliffe, A J Rich
雑誌名: Ann R Coll Surg Engl. 1994 Nov;76(6):418-9.
Abstract/Text The Alvarado score was assessed as to its accuracy in the preoperative diagnosis of acute appendicitis. A series of 49 consecutive patients was studied prospectively over a period of 9 months in two hospitals (Gateshead and Sunderland). The presence of a high score was found to be an easy and satisfactory aid to early diagnosis of appendicitis in children and men. However, the false-positive rate for appendicitis in women was unacceptably high.

PMID 7702329  Ann R Coll Surg Engl. 1994 Nov;76(6):418-9.
著者: R L Eisenberg, P Heineken, M W Hedgcock, M Federle, H I Goldberg
雑誌名: Ann Surg. 1983 Apr;197(4):464-9.
Abstract/Text In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5%) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinically useful information, large financial savings, and a reduction in radiation exposure.

PMID 6830353  Ann Surg. 1983 Apr;197(4):464-9.
著者: Zina S Kellow, Meaghan MacInnes, David Kurzencwyg, Sapna Rawal, Rehana Jaffer, Bojan Kovacina, Lawrence A Stein
雑誌名: Radiology. 2008 Sep;248(3):887-93. doi: 10.1148/radiol.2483071772.
Abstract/Text PURPOSE: To characterize the utility of abdominal radiography for nontrauma emergency patients in a single-institution setting.
MATERIALS AND METHODS: Following approval from the Director of Professional Services, a retrospective review of radiography and of patient records was conducted for patients who presented to a nontrauma emergency department over a period of 6 months and who were imaged by using abdominal radiography. Only the first radiograph per patient was used for analysis. The interpretations were sorted as normal, nonspecific, or abnormal. The patients' medical records were reviewed to determine whether further imaging was performed (computed tomography, ultrasonography, or upper gastrointestinal imaging) and results were compared with abdominal radiography. Chart reviews were conducted to identify patients in whom abdominal radiography alone influenced treatment.
RESULTS: In 874 patients, interpretation of abdominal radiography was normal in 34% (n = 300), nonspecific in 46% (n = 406), and abnormal in 19% (n = 168). Further imaging was performed for 50% (436) of all patients. Of 300 patients whose abdominal radiography results were normal, 42% (n = 125) had follow-up imaging; 72% (n = 90) of these showed abnormal, 78% (165 of 212) showed nonspecific, and 87% (86 of 99) showed abnormal findings. Of 438 patients who did not undergo follow-up imaging, 75% (n = 327) were discharged. For all indications other than catheter placement, abdominal radiography helped confirm the suspected diagnosis in 2%-8% of cases. In 37 (4%) of 874 patients, abdominal radiography was possibly helpful in changing patient treatment without a follow-up study.
CONCLUSION: Abdominal radiography is often requested; however, its results contribute to patient treatment in a small percentage of cases. With the exception of catheter placement, if a patient requires investigation beyond clinical history, physical examination, and lab results, the emergency physician should be encouraged to request more definitive imaging.

RSNA, 2008
PMID 18710981  Radiology. 2008 Sep;248(3):887-93. doi: 10.1148/radiol.・・・
著者: Khalid S Shreef, Amira Hasan Waly, Sarhan Abd-Elrahman, M A Abd Elhafez
雑誌名: Afr J Paediatr Surg. 2010 Sep-Dec;7(3):163-5. doi: 10.4103/0189-6725.70417.
Abstract/Text BACKGROUND: Acute appendicitis is an important differential diagnosis in children with pain in the right iliac fossa. Some patients have equivocal signs that make the diagnosis difficult. Many patients with suspected acute appendicitis are admitted for observation and finally discharged because they did not have appendicitis. We decided to design this study to investigate whether the Alvarado score could be used by emergency room doctors as a criterion for admission to hospital.
PATIENTS AND METHODS: This is a prospective study comprising 350 patients who attended the emergency department with suspected acute appendicitis in the period from May 2007 to April 2009. All patients were scored by Alvarado score in the emergency department before admission. The Alvarado score is based on three symptoms, three signs and two laboratory findings. The decision for admission and surgery was made independent of the score. The diagnosis of patients who underwent appendicectomy was confirmed by both operative findings and postoperative histopathology.
RESULTS: We studied the Alvarado scores of 350 patients who presented to the emergency department with pain in the right iliac fossa; their age ranged from 8 to 14 years; 182 patients (52%) operated with the aim to treat acute appendicitis, 168 patients (48%) were discharged without surgical intervention and advised to attend the out-patient clinic after 24 hours for re-evaluation. we have found that patients with a low Alvarado score (less than 6) did not have acute appendicitis.
CONCLUSION: Patients with equivocal signs can present a diagnostic challenge and are very often admitted to the surgical department for observation. The Alvarado score can be used as a scoring system that help in taking the decision for admission of cases with suspected acute appendicitis especially by primary healthcare providers.

