今日の臨床サポート

腸間膜動脈虚血

著者: 石澤嶺 東京医療センター 救命救急センター

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:2022/01/05
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 腸間膜動脈塞栓症およびNOMIの患者にはパパベリンを使用することが勧められる(推奨度3)
  1. 閉塞性腸間膜動脈虚血には経皮的血管治療を検討する(推奨度3)
  1. 身体所見や採血検査の結果からは原因不明の重症腹痛をみたときには、腹部造影CTを行うべきである(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※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:
石澤嶺 : 未申告[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. パパベリンの推奨は文献的根拠を鑑みて推奨度3とした。
  1. 腸管壊死の認識の遅れは患者転帰に直結するため新たに推奨を加えた。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腸間膜動脈虚血には腸間膜動脈の動脈硬化による慢性腸間膜動脈虚血と、突然発症の急性腸間膜動脈虚血がある。
  1. 急性腸間膜動脈虚血は腸間膜虚血全体の60~70%を占め、その死亡率は60%を超える[1]
  1. 確定診断が遅れてしまうことが多く、死亡率が高い理由の1つである。そのため早期の診断が重要である[2]
  1. リスクファクターは高齢、動脈硬化、低心拍出力、不整脈、心血管疾患、腹腔内腫瘍である[1]
  1. 上腸間膜動脈塞栓症が50%、上腸間膜動脈血栓症が20%、非閉塞性虚血(Non-occlusive mesenteric ischemia、NOMI)が25%程度である[3][4]
  1. 腸間膜虚血により、腹痛、嘔吐、嘔吐、血便などの症状を来し、進行し腸管壊死が起こると汎発性腹膜炎に至る。
  1. 確定診断のゴールドスタンダードは血管造影か試験開腹となるが、腹部造影CTやCT angiographyも選択肢となり得る。
  1. 画像検査で腸間膜虚血を疑っている場合に、試験開腹を躊躇うべきではない。
問診・診察のポイント  
問診:
  1. 典型的な主訴は急性に発症した腹痛である。

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文献 

J F McKinsey, B L Gewertz
Acute mesenteric ischemia.
Surg Clin North Am. 1997 Apr;77(2):307-18.
Abstract/Text The morbidity and mortality of acute mesenteric ischemia have remained high over the past 30 years despite heightened sensitivity to the diagnosis. Because the duration of the ischemic episode is the most significant determinant of outcome, an aggressive diagnostic and treatment protocol must be maintained. Although this stance may precipitate a number of negative angiographic studies, such an approach is the only opportunity for salvage in these critically ill patients.

PMID 9146714
Panagiotis Kougias, Donald Lau, Hosam F El Sayed, Wei Zhou, Tam T Huynh, Peter H Lin
Determinants of mortality and treatment outcome following surgical interventions for acute mesenteric ischemia.
J Vasc Surg. 2007 Sep;46(3):467-74. doi: 10.1016/j.jvs.2007.04.045. Epub 2007 Jul 30.
Abstract/Text BACKGROUND: Acute mesenteric ischemia (AMI) is associated with high morbidity and mortality due in part to its diagnostic difficulty and operative challenges. The purpose of this study was to review our experience of surgical management in patients with this condition and to identify variables associated with adverse outcomes following surgical interventions.
METHODS: Hospital records and clinical data of all patients undergoing surgical interventions for AMI were reviewed during a recent 12-year period. Clinical outcomes as well as factors influencing mortality were analyzed.
RESULTS: A total of 72 patients (41 females, overall mean age 65 years, range 34 to 83 years) were included in the study. Thrombosis and embolism were the cause of AMI in 48 patients (67%) and 24 patients (33%), respectively. Abdominal pain was the most common presenting symptom (96%), followed by nausea (56%). Preoperative angiogram was performed in 61 patients (85%). All patients underwent operative interventions, which included thromboembolectomy (n = 22, 31%), mesenteric bypass grafting (n = 33, 46%), patch angioplasty (n = 9, 12%), reimplantation (n = 5, 7%), and endarterectomy (n = 3, 4%). Bowel resection was necessary in 22 patients (31%) during the initial operation, and second-look operation was performed in 38 patients (53%). Perioperative morbidity and 30-day mortality rates were 39% and 31%, respectively. Univariate analysis showed renal insufficiency (P < .02), age >70 (P < .001), metabolic acidosis (P < .02), and symptom duration (P < .005), and bowel resection in second-look operations (P < .01) were associated with mortality. Logistic regression analysis showed age >70 (P = .03) and prolonged symptom duration (P = .02) were independent predictors of mortality.
CONCLUSIONS: Elderly patients and those with a prolonged duration of symptoms had worse outcomes following surgical intervention for AMI. A high index of suspicion with prompt diagnostic evaluation may reduce time delay prior to surgical intervention, which may lead to improved patient survival. Aggressive surgical intervention should be performed as promptly as possible in patients once the diagnosis of AMI is made.

