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臨床推論3 アッペの数字

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臨床推論3 アッペの数字

  1. 1. お腹の数字臨床推論シリーズ
  2. 2. 症例; 40歳 腹痛生来健康な40歳男性. 来院前日より臍中心の間欠痛を自覚. 嘔気あり. 嘔吐は1回のみ. 外来受診し, 急性胃腸炎の診断で帰宅. 下痢は無かった. 来院日の朝9時頃より徐々に右下腹部痛が出現. 増悪傾向あり, その際嘔吐あり. 下痢は無し. 自宅での体温は36.4度. 悪寒戦慄無し. 最終食事は前日の昼. ここ1週間以内の生もの摂取無し. Ill contact無し.
  3. 3. 虫垂炎の病歴 JAMA; RATIONAL CLINICAL EXAMINATION Symptom Sn(%) Sp(%) LR(+) LR(-) RLQ pain 84 90 7.3-8.5 0-0.28 以前に同様の 痛(-) 86 40 1.50[1.46-1.7] 0.32[0.25-0.42] 移動する 痛 64 82 3.2[2.4-4.2] 0.50[0.42-0.59] 嘔吐の前に 痛(+) 100 64 2.8[1.9-3.9] NA 食欲低下 68 36 1.3[1.2-1.4] 0.64[0.54-0.75] 悪心 58 37 0.69-1.2 0.70-0.84 嘔吐 51 45 0.92[0.82-1.0] 1.1[0.95-1.3] “虫垂炎”という診断を引っ掛ける為の情報. 病歴上, 虫垂炎ぽいなぁ、と思う切っ掛けとなる情報. 嘔吐の前に 痛+という情報は感度100%. (ただし鵜呑み×) 訴えられない高齢者や精神疾患ではあり得る話. 母集団に注意.
  4. 4. 病歴続き; Vital BP 120/60, HR 90, RR22, Sat 99%(RA), BT 37.4度 腹部所見; 腹部は平坦, 軟. Tapping Painは右下腹部で陽性.  触診; Mass触れず. 右下腹部の圧痛あり, McBurney圧痛点(+)  筋性防御無し. 反跳痛無し. 直腸診では 痛の訴え無し.  Psoas Sign陰性. Obturator sign陰性.
  5. 5. Signs Sn(%) Sp(%) LR(+) LR(-) 板状硬 20 89 3.8[3.0-4.8] 0.82[0.79-0.85] 虫垂炎? 右下腹部圧痛 65-100 1-92 1.8 0.3 McBurney圧痛点 50-94 75-86 3.4 0.4 Psoas Sign 16 95 2.4[1.2-4.7] 0.90[0.83-0.98] Obturator sign 8 94 NS NS 発熱 67 79 1.9[1.6-2.3] 0.58[0.51-0.67] 反跳痛 63 69 1.1-6.3 0-0.86 筋性防御 73 52 1.7-1.8 0-0.54 直腸圧痛 41 77 0.83-5.3 0.36-1.1 Rovsing’s sign 68 58 2.3 0.8 JAMA; RATIONAL CLINICAL EXAMINATION, Evidence-based Physical Diagnosis 3rd ed., Steven McGee虫垂炎は検査後確率を上げる所見はあるものの, 除外に向く身体所見はあまり無い.右下腹部痛や, 腹痛⇒嘔吐の流れがある場合は必ず虫垂炎を疑う必要がある.ただし, その後, 病歴や所見で除外が難しい.
  6. 6. Psoas sign
  7. 7. Obturator sign
  8. 8. 腹膜炎になっているか? 腹膜炎の所見は? 所見 感度 特異度 LR(+) LR(-) 発熱 20-96% 11-86% 1.4 0.7 筋性防御 13-90% 40-97% 2.2 0.6 板状硬 6-66% 76-100% 3.7 0.7 反跳痛 37-95% 13-91% 2 0.4 Percussion tenderness 57-65% 61-86% 2.4 0.5 蠕動音異常 25-61% 44-95% NS 0.8 直腸圧痛 22-82% 41-85% NS NS 腹壁圧痛テスト 1-5% 32-72% 0.1 NS 咳嗽テスト 50-85% 38-79% 1.6 0.4Evidence-Based Physical Diagnosis 3rd ed, Steven McGee.
