術後早期の経腸栄養投与中に非閉塞性腸間膜虚血を発症した1例

症例は71歳男性。胃癌の診断で胃全摘術を施行し，術後食道空腸吻合部の縫合不全あり，第4病日から経腸栄養を開始した。第7病日に抗生剤の変更を行ったところ，アナフィラキシーショックを起こし，アドレナリン静脈内投与で軽快した。経腸栄養を再開したところ，強い腹痛あり，CTでは腸管壁内気腫と門脈内ガス像を認め，腸管壊死の疑いで試験開腹を行った。腸管の虚血所見はあるも明らかな壊死所見なく，翌日にsecond lookを行い，腸切除は行わず保存的治療で軽快した。術後早期の経腸栄養は，在院日数や術後合併症の低減に寄与するといわれ，近年では積極的に術後早期の経腸栄養投与が行われている。しかし，経腸栄養の合併症に...

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Published in日本腹部救急医学会雑誌 Vol. 38; no. 6; pp. 1121 - 1125
Main Authors 尾崎, 正彦, 平田, 篤史, 岡崎, 靖史, 松原, 久裕, 篠藤, 浩一
Format Journal Article
LanguageJapanese
Published 日本腹部救急医学会 30.09.2018
Subjects
経腸栄養
腸管壊死
非閉塞性腸間膜虚血（NOMI）
Online AccessGet full text
ISSN1340-2242
1882-4781
DOI10.11231/jaem.38.1121

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Abstract 症例は71歳男性。胃癌の診断で胃全摘術を施行し，術後食道空腸吻合部の縫合不全あり，第4病日から経腸栄養を開始した。第7病日に抗生剤の変更を行ったところ，アナフィラキシーショックを起こし，アドレナリン静脈内投与で軽快した。経腸栄養を再開したところ，強い腹痛あり，CTでは腸管壁内気腫と門脈内ガス像を認め，腸管壊死の疑いで試験開腹を行った。腸管の虚血所見はあるも明らかな壊死所見なく，翌日にsecond lookを行い，腸切除は行わず保存的治療で軽快した。術後早期の経腸栄養は，在院日数や術後合併症の低減に寄与するといわれ，近年では積極的に術後早期の経腸栄養投与が行われている。しかし，経腸栄養の合併症に非閉塞性腸間膜虚血や腸管壊死があることは本邦ではあまり広く知られていない。今回われわれは，術後早期の経腸栄養投与中に腸管壊死が疑われ試験開腹を行った1例を経験したので，文献的考察を加え報告する。
AbstractList 症例は71歳男性。胃癌の診断で胃全摘術を施行し，術後食道空腸吻合部の縫合不全あり，第4病日から経腸栄養を開始した。第7病日に抗生剤の変更を行ったところ，アナフィラキシーショックを起こし，アドレナリン静脈内投与で軽快した。経腸栄養を再開したところ，強い腹痛あり，CTでは腸管壁内気腫と門脈内ガス像を認め，腸管壊死の疑いで試験開腹を行った。腸管の虚血所見はあるも明らかな壊死所見なく，翌日にsecond lookを行い，腸切除は行わず保存的治療で軽快した。術後早期の経腸栄養は，在院日数や術後合併症の低減に寄与するといわれ，近年では積極的に術後早期の経腸栄養投与が行われている。しかし，経腸栄養の合併症に非閉塞性腸間膜虚血や腸管壊死があることは本邦ではあまり広く知られていない。今回われわれは，術後早期の経腸栄養投与中に腸管壊死が疑われ試験開腹を行った1例を経験したので，文献的考察を加え報告する。
Author 尾崎, 正彦
篠藤, 浩一
平田, 篤史
松原, 久裕
岡崎, 靖史
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  organization: 千葉大学大学院医学研究院先端応用外科
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  fullname: 篠藤, 浩一
  organization: 横浜労災病院外科
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References 1) Kudsk KA: Beneficial effect of enteral feeding. Gastrointest Endosc Clin N Am 2007; 17: 647-662.
11) Marvin RG, McKinley BA, McQuiggan M, at al: Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection. Am J Surg 2000; 179: 7-12.
5) Marik PE, Zaloga GP: Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 2001; 29: 2264-2270.
24) Gaddy MC, Max MH, Schwab CW, et al: Small bowel ischemia: a consequence of feeding jejunostomy? South Med J 1986; 79: 180-182.
