今日の臨床サポート

経管栄養患者の下痢

著者: 末松篤樹 名古屋第二赤十字病院 総合内科

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正/監修レビュー済:2021/03/03
参考ガイドライン:
  1. 日本静脈経腸栄養学会:静脈経腸栄養ガイドライン 第3版
  1. ESPEN guideline on home enteral nutrition. Clin Nutr. 2020 Jan; 39(1): 5-22.
患者向け説明資料
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:
末松篤樹 : 特に申告事項無し[2021年]
監修:野口善令 : 特に申告事項無し[2021年]

改訂のポイント
  1. 静脈経腸栄養ガイドライン、ESPENガイドラインに基づき、定期レビューを行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 急性疾患であっても、慢性疾患であっても、栄養不良の患者は栄養が良好な患者と比べて、よい転機をとらず、合併症や感染症、必要とする医療資源が増加する。
  1. 経管栄養は一般的に、その簡便さ、安全性、低コスト、粘膜バリア機能の維持によいことから、経静脈栄養より好まれる。
  1. 重症患者において、下痢は、経管栄養を未施行の患者では6%であるのに比して、経管栄養を施行中の患者では大体15~18%程度の患者に起こる[1][2]
  1. 抗菌薬、プロトンポンプ阻害薬(PPI)、ソルビトールなどの下痢を起こし得る明らかな原因薬剤、基礎疾患による吸収不良、Clostridium difficile(CD)腸炎、経管栄養剤の種類、不適切な投与法が原因となり得る。ただし、経管栄養患者において、下痢が起こる正確な機序はわかっていない。
 
  1. PEG造設後の患者には、留置後のPEG先端の位置を確認することが勧められる。
  1. 胃と腹壁の間に横行結腸が位置する患者では、PEG造設時に結腸を貫通して胃へのチューブ留置が行われることがある。多くの場合、造設後は無症状で経過し、初回のチューブ交換後に結腸内にチューブが留置されると栄養剤が横行結腸へと注入され下痢が出現する。
  1. 初回のPEG交換直後より発生する栄養剤の甘い臭いのする水溶性下痢便が特徴である。
問診・診察のポイント  
 
  1. 抗菌薬、プロトンポンプ阻害薬、ソルビトールなどの下痢を起こし得る明らかな原因薬剤がないか確認する[3][4]
  1. 基礎疾患に炎症性腸疾患、甲状腺機能亢進症といった腸管蠕動運動の亢進や異常を呈する疾患や、糖尿病や強皮症といった腸管蠕動運動の低下による小腸内細菌の増殖を起こす疾患や、乳糖不耐症などの既往歴がないか確認する。

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: J C Montejo
雑誌名: Crit Care Med. 1999 Aug;27(8):1447-53.
Abstract/Text OBJECTIVE: To evaluate the frequency of gastrointestinal complications (GICs) in a prospective cohort of critically ill patients receiving enteral nutrition and to assess its effect on nutrient administration and its relationship to the patient's outcome.
DESIGN: Multicenter, prospective cohort study.
SETTING: Thirty-seven multidisciplinary intensive care units (ICUs) in Spain.
PATIENTS: Prospective cohort of 400 consecutive patients admitted to the ICU and receiving enteral nutrition.
INTERVENTIONS: Noninterventional, follow-up study.
MEASUREMENTS AND MAIN RESULTS: Enteral nutrition-related GICs and their management were defined by consensus before data collection. A set of variables related to enteral nutrition administration and the presence of GICs was recorded. During the 1-month study period, 400 patients were enrolled, and a total of 3,778 enteral feeding days were analyzed. The mean time of enteral nutrition was 9.6+/-0.4 days. Mean elapsed time from ICU admission to the start of enteral feeding was 3.1+/-0.2 days. A total of 265 patients (66.2%) received a standard polymeric formula, and 132 (33.8%) received a disease-specific one. Enteral feeds were administered mainly through a nasogastric tube (91%). One or more GICs were presented by 251 patients (62.8%) during the feeding course. The frequency of each particular GIC was as follows: high gastric residuals, 39%; constipation, 15.7%; diarrhea, 14.7%; abdominal distention, 13.2%; vomiting, 12.2%; and regurgitation, 5.5%. Enteral nutrition withdrawal as a consequence of noncontrollable GICs occurred in 15.2% of patients. The volume ratio (expressed as the ratio between administered and prescribed volumes) was calculated daily and was used as an index of diet administration efficacy. Patients with GICs had a lower volume ratio than did patients without GICs (63.1+/-1.20% vs. 93.3+/-0.3%) (p < .001), a longer length of stay (20.6+/-1.2 vs. 15.2+/-1.3 days) (p < .01), and higher mortality (31% vs. 16.1%) (p < .001).
CONCLUSIONS: The frequency of enteral nutrition-related GICs in critically ill patients is high. High gastric residuals is the most frequent GIC. These complications decreased nutrient intake and, if persistent, could expose the patients to undernutrition. Enteral feeding gastrointestinal intolerance seems to have an evolutive effect in prolonging the ICU stay and increasing patient mortality.