PMID 17681712
J F Reinus, L J Brandt, S J Boley
Ischemic diseases of the bowel.
Gastroenterol Clin North Am. 1990 Jun;19(2):319-43.
Abstract/Text The ischemic bowel diseases are a heterogeneous group of disorders usually seen in elderly individuals. They represent ischemic damage to different portions of the bowel and therefore produce a variety of clinical syndromes and outcomes. Proper diagnosis and management of patients with ischemic bowel disease require vigilance on the part of the physician and a willingness to embark on an aggressive plan of diagnosis and management in the appropriate setting.

PMID 2194948
M S Cappell
Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy.
Gastroenterol Clin North Am. 1998 Dec;27(4):783-825, vi.
Abstract/Text Intestinal vasculopathy is not rare, comprising about 1 per 1000 hospital admissions. Primary mesenteric vasculopathy causes cardiovascular disease, whereas secondary mesenteric ischemia causes extrinsic vascular compression or vascular trauma. Acute superior mesenteric arteriopathy is caused by a mesenteric embolus, thrombus, or vasospasm (i.e., nonocclusive vasculopathy). Acute superior mesenteric venopathy is caused by a thrombus, which is often associated with a hypercoagulopathy. The clinical presentation of both diseases is often subtle and nonspecific at an early stage and becomes overt and specific only when advanced and severe, when ischemia progresses to necrosis. The mortality of acute superior mesenteric arteriopathy is still very high, whereas superior mesenteric venopathy is less rapidly progressive and has a lower, but still significant, mortality. Early diagnosis and aggressive therapy significantly reduces the mortality of these life-threatening diseases.

PMID 9890114
L J Brandt, S J Boley
AGA technical review on intestinal ischemia. American Gastrointestinal Association.
Gastroenterology. 2000 May;118(5):954-68.
Abstract/Text This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 25, 1999, and by the AGA Governing Board on November 25, 1999.

PMID 10784596
H Lange, R Jäckel
Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease.
Eur J Surg. 1994 Jun-Jul;160(6-7):381-4.
Abstract/Text OBJECTIVE: To verify the diagnostic importance of the plasma lactate concentration in acute abdominal disease and to examine its role as a marker of mesenteric ischaemia.
DESIGN: Prospective study.
SETTING: Two departments of surgery, one in Sweden and one in Germany.
SUBJECTS: 85 patients with acute abdominal symptoms.
MAIN OUTCOME MEASURES: Correlation between the plasma lactate concentration before operation or (in the case of those not operated on) before the diagnosis was established, and the final diagnosis.
RESULTS: Plasma lactate concentrations exceeded the reference range in all cases of mesenteric ischaemia (n = 20) and general bacterial peritonitis (n = 15) and in half of the 20 cases of intestinal obstruction. They were also raised in 3 of 10 cases of acute pancreatitis.
CONCLUSIONS: A raised plasma lactate concentration is always a sign of an acute life-threatening condition, and usually indicates the need for an emergency operation. As a marker of mesenteric ischaemia its sensitivity was 100% and its specificity 42%. We conclude that a raised serum lactate concentration is the best marker of mesenteric ischaemia to date.

