上腹部痛(Epigastric Pain)シリーズ2 RESIDENT COURSE 解答 【症例 ER 6】

十二指腸潰瘍による閉塞.Obstructive duodenal ulcer.




図12〜図15は省略.胃拡張である.その原因を追及するために図11の胃前庭部(antrum)A1から頭側へ追跡すると図2のA10での閉塞で,図3と図4の十二指腸↑が閉塞部位である.図8の十二指腸D1から頭側へ追跡しても図4のD5の閉塞部位へ到達する.閉塞部位↑は腫瘍性に濃染する壁肥厚ではなく,周囲に十二指腸を圧排する病変もないので十二指腸潰瘍の瘢痕化による閉塞であろうと診断する.図8の腎静脈が下大静脈(IVC:inferior vena cava)へ合流する部位の頭側図6と図7のIVCの形と大きさで脱水(循環血液量不足)の程度が推測できる(下記文献参照).通常IVCの大きさは大動脈の1.2〜1.5倍ありやや楕円形を呈する.この症例のIVCは平坦になっており,体重60kgの成人として2000ml程度の,平坦ではないが大動脈より小さいIVCは1000ml程度の循環血液量不足と思って良い.2日後の内視鏡検査で十二指腸潰瘍瘢痕化による狭窄と急性潰瘍を認めた.








文献考察:hypovolemiaとIVC
1)AJR Am J Roentgenol. 1988 Feb;150(2):431-2.
The collapsed inferior vena cava: CT evidence of hypovolemia.
Jeffrey RB Jr, Federle MP.

In a review of 100 patients undergoing abdominal CT for blunt abdominal trauma, seven had flattening of the infrahepatic inferior vena cava at multiple levels. In six of these patients, emergency surgery was required to control major hemorrhage. Three patients had hypotension documented during or shortly after abdominal CT. Five patients had major intraabdominal injuries, and one patient had massive hemorrhage from facial lacerations. The severity of the blood loss was not fully appreciated clinically in five of the six patients before CT. The seventh patient had no clinical evidence of significant blood loss; in this case the flattened inferior vena cava probably was related to a normal variant. In a group of 100 patients scanned for nonacute conditions, none had flattening of the infrahepatic inferior vena cava at multiple levels. Presence of a collapsed inferior vena cava may be CT evidence of significant hypovolemia from major blood loss and should prompt careful hemodynamic and central venous pressure monitoring.PMID: 3257336

2)Am J Emerg Med. 2005 Jan;23(1):45-50.
Sonographic measurement of the inferior vena cava as a marker of blood loss.
Lyon M, Blaivas M, Brannam L.

Detecting and monitoring blood loss in trauma patients can often be challenging when an obvious source of hemorrhage is not readily seen. OBJECTIVE: To provide a noninvasive measurement of circulating blood volume and of drop therein by measuring the change in the inferior vena cava diameter (IVCd) in relationship to blood loss. METHODS: This was a prospective observational study on blood donors at a donation center. The IVCd, both during inspiration (IVCi) and during expiration (IVCe), was measured in volunteers both before and after blood donation of 450 mL. All actual blood donors aged 18 years and older were eligible for enrollment. Persons who were younger than 18 years, who declined to participate in the study, or who did not meet blood center criteria for blood donation were excluded. All examinations were performed in the supine position with the ultrasound transducer placed in a subxyphoid location. Sagittal sections of the IVC behind the liver were imaged and the maximal diameter of the IVCe and the minimal diameter of the IVCi were measured. Statistical analysis included test for normality, paired t test, and correlation analysis. RESULTS: A total of 31 volunteers (18 male) with a mean age of 49.5 years (range, 18-73) were studied. The mean IVCe before blood donation was 17.4 mm (95% CI, 15.2-19.7 mm) and after blood donation was 11.9 mm (95% CI, 10.3-13.6 mm). The mean IVCi before blood donation was 13.3 mm (95% CI, 11.3-15.3 mm), but after blood donation was 8.13 mm (95% CI, 6.7-9.6 mm). The difference between IVCe before and after blood donation (dIVCe) was 5.5 mm (95% CI, 4.3-6.3 mm) yielding a P < .0001. The difference between IVCi before and after donation (dIVCi) was 5.16 mm (95% CI, 4.2-5.9 mm) yielding a P < .0001. The dIVCe and the dIVCi were closely correlated ( r = 0.83). Similarly, the pre-IVCe correlated well to the post-IVCe ( r = 0.74) and the pre-IVCi correlated well to the post-IVCi ( r = 0.75). CONCLUSIONS: Our data indicates that the measurement of the IVC diameter is a reliable indicator of blood loss, even in small amounts of 450 mL. On average, there was about a 5-mm decrease in both the IVCe and IVCi after donation of 450 mL of blood. The measurement of the IVCe may be an important addition to the ultrasonographic evaluation of trauma and other potentially volume-depleted patients.PMID: 15672337

3)J Trauma. 2005 Apr;58(4):825-9.
Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients.
Yanagawa Y, Nishi K, Sakamoto T, Okada Y.

BACKGROUND: The diameter of the inferior vena cava in trauma patients may be useful for evaluating hypovolemia. METHODS: Between June 2003 and September 2003, 35 injured patients transferred to the authors' hospital were prospectively investigated. They were divided into two groups: a shock group (n = 10) and a control group (n = 25). The maximum anteroposterior diameter of the inferior vena cava was measured using a sonography at arrival and on hospital day 5. RESULTS: The average diameter of the inferior vena cava in the shock group was significantly smaller than in the control group. There was no significant change in the diameter of the inferior vena cava in the control group, but significant change was seen in the shock group between arrival and hospital day 5. CONCLUSION: The diameter of the inferior vena cava was found to correlate with hypovolemia in trauma patients.PMID: 15824662

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