  9. 9. AFP 2008;77:1153-55血液検査 Ann R Coll Surg Engl 2009; 91: 113–115 Radiology 2004;230:472-8   WBC 8000(Neu 80%, Ly 10%), Hg 14.5, PLT 200k AST 36, ALT 28, ALP 240, GGT 40, LDH 290, Cre 0.8, BUN 28, Na 138, K 4.3, Cl 102. CRP 0.5 Lab 感度 特異度 LR(+) LR(-) WBC>10000/µL* 77[70-84] 63[55-71] 2.1-2.5 0.26-0.4 WBC>11000/µL 85% 72% 3.0 0.2 WBC>15000/µL 3.5 0.81 Neu >75% 2.4 0.24 CRP>1.0mg/dL* 60[51-69] 68[60-76] 1.9 0.6 CRP>2.0mg/dL 2.4 0.47 WBC>10000/µL + CRP>1.0* 47[38-56] 84[78-90] 2.9 0.6 WBC>11000/µL + CRP>1.0 50% 90% 5.0 0.6 WBC>10000/µL or CRP>1.0* 88[82-94] 53[44-62] 1.9 0.2 WBC>11000/µL or CRP>1.0 100% 51% 2.0 0
  10. 10. 40歳男性, 腹痛. 腹部中心の間欠痛から右下腹部痛, 痛後に出現した嘔吐. 右下腹部の圧痛(+), Tapping Pain(+). LabはNeu80%以外は特に問題無し. さて、どうする? Labって必要だった?
  11. 11. Alvarado score Migration of pain 心窩部、臍周囲→右下腹部 1 MANTRELS score Anorexia 食欲不振 1 Nausea 嘔気、嘔吐 1 Tenderness in RLQ 右下腹部痛 1 Rebound tenderness 反跳痛 2 Elevated temperature 発熱>37.3℃ 1 Leukocytosis WBC>10,000/µl 2 Shift of WBC count 白血球の左方移動 17点以上; Sn 24-95%, Sp 46-99%, LR 3.15-6点; Sn 4-43%4点以下; Sn 0-28%, Sp 6-87%, LR 0.1
  12. 12. Temperature ≥7.3°C 28 (14.7%) symptoms, and 93% of patients had tenderness in the right White blood cell count (/μL) 11 999.7 ± 4420.9 lower quadrant of the abdomen. The signs and symptoms研修医の印象とAlvarado scoreは White blood cell count ≥ 10 000/μL 126 (66.0%) used to calculate the Alvarado score are shown in Table 1. Segmented neutrophil (%) 76.8 ± 11.4 Of a total of 191 patients, 120 (62.8%) patients underwent Segmented neutrophil ≥75% 121 (63.4) surgical exploration and 71 (37.2%) were discharged home. Data are expressed mean ± SD or number (percentage) as appropriate. Of the 120 patients who underwent exploration, one patientどちらが有用か? was compared using the χ 2 or Fisher exact test as was diagnosed with an ovarian torsion before operation and the surgery was performed by a gynecologist. The remaining American Journal of went to the operating room with the impression 119 patients Emergency Medicine (2010) 28, 766–770 appropriate. We performed receiver operating characteristic of acute appendicitis. Of these patients, 111 (93.2%) were curve analysis to compare the diagnostic characteristics of confirmed to have appendicitis by pathologic findings, and ER研修医, 外科研修医が右下腹部痛でER受診した191名を評価 EMR, SR, the Alvarado score, and the CT scan. The area under the curve (AUC) was calculated and a univariate Z test one was found to have a mucinous tumor. Telephone follow- up was completed on all patients who did not undergo was used to compare the AUC as described by Hanley and operation, and there was no additional case of acute McNeil [10]. appendicitis within the 3-month follow-up period. 虫垂炎に対する診断能をROC curveで評価. Statistical analyses were conducted using SPSS software version 13.0 (SPSS Inc, Chicago, Ill). Medcalc (MedCalc Software, Belgium) was used to compare the AUC. A P value of less than .05 was considered statistically significant. AUCは, 3. Results  CT; " " " 0.978[0.953-1.002]  During the study period, 278 consecutive patients with pain to the right lower quadrant of the abdomen were  Alvarado; " 0.735[0.661-0.809]  enrolled. Of these patients, 87 were not evaluated by an SR before CT imaging and were excluded. Therefore, 191  ER研修医; " 0.698[0.622-0.773] patients were included into the final analysis. Their mean age was 37.3 ± 16.7 years and 87 patients (45.6%) were male. Nausea and vomiting were the most common presenting  外科研修医;" 0.657[0.579-0.735] Table 2 Comparison of the probability groups between EMR and SRs Group Surgery (N = 191)