PMID 10470748  Crit Care Med. 1999 Aug;27(8):1447-53.
著者: Vivian Cristine Luft, Mariur Gomes Beghetto, Elza Daniel de Mello, Carísi Anne Polanczyk
雑誌名: Nutrition. 2008 Jun;24(6):528-35. doi: 10.1016/j.nut.2008.02.004. Epub 2008 Apr 15.
Abstract/Text OBJECTIVE: This study examined the risk of diarrhea as a result of providing enteral nutrition in the hospital setting, adjusting for other clinical and therapeutic factors.
METHODS: Adults admitted to a general tertiary care university hospital, in clinical or surgical units, were enrolled in the study between June 2004 and May 2005 and prospectively followed during their hospital stay. For each patient treated with enteral nutrition (n = 302), a comparable non-treated patient from the same ward (who also received antibiotics previously) and was similarly cared for by the same hospital staff was included in the study (n = 302), constituting a double-cohort study. All patients were seen three times per week, on alternating days, until the occurrence of diarrhea or hospital discharge. Cox's regression analyses were applied for adjustments.
RESULTS: The incidence of diarrhea was 18% for patients receiving enteral nutrition and 6% for non-treated patients (P < 0.01). In multivariate analyses, enteral nutrition was independently associated with diarrhea (hazard ratio 2.7, 95% confidence interval 1.6-4.7), even adjusting for age (hazard ratio 1.02, 95% confidence interval 1.00-1.03) and hospitalization during the summer months (hazard ratio 2.4, 95% confidence interval 1.5-3.9). Patients for whom strict adherence to delivery-set washing-and-changing procedures was observed (on >75% of days) presented a lower incidence of diarrhea (6.5% versus 20.3%, P = 0.02; and 5.9% versus 19.8%, P = 0.05, respectively).
CONCLUSION: Providing enteral nutrition to the hospitalized elderly during the summer months is associated with a higher risk of diarrhea. Strategies aimed toward improvement in the quality of enteral nutrition practices should be evaluated to minimize this deleterious clinical outcome.

PMID 18417321  Nutrition. 2008 Jun;24(6):528-35. doi: 10.1016/j.nut.20・・・
著者: ASPEN Board of Directors and the Clinical Guidelines Task Force
雑誌名: JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):1SA-138SA.
Abstract/Text
PMID 11841046  JPEN J Parenter Enteral Nutr. 2002 Jan-Feb;26(1 Suppl):・・・
著者: Robin Bankhead, Joseph Boullata, Susan Brantley, Mark Corkins, Peggi Guenter, Joseph Krenitsky, Beth Lyman, Norma A Metheny, Charles Mueller, Sandra Robbins, Jacqueline Wessel, A.S.P.E.N. Board of Directors
雑誌名: JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):122-67. doi: 10.1177/0148607108330314. Epub 2009 Jan 26.
Abstract/Text
PMID 19171692  JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):122-67・・・
著者: Stephan C Bischoff, Peter Austin, Kurt Boeykens, Michael Chourdakis, Cristina Cuerda, Cora Jonkers-Schuitema, Marek Lichota, Ibolya Nyulasi, Stéphane M Schneider, Zeno Stanga, Loris Pironi
雑誌名: Clin Nutr. 2020 Jan;39(1):5-22. doi: 10.1016/j.clnu.2019.04.022. Epub 2019 May 30.
Abstract/Text This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers about the indications and contraindications for HEN, and its implementation and monitoring. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. This guideline will also inform interested patients requiring HEN. The guideline is based on current evidence and expert opinion and consists of 61 recommendations that address the indications for HEN, relevant access devices and their use, the products recommended, the monitoring and criteria for termination of HEN, and the structural requirements needed to perform HEN. We searched for meta-analyses, systematic reviews and single clinical trials based on clinical questions according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing the SIGN method. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd.. All rights reserved.
PMID 31255350  Clin Nutr. 2020 Jan;39(1):5-22. doi: 10.1016/j.clnu.201・・・
著者: R Scott, T E Bowling
雑誌名: J R Coll Physicians Edinb. 2015 Mar;45(1):49-54. doi: 10.4997/JRCPE.2015.112.
Abstract/Text Enteral tube feeding is usually a relatively straightforward method of nutritional support, and should be facilitated by a multiprofessional team. For short-term use (<4 weeks) a fine bore feeding nasogastric tube is indicated but if longer term feeding is required then a gastrostomy is appropriate, usually inserted endoscopically (a percutaneous endoscopic gastrostomy tube). The most common serious complication of a nasogastric tube is not identifying a misplaced tube within the lungs: there are clear recommendations from the National Patient Safety Agency as to how to check tube placement. Nasojejunal tubes are required in patients with gastroparesis. Tube blockage is common and is prevented by careful and regular flushing. Diarrhoea is the most complication of feeding and is often related to other medication. Clinicians need an algorithm for systematically dealing with such a problem. Refeeding syndrome may occur in malnourished patients and is characterised by low levels of potassium, phosphate, and/or magnesium, as well as disorders of water and salt balance. Identifying the at-risk patient with careful monitoring is crucial.