PMID 7948358
T Block, T K Nilsson, M Björck, S Acosta
Diagnostic accuracy of plasma biomarkers for intestinal ischaemia.
Scand J Clin Lab Invest. 2008;68(3):242-8. doi: 10.1080/00365510701646264.
Abstract/Text OBJECTIVE: Intestinal ischaemia is a life-threatening condition with high mortality, and the lack of accurate and readily available diagnostic methods often results in delay in diagnosis and treatment. The aim of this study was to investigate the accuracy of different plasma biomarkers in diagnosing intestinal ischaemia.
MATERIAL AND METHODS: Prospective inclusion of patients older than 50 years with acute abdomen admitted to hospital in Karlskrona, Sweden, between 2001 and 2003. Venous blood was sampled prior to any surgery and within 24 h from onset of pain. D-lactate, alpha glutathione S-transferase, intestinal fatty acid binding protein, creatine kinase B, isoenzymes of lactate dehydrogenase (LD) and alkaline liver phosphatase (ALP) were analysed. D-dimer was analysed using four different commercially available test kits.
RESULTS: In-hospital mortalities among patients with (n = 10) and without (n = 61) intestinal ischaemia were 40 % and 3 %, respectively (p = 0.003). D-dimer was associated with intestinal ischaemia (p = 0.001) independently of which assay was used. No patient presenting with a normal D-dimer had intestinal ischaemia. D-dimer >0.9 mg/L had a specificity, sensitivity and accuracy of 82 %, 60 % and 79 %, respectively. Total LD, isoenzymes of LD 1-4 and liver isoenzyme of ALP (ALP liver) were significantly higher in patients with intestinal ischaemia, and accuracies for LD 2 (cut-off 2.3 microkat/L) and ALP liver (cut-off 0.7 microkat/L) were 69 % and 66 %, respectively.
CONCLUSIONS: D-dimer may be used as an exclusion test for intestinal ischaemia, but lacks specificity. The other plasma biomarkers studied had insufficient accuracy for this group of patients. Further studies are needed.

PMID 17934974
Ivo G Schoots, Marcel M Levi, Jim A Reekers, Johan S Lameris, Thomas M van Gulik
Thrombolytic therapy for acute superior mesenteric artery occlusion.
J Vasc Interv Radiol. 2005 Mar;16(3):317-29. doi: 10.1097/01.RVI.0000141719.24321.0B.
Abstract/Text The aim of this review is to evaluate thrombolytic therapy for acute superior mesenteric artery occlusion as an alternative or adjunctive treatment modality to surgical therapy and to provide current knowledge for timely and informed decisions regarding treatment of acute mesenteric ischemia. A systematic analysis of the available literature from 1966 to 2003 regarding thrombolytic therapy for superior mesenteric artery thromboembolism was performed. A total of 20 case reports and seven small series covered 48 patients with acute superior mesenteric artery thromboembolism. In the herein reviewed series, thrombolytic therapy of acute superior mesenteric artery thromboembolism resulted in angiographic resolution of the thromboembolism in 43 patients, in clinical success without requiring additional surgical intervention in 30 patients, and in survival in 43 patients, with similar complication rates as in thrombolytic treatment of peripheral vascular occlusions. Remission of abdominal pain during the first few hours of treatment formed the most important indicator of therapeutic success. Insufficient evidence from reviewed literature is available to determine the relative effectiveness and safety of thrombolytic treatment for acute superior mesenteric artery thromboembolism; however, initial results appear to be promising. Thrombolytic therapy can be effective relatively quickly, may obviate surgery, and has the potential to resolve the clot completely. In some cases it can be used as an alternative or neo-adjunctive treatment modality to surgery. A treatment guideline for thrombolysis of acute superior mesenteric artery thromboembolism should be developed.

PMID 15758127
J Klempnauer, F Grothues, H Bektas, R Pichlmayr
Long-term results after surgery for acute mesenteric ischemia.
Surgery. 1997 Mar;121(3):239-43.
Abstract/Text BACKGROUND: Acute mesenteric ischemia is associated with high mortality rates, and little is known about the long-term prognosis of patients after initially successful surgical intervention.
METHODS: Ninety patients were treated by vascular reconstruction or bowel resection, or both, between 1972 and 1993. The overall mortality was 66%. The outcomes and rehabilitational statuses of those 31 patients who were discharged from the hospital were analyzed retrospectively. Anticoagulation consisted of vitamin K antagonists in patients with venous thrombosis and arterial embolism or inhibition of thrombocyte aggregation in patients with arterial thrombosis and nonocclusive mesenteric ischemia.
RESULTS: In 31 patients discharged from the hospital venous thrombosis, arterial embolism, arterial thrombosis, and nonocclusive disease occurred in 19, 5, 5, and 2 patients, respectively. The 2- and 5-year survival rates were 70% and 50% and mainly related to cardiovascular comorbidity and malignant disease. Only one patient died after a recurrent attack of arterial mesenteric thrombosis. Twenty percent of the patients suffered from chronic short bowel syndrome after extensive bowel resection, but none required permanent parenteral nutrition.
CONCLUSIONS: Under appropriate anticoagulation there is a remarkably low risk of recurrent mesenteric ischemia. The impaired life expectancy of long-surviving patients is mainly due to cardiovascular comorbidity and malignancies.

PMID 9068664

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