  13. 13. 検査は?腹部エコー単純CT造影CT
  14. 14. 腹部エコー; 虫垂炎の腹部エコーってどんな所見? US所見 Radiology 2004;230:472-8 感度 特異度 直径 ≥6mm 98[95-100] 98[95-100] 圧迫にて潰されない 96[94-100] 96[94-100] 粘膜内Fluid貯留 53[43-63] 92[87-97] Dopplerで虫垂壁にFlowあり 52[43-61] 96[94-100] 周囲脂肪組織の炎症変化 91[86-96] 76[69-83] 盲腸壁肥厚 25[17-33] 88[82-94] 回腸周囲リンパ節腫大 32[24-40] 62[53-71] 腹水 51[42-60] 71[63-79] 虫垂は右下腹部の管腔臓器.他の小腸との違いは, 蠕動運動が無く, 盲端.
  15. 15. cantly higher PPV (95% vs 71%). The US- aided identification of a normal appen- dix was a significantly more common finding for the exclusion of appendicitis 虫垂炎所見; 直径が9.3mm than was the normality of both WBC and CRP levels (72% vs 47%) and had a sig- nificantly higher NPV (98% vs 84%). DISCUSSION The inability to visualize the normal ap- pendix is classically considered a major weakness of using US in the assessment Figure 1. (a) Transverse and (b) longitudinal US images obtained in a 27-year-old man with of patients suspected of having appendi- 正常の虫垂所見 appendicitis (arrows). The appendix has an anteroposterior diameter of 9.2 mm. citis, because it represents a serious limi- tation to confidently excluding the diag- nosis of appendicitis (5). In their state-of- using US and 21 patients in whom it was cluded eight patients with ileocolitis (Fig the-art article, Birnbaum and Wilson (9) not identified. Of these latter 21 patients, 5), four patients with mesenteric adeni- claimed that in their experience and in two had a final diagnosis of appendicitis, tis, one patient with mesenteric isch- that of others (11,15), a normal appendix thus giving the lack of visualization of emia, and one patient with pyelonephri- is visualized in only 0%– 4% of cases in the appendix at US an NPV of 90%; each tis. Cecal wall thickening (Fig 5) was the adult population, regardless of the US of these two patients was found to have detected at US in only 25% of patients technique used, and they stated that the an appendiceal perforation at surgery. with appendicitis and in more than 10% results of Rioux (12), who visualized a The 104 patients in whom the appendix of patients without appendicitis. Perito- normal appendix in 82% of patients was visualized constituted a group in neal fluid was noted in 51% of patients without acute appendicitis, were “amaz-Figure 2.appendiceal US findings could be a normal appendix (arrows) in three different patients. which (a– c) Longitudinal US images show with appendicitis but also in almost 30% ing.” 基部は正常径だが, tested. Table 2 shows (a) the frequency of patients without appendicitis. Right In contrast with this classic viewpoint, with which each appendiceal finding was lower abdominal quadrant adenopathy we visualized a normal appendix in 72%normal appendix visualization rate (12). interpreted as positive or negative, (b) the was present in 32% of patients with ap- of the patients without appendicitis,As a result, nonvisualization of the ap- TABLE 2 末端で肥大した虫垂 number of true-positive, true-negative, pendicitis and in 38% of patients without for the Diagnosisclose to the 64% appendix Appendiceal US and Doppler US Signs which is a rate of Appendicitispendix can only befalse-negative results, appendicitis. Combining the nonappen- visualization rate obtained by Retten- false-positive, and valid as an accurate Radiologyfinding to exclude appendicitis for sonog- and (c) the