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急性胃腸炎のピットフォール_新撰医チバ第2回ミニセミナー_20170414

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新撰医チバ第2回ミニセミナー(2017年4月14日)
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急性胃腸炎のピットフォール_新撰医チバ第2回ミニセミナー_20170414

  1. 1. 急性胃腸炎の ピットフォール 2017年4月14日 新撰医チバ 第2回ミニセミナー 千葉大学医学部附属病院 総合診療科 鋪野 紀好 東京ベイ・浦安市川医療センター 救急集中治療科 志賀 隆 Copyright by Shinsenichiba
  2. 2. 本日のテーマ 急性胃腸炎の… • 診断 • ピットフォール • マネジメント Copyright by Shinsenichiba
  3. 3. Copyright by Shinsenichiba 急性胃腸炎とは 下痢:軟便/水様便が24時間で3回以上 急性:2週以内 持続性:2〜4週 慢性 :4週以上 原因:9割以上が感染症
  4. 4. Shikino K, MD, PhD 問診のポイント • 便の性状(水様, 血性, 粘液, 脂肪) • 下痢の回数 • 大腸型か?(発熱, テネスムス, 血便) • 海外渡航歴 • 食物(生肉, 卵, 貝類etc.) • 周囲に同じような人はいるか • ペット(カメ, 動物) • 職業歴(食品関連, 施設, 保育士) *大学生でもバイトは何かまで細かく聴取! • 性交渉(MSM, 特に肛門性交) • 内服歴(抗菌薬は60日以内まで確認) • 基礎疾患(HIVなどの免疫抑制) Copyright by Shinsenichiba
  5. 5. Copyright by Shinsenichiba 急性胃腸炎の症状 • 「大腸型」「小腸型」(「混合型」) 大腸型:腸管粘膜の破壊 粘血便, テネスムス, 頻回で少量の便 高熱, 激しい腹痛 小腸型:小腸からの分泌物増加 嘔気, 嘔吐, 大量の水様便
  6. 6. 「急性胃腸炎」と紛らわしい疾患 Shikino K, MD, PhD 感染性 • 骨盤内感染症:PID, 腸腰筋膿瘍, 急性虫垂炎 • 胆道系感染症 • 腸管:HUS • 肺炎(異形肺炎) • 敗血症:トキシン関連疾患(TSS/TLSS) 非感染性 • 血管性:心筋梗塞, 肺塞栓, 解離性大動脈瘤, 腸管膜血栓 塞栓症, くも膜下出血, 虚血性腸炎 • 悪性腫瘍 • 消化器疾患:消化性潰瘍, 膵炎 • 内分泌代謝:糖尿病, 尿毒症, 副腎不全, 甲状腺機能亢進 症, ホルモン分泌腫瘍 • その他:妊娠, 緑内障 Copyright by Shinsenichiba
  7. 7. 便培養の推奨 Shikino K, MD, PhD 1. 長引く 2. 流行地域 3. 保育所 4. 男性同性愛 5. AIDS 6. 水資源由来の集団発生(ランブル鞭毛虫, クリプトスポリジウム) 7. 血便 8. IBDと鑑別 9. 偽膜性腸炎 Copyright by Shinsenichiba
  8. 8. Shikino K, MD, PhD 治療 ・十分な補液 希釈リンゴジュースが効果的 ・抗菌薬は原則使用しない(無効) 下痢の悪化, 菌の耐性化, Clostridium difficile関 連腸炎(偽膜性腸炎) ・一部の細菌性腸炎は抗菌薬の適応がある 例:渡航者下痢症や職業上の問題 ・帰宅指示書やパンフレット作成が有用 Copyright by Shinsenichiba Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016;315(18):1966-74.
  9. 9. 渡航者下痢症 予防投与は以下の場合のみ • 脱水状態に耐えられない患者(重篤な心臓・血管疾患, 慢性腎不全) • 免疫不全者 • 炎症性腸疾患の患者 • 3日間投与(通常は5日で自然軽快) • ニューキノロン, ST合剤など • キノロン耐性にはマクロライド 治療(抗菌薬の適応) Shikino K, MD, PhD Copyright by Shinsenichiba
  10. 10. Take Home Message ・急性下痢症の9割は感染症 (ただし安易に”急性胃腸炎”と診断するべからず) ・感染性腸炎では対症療法がメイン (抗菌薬の適応を見極めるべし) Shikino K, MD, PhD Copyright by Shinsenichiba
  11. 11. Copyright by Shinsenichiba 第2回新撰医チバセミナー 2017年6月25日(日)13時30分〜 @千葉大学医学部附属病院クリニカル・スキルズ・センター Coming Soon!
  12. 12. Copyright by Shinsenichiba ホームページ https://shinsenichiba.jimdo.com/ Facebookページ https://www.facebook.com/shinsenichiba1/

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