PMID 25874832  J R Coll Physicians Edinb. 2015 Mar;45(1):49-54. doi: 1・・・
著者: T A Tarek Ali Rushdi, Claude Pichard, Y H Yehia Helmy Khater
雑誌名: Clin Nutr. 2004 Dec;23(6):1344-52. doi: 10.1016/j.clnu.2004.04.008.
Abstract/Text BACKGROUND AND AIMS: Enteral fiber-free diets alter intestinal transit and produce diarrhea or constipation. This prospective double blind, controlled study evaluates the use of guar gum, a soluble fiber and a candidate prebiotic in enteral feeds, to prevent diarrhea and potential health benefits in intensive care unit patients.
METHODS: Twenty patients on enteral nutrition with persistent diarrhea were randomized to receive a new enteral feed either enriched with 2% soluble guar gum (study group, n = 10) or fiber-free (control group, n = 10) for 4 successive days.
RESULTS: The number of liquid stools in response to a soluble fiber-enriched diet was 2.0+/-0.9 (first day) vs. 1.0+/-0.7 (fourth day) (P < 0.01), and in the control group 1.2+/-0.7 (first day) vs. 2.1+/-0.8 (fourth day) (P < 0.05). In the fiber-enriched feed group, plasma glucose and cholesterol levels at termination of the study, respectively, reached 126+/-81 and 164+/-71 mg dl(-1), as compared to 333+/-108 and 378+/-26 mg dl(-1) on Day first (P < 0.01). In the control group, these values on the fourth day were, respectively, 267+/-94 and 263+/-79 vs. 247+/-115 and 315+/-78 on Day first (P > 0.05).
CONCLUSIONS: Guar gum-enriched enteral nutrition was related to a decrease of diarrheal episodes in ICU patients with preexisting diarrhea; and to a trend for lower plasma glucose and cholesterol levels.

PMID 15556256  Clin Nutr. 2004 Dec;23(6):1344-52. doi: 10.1016/j.clnu.・・・
著者: M G H Besselink, H C van Santvoort, E Buskens, M A Boermeester, H van Goor, H M Timmerman, V B Nieuwenhuijs, T L Bollen, B van Ramshorst, B J M Witteman, C Rosman, R J Ploeg, M A Brink, A F M Schaapherder, C H C Dejong, P J Wahab, C J H M van Laarhoven, E van der Harst, C H J van Eijck, M A Cuesta, L M A Akkermans, H G Gooszen, Acute Pancreatitis Werkgroep Nederland
雑誌名: Ned Tijdschr Geneeskd. 2008 Mar 22;152(12):685-96.
Abstract/Text OBJECTIVE: To evaluate whether enteral prophylaxis with probiotics in patients with predicted severe acute pancreatitis prevents infectious complications.
DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial.
METHOD: A total of 296 patients with predicted severe acute pancreatitis (APACHE II score > or = 8, Imrie score > or = 3 or C-reactive protein concentration > 150 mg/l) were included and randomised to one of two groups. Within 72 hours after symptom onset, patients received a multispecies preparation of probiotics or placebo given twice daily via a jejunal catheter for 28 days. The primary endpoint was the occurrence of one of the following infections during admission and go-day follow-up: infected pancreatic necrosis, bacteraemia, pneumonia, urosepsis or infected ascites. Secondary endpoints were mortality and adverse reactions. The study registration number is ISRCTN38327949.
RESULTS: Treatment groups were similar at baseline with regard to patient characteristics and disease severity. Infections occurred in 30% of patients in the probiotics group (46 of 152 patients) and 28% of those in the placebo group (41 of 144 patients; relative risk (RR): 1.1; 95% CI: 0.8-1.5). The mortality rate was 16% in the probiotics group (24 of 152 patients) and 6% (9 of 144 patients) in the placebo group (RR: 2.5; 95% CI: 1.2-5.3). In the probiotics group, 9 patients developed bowel ischaemia (of whom 8 patients died), compared with none in the placebo group (p = 0.004).
CONCLUSION: In patients with predicted severe acute pancreatitis, use of this combination of probiotic strains did not reduce the risk of infections. Probiotic prophylaxis was associated with a more than two-fold increase in mortality and should therefore not be administered in this category of patients.