PMID 20859021  Afr J Paediatr Surg. 2010 Sep-Dec;7(3):163-5. doi: 10.4・・・
著者: Salomone Di Saverio, Mauro Podda, Belinda De Simone, Marco Ceresoli, Goran Augustin, Alice Gori, Marja Boermeester, Massimo Sartelli, Federico Coccolini, Antonio Tarasconi, Nicola De' Angelis, Dieter G Weber, Matti Tolonen, Arianna Birindelli, Walter Biffl, Ernest E Moore, Michael Kelly, Kjetil Soreide, Jeffry Kashuk, Richard Ten Broek, Carlos Augusto Gomes, Michael Sugrue, Richard Justin Davies, Dimitrios Damaskos, Ari Leppäniemi, Andrew Kirkpatrick, Andrew B Peitzman, Gustavo P Fraga, Ronald V Maier, Raul Coimbra, Massimo Chiarugi, Gabriele Sganga, Adolfo Pisanu, Gian Luigi De' Angelis, Edward Tan, Harry Van Goor, Francesco Pata, Isidoro Di Carlo, Osvaldo Chiara, Andrey Litvin, Fabio C Campanile, Boris Sakakushev, Gia Tomadze, Zaza Demetrashvili, Rifat Latifi, Fakri Abu-Zidan, Oreste Romeo, Helmut Segovia-Lohse, Gianluca Baiocchi, David Costa, Sandro Rizoli, Zsolt J Balogh, Cino Bendinelli, Thomas Scalea, Rao Ivatury, George Velmahos, Roland Andersson, Yoram Kluger, Luca Ansaloni, Fausto Catena
雑誌名: World J Emerg Surg. 2020 Apr 15;15(1):27. doi: 10.1186/s13017-020-00306-3. Epub 2020 Apr 15.
Abstract/Text BACKGROUND AND AIMS: Acute appendicitis (AA) is among the most common causes of acute abdominal pain. Diagnosis of AA is still challenging and some controversies on its management are still present among different settings and practice patterns worldwide. In July 2015, the World Society of Emergency Surgery (WSES) organized in Jerusalem the first consensus conference on the diagnosis and treatment of AA in adult patients with the intention of producing evidence-based guidelines. An updated consensus conference took place in Nijemegen in June 2019 and the guidelines have now been updated in order to provide evidence-based statements and recommendations in keeping with varying clinical practice: use of clinical scores and imaging in diagnosing AA, indications and timing for surgery, use of non-operative management and antibiotics, laparoscopy and surgical techniques, intra-operative scoring, and peri-operative antibiotic therapy.
METHODS: This executive manuscript summarizes the WSES guidelines for the diagnosis and treatment of AA. Literature search has been updated up to 2019 and statements and recommendations have been developed according to the GRADE methodology. The statements were voted, eventually modified, and finally approved by the participants to the consensus conference and by the board of co-authors, using a Delphi methodology for voting whenever there was controversy on a statement or a recommendation. Several tables highlighting the research topics and questions, search syntaxes, and the statements and the WSES evidence-based recommendations are provided. Finally, two different practical clinical algorithms are provided in the form of a flow chart for both adults and pediatric (< 16 years old) patients.
CONCLUSIONS: The 2020 WSES guidelines on AA aim to provide updated evidence-based statements and recommendations on each of the following topics: (1) diagnosis, (2) non-operative management for uncomplicated AA, (3) timing of appendectomy and in-hospital delay, (4) surgical treatment, (5) intra-operative grading of AA, (6) ,management of perforated AA with phlegmon or abscess, and (7) peri-operative antibiotic therapy.

PMID 32295644  World J Emerg Surg. 2020 Apr 15;15(1):27. doi: 10.1186/・・・

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