sensitivity, specificity, accu- diceal findings with appendiceal findings Lack of Finding and Diameter Ն Intraluminal bacher et al (19) in a population ofraphers whoand PPV of each appendiceal did not increase the NPV or PPV of indi- healthy subjects. The notion thatWall racy, NPV, can usually identify a normal Value 6 mm Compressibility Fluid Flow in theappendix.The two most accurate appen- vidual appendiceal findings, such as an normal appendix is seldom visualized at finding. Finding at US US evaluation ofappendicitis were a di- appendix 6 mm or larger55 diameter or 55 is based on reports published more diceal findings for the appendix ideally Positive in US 33 30includes of 6 mm or of theand a lack of noncompressibility of the50 ameter evaluation larger appendiceal Negative appendix. 49 71 74 than 10 years ago (10,14) or on data ob-wall and appendiceal content. with de- Finding at final compressibility. In the patient We ap- diagnosis tained by sonographers who are not ra-cided to measure the outer appendiceal pendicitis and an outer appendiceal di- diologists with experience in US28 assess-diameter less than 6 mm, surgical wall Laboratory Findings 54 True-positive 53 29 ameter rather than appendiceal and True-negative 48 47 45 47 ment of the gastrointestinal tract (20).thickness forexamination First, as shown pathologic two reasons. revealed distalby Rioux (12), inflammation of the ap- The number False-negative 1 1 糞石と False-positive of true-positive, true-neg- 2 4 Technologic advances combined with in- 2 26 2 26 appendicitis, but, although the distal ap- ative, false-positive, and false-negative re- depth radiologic experience have dra- Value*pendiceal wall may be indistinguishable pendix was dilated in comparison with Figure 3. the sensitivity,(95, 100) shows ap- 100) Sensitivityfromproximal one,intraluminal pus, thus showsNPV, and PPV of the two laboratory (94, 100) hypoechoic both the proximal and racy, ap- 粘膜内Fluid貯留 sults and Longitudinal US image accu- (94, 98 specificity, 96 matically improved 63) use of US in the 53 (43, the 52 (43, 61) the Radiology 2004;230:472-8 Figure 3. Longitudinal US image pendicitis in a 43-year-old woman. This 96 a Specificity 98 (95, 100) was visualization 92 (87, 97) of a normal appendix. The 96 (94, 100)making measurement of the appendiceal false-negative diagnosis at US. The appendiceal 100) improvement94) PPV 98 WBC levels) are (94, (95, 100) 96 same 88 (82, has been (88, 98) 93 reported pendicitis in a 43-year-old woman. findings (ie, CRP and (95, 100) distal appendix measured less than 6 mm This was a NPV in Table 4. A WBC level above (94, 100) 98 96 with use of computed tomography 73) 63 (64, 72) 64 (55, (CT);wallUS (Fig 3). Second, the mucosal sur- diameter measured less than 6 mm, but after a at inaccurate. In the nonappendicitis shown false-negative diagnosis at US. The appendiceal
  16. 16. 造影CTと単純CTはどちらが良い? 造影CTの感度 90-100%, 特異度 91-99%.単純CTは? 7 trialsのmeta-analysis(Ann Emerg Med 2010;55:51-9)では, 単純Helical-CTの感度 92.7%[89.5-95.0], 特異度 96.1%[94.2-97.5]ちなみに, 単純CTで診断つけた場合, 5日間の入院で元が取れる造影CTで診断をつけた場合,7日間の入院でないと元がとれない(医事課の話). 通常手術ならば3日で退院可能.
  17. 17. 気を付けないといけない場合• 妊娠可能年齢の女性…PID、胃腸炎、尿路感染も多い。 妊婦もあまり虫垂の位置は変わらない。 破裂虫垂炎では胎児死亡率は約35%なので適切な判断が必要。• 高齢者・精神疾患…典型的な症状を示しにくい。 虫垂破裂率30∼70%、死亡率3∼15%• 右側の片麻痺患者・糖尿病患者… 症状が分かりにくく、悪化しやすい• 小児…6∼14歳に起こりやすいが3歳以下でも起こり、 見落としが多い。 孔しやすく、 下痢や排尿時痛など非特異的症状が多い。 必ず少しでも疑えば5mmスライスCTで撮影する。
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