PMID 18438065  Ned Tijdschr Geneeskd. 2008 Mar 22;152(12):685-96.
著者: Lynne V McFarland
雑誌名: Am J Gastroenterol. 2006 Apr;101(4):812-22. doi: 10.1111/j.1572-0241.2006.00465.x.
Abstract/Text CONTEXT: Antibiotic-associated diarrhea (AAD) is a common complication of most antibiotics and Clostridium difficile disease (CDD), which also is incited by antibiotics, is a leading cause of nosocomial outbreaks of diarrhea and colitis. The use of probiotics for these two related diseases remains controversial.
OBJECTIVE: To compare the efficacy of probiotics for the prevention of AAD and the treatment of CDD based on the published randomized, controlled clinical trials.
DATA SOURCES: PubMed, Medline, Google Scholar, NIH registry of clinical trials, metaRegister, and Cochrane Central Register of Controlled Trials were searched from 1977 to 2005, unrestricted by language. Secondary searches of reference lists, authors, reviews, commentaries, associated diseases, books, and meeting abstracts.
STUDY SELECTION: Trials were included in which specific probiotics given to either prevent or treat the diseases of interest. Trials were required to be randomized, controlled, blinded efficacy trials in humans published in peer-reviewed journals. Trials that were excluded were pre-clinical, safety, Phase 1 studies in volunteers, reviews, duplicate reports, trials of unspecified probiotics, trials of prebiotics, not the disease being studied, or inconsistent outcome measures. Thirty-one of 180 screened studies (totally 3,164 subjects) met the inclusion and exclusion criteria.
DATA EXTRACTION: One reviewer identified studies and abstracted data on sample size, population characteristics, treatments, and outcomes.
DATA SYNTHESIS: From 25 randomized controlled trials (RCTs), probiotics significantly reduced the relative risk of AAD (RR = 0.43, 95% CI 0.31, 0.58, p < 0.001). From six randomized trials, probiotics had significant efficacy for CDD (RR = 0.59, 95% CI 0.41, 0.85, p = 0.005).
CONCLUSION: A variety of different types of probiotics show promise as effective therapies for these two diseases. Using meta-analyses, three types of probiotics (Saccharomyces boulardii, Lactobacillus rhamnosus GG, and probiotic mixtures) significantly reduced the development of antibiotic-associated diarrhea. Only S. boulardii was effective for CDD.

PMID 16635227  Am J Gastroenterol. 2006 Apr;101(4):812-22. doi: 10.111・・・
著者: M Elia, M B Engfer, C J Green, D B A Silk
雑誌名: Aliment Pharmacol Ther. 2008 Jan 15;27(2):120-45. doi: 10.1111/j.1365-2036.2007.03544.x. Epub 2007 Oct 8.
Abstract/Text BACKGROUND: Enteral nutrition can be associated with gastrointestinal side effects and fibre supplementation has been proposed as a means to normalize bowel function.
AIM: To evaluate systematically the effects of fibre supplementation of enteral feeds in healthy volunteers and patients both in the hospital and community settings.
METHODS: Electronic and manual bibliographic searches were conducted. Controlled studies in adults or children, comparing fibre-supplemented vs. fibre-free formulae given as the sole source of nutrition for at least 3 days, were included.
RESULTS: Fifty-one studies (including 43 randomized-controlled trials), enrolling 1762 subjects (1591 patients and 171 healthy volunteers) met the inclusion criteria. Fibre supplementation was generally well tolerated. In the hospital setting, the incidence of diarrhoea was reduced as a result of fibre administration (OR 0.68, 95% CI: 0.48-0.96; 13 randomized-controlled trials). Meta-regression showed a more pronounced effect when the baseline incidence of diarrhoea was high. In both patients and healthy subjects, fibre significantly reduced bowel frequency when baseline frequency was high and increased it when it was low, revealing a significant moderating effect of fibre.
CONCLUSIONS: The review indicates that the fibre-supplemented enteral formulae have important physiological effects and clinical benefits. There is a need to use a consistent approach to undertake more studies on this issue in the community setting.

PMID 17922802  Aliment Pharmacol Ther. 2008 Jan 15;27(2):120-45. doi: ・・・

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