10) Thompson JS: Pneumatosis intestinalis and needle catheter jejunostomy: a word of caution. JPEN J Parenter Enteral Nutr 1983; 7: 495.
9) Melis M, Fichera A, Ferguson MK: Bowel necrosis associated with early jejunal tube feeding: A complication of postoperative enteral nutrition. Arch Surg 2006; 141: 701-704.
17) Gwon JG, Lee YJ, Kyoung KH, et al: Enteral nutrition associated non-occlusive bowel ischemia. J Korean Surg Soc 2012; 83: 171-174.
8) Lawlor DK, Inculet RI, Malthaner RA: Small-bowel necrosis associated with jejunal tube feeding. Can J Surg 1998; 41: 459-462.
19) Sarap AN, Sarap MD, Childers J: Small bowel necrosis in association with jejunal tube feeding. JAAPA 2010; 23: 28, 30-32.
15) Jorba R, Fabregat J, Borobia FG, et al: Small bowel necrosis in association with early postoperative enteral feeding after pancreatic resection. Surgery 2000; 128: 111-112.
2) 日本静脈経腸栄養学会編：静脈経腸栄養ガイドライン，第3版，東京，照林社，2013，226-227
4) Page CP, Carlton PK, Andrassy RJ, et al: Safe, cost-effective postoperative nutrition. Defined formula diet via needle catheter jejunostomy. Am J Surg 1979; 138: 939-945.
16) Schunn CD, Daly JM: Small bowel necrosis associated with postoperative jejunal tube feeding. J Am Coll Surg 1995; 180: 410-416.
13) Munshi IA, Steingrub JS, Wolpert L: Small bowel necrosis associated with early postoperative jejunal tube feeding in a trauma patient. J Trauma 2000; 49: 163-165.
18) 眞部祥一，桑原史郎，池野嘉信，ほか：経腸栄養投与中に生じた門脈ガス血症の1例．日臨外会誌2013；74：2782-2786
12) Thaler K, Garreau J, Hansen PD: Non-occlusive small bowel necrosis during enteral feeding after pancreaticoduodenectomy. Dig Surg 2005; 22: 375-377.
20) Spalding DR, Behranwala KA, Straker P, et al: Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery. Ann R Coll Surg Engl 2009; 91: 477-482.
3) 藤城　健，大島郁也，有我隆光，ほか：経腸栄養投与中に腸管壊死を発症した2例．日消外会誌2011；44：1639-1646
21) Rai J, Flint LM, Ferrara JJ: Small bowel necrosis in association with jejunostomy tube feedings. Am Surg 1996; 62: 1050-1054.
23) Brenner DW, Schellhammer PF: Mortality associated with feeding catheter jejunostomy after radical cystectomy. Urology 1987; 30: 337-340.
7) Smith-Choban P, Max MH: Feeding jejunostomy: a small bowel stress test? Am J Surg 1988; 155: 112-117.
6) Stewart BT, Woods RJ, Collopy BT, et al: Early feeding after elective open colorectal resections: a prospective randomized trial. Aust NZ J Surg 1998; 68: 125-128.
14) Messiner R, Griffen M, Crass R: Small bowel necrosis related to enteral nutrition after duodenal surgery. Am Surg 2005; 71: 993-995.
25) Cogbill TH, Wolfson RH, Moore EE, et al: Massive pneumatosis intestinalis and subcutaneous emphysema: complication of needle catheter jejunostomy. JPEN J Parenter Enteral Nutr 1983; 7: 171-175.
22) Smith CD, Sarr MG: Clinically significant pneumatosis intestinalis with postoperative enteral feedings by needle catheter jejunostomy: an unusual complication. JPEN J Parenter Enteral Nutr 1991; 15: 328-331.
References_xml – reference: 5) Marik PE, Zaloga GP: Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 2001; 29: 2264-2270.
– reference: 2) 日本静脈経腸栄養学会編：静脈経腸栄養ガイドライン，第3版，東京，照林社，2013，226-227．
– reference: 13) Munshi IA, Steingrub JS, Wolpert L: Small bowel necrosis associated with early postoperative jejunal tube feeding in a trauma patient. J Trauma 2000; 49: 163-165.
– reference: 24) Gaddy MC, Max MH, Schwab CW, et al: Small bowel ischemia: a consequence of feeding jejunostomy? South Med J 1986; 79: 180-182.
– reference: 6) Stewart BT, Woods RJ, Collopy BT, et al: Early feeding after elective open colorectal resections: a prospective randomized trial. Aust NZ J Surg 1998; 68: 125-128.
– reference: 12) Thaler K, Garreau J, Hansen PD: Non-occlusive small bowel necrosis during enteral feeding after pancreaticoduodenectomy. Dig Surg 2005; 22: 375-377.
– reference: 7) Smith-Choban P, Max MH: Feeding jejunostomy: a small bowel stress test? Am J Surg 1988; 155: 112-117.
– reference: 21) Rai J, Flint LM, Ferrara JJ: Small bowel necrosis in association with jejunostomy tube feedings. Am Surg 1996; 62: 1050-1054.
– reference: 25) Cogbill TH, Wolfson RH, Moore EE, et al: Massive pneumatosis intestinalis and subcutaneous emphysema: complication of needle catheter jejunostomy. JPEN J Parenter Enteral Nutr 1983; 7: 171-175.
– reference: 10) Thompson JS: Pneumatosis intestinalis and needle catheter jejunostomy: a word of caution. JPEN J Parenter Enteral Nutr 1983; 7: 495.
– reference: 22) Smith CD, Sarr MG: Clinically significant pneumatosis intestinalis with postoperative enteral feedings by needle catheter jejunostomy: an unusual complication. JPEN J Parenter Enteral Nutr 1991; 15: 328-331.
– reference: 3) 藤城　健，大島郁也，有我隆光，ほか：経腸栄養投与中に腸管壊死を発症した2例．日消外会誌2011；44：1639-1646．
– reference: 4) Page CP, Carlton PK, Andrassy RJ, et al: Safe, cost-effective postoperative nutrition. Defined formula diet via needle catheter jejunostomy. Am J Surg 1979; 138: 939-945.
– reference: 8) Lawlor DK, Inculet RI, Malthaner RA: Small-bowel necrosis associated with jejunal tube feeding. Can J Surg 1998; 41: 459-462.
– reference: 11) Marvin RG, McKinley BA, McQuiggan M, at al: Nonocclusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection. Am J Surg 2000; 179: 7-12.
– reference: 20) Spalding DR, Behranwala KA, Straker P, et al: Non-occlusive small bowel necrosis in association with feeding jejunostomy after elective upper gastrointestinal surgery. Ann R Coll Surg Engl 2009; 91: 477-482.
– reference: 15) Jorba R, Fabregat J, Borobia FG, et al: Small bowel necrosis in association with early postoperative enteral feeding after pancreatic resection. Surgery 2000; 128: 111-112.
– reference: 17) Gwon JG, Lee YJ, Kyoung KH, et al: Enteral nutrition associated non-occlusive bowel ischemia. J Korean Surg Soc 2012; 83: 171-174.
– reference: 19) Sarap AN, Sarap MD, Childers J: Small bowel necrosis in association with jejunal tube feeding. JAAPA 2010; 23: 28, 30-32.
– reference: 14) Messiner R, Griffen M, Crass R: Small bowel necrosis related to enteral nutrition after duodenal surgery. Am Surg 2005; 71: 993-995.
– reference: 18) 眞部祥一，桑原史郎，池野嘉信，ほか：経腸栄養投与中に生じた門脈ガス血症の1例．日臨外会誌2013；74：2782-2786．
– reference: 1) Kudsk KA: Beneficial effect of enteral feeding. Gastrointest Endosc Clin N Am 2007; 17: 647-662.
– reference: 9) Melis M, Fichera A, Ferguson MK: Bowel necrosis associated with early jejunal tube feeding: A complication of postoperative enteral nutrition. Arch Surg 2006; 141: 701-704.
– reference: 16) Schunn CD, Daly JM: Small bowel necrosis associated with postoperative jejunal tube feeding. J Am Coll Surg 1995; 180: 410-416.
– reference: 23) Brenner DW, Schellhammer PF: Mortality associated with feeding catheter jejunostomy after radical cystectomy. Urology 1987; 30: 337-340.
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SubjectTerms 経腸栄養
腸管壊死
非閉塞性腸間膜虚血（NOMI）
Title 術後早期の経腸栄養投与中に非閉塞性腸間膜虚血を発症した1例
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