消化器 / 大腸外科 / 集中治療
急性結腸偽閉塞（Ogilvie）
機械的閉塞なしの結腸拡張。保存無効や盲腸径大ならネオスチグミン/減圧。
根拠：ASGE / NEJM。各ノードはガイドラインの判断ロジックを要約したものであり、原文の転載ではありません。 医療従事者向けの参考情報であり、臨床判断の代替ではありません。日本の関連学会指針および施設プロトコルを優先してください。
ステップごとに回答すると、結論と対応の目安が表示されます。前の質問に戻ることもできます。
ステップ 1 · Ischemia/perforation?
Ischemia/perforation/peritonitis; response to 24–48 h of conservative care?
💡 Acute colonic pseudo-obstruction (Ogilvie) = massive colonic dilation (especially cecum/right colon) without mechanical obstruction, from autonomic imbalance; common in hospitalized/postoperative (cesarean, orthopedic)/critically ill/electrolyte disturbance/drugs (opioids, anticholinergics). Perforation risk rises with cecal diameter: <12 cm ~0%, 12–14 cm ~7%, >14 cm ~23%. Diagnosis: plain film (cecal dilation), CT + oral/rectal contrast to exclude mechanical obstruction, check for ischemia/perforation.
パス全体像
- 【判断】Ischemia/perforation?Ischemia/perforation/peritonitis; response to 24–48 h of conservative care?（Acute colonic pseudo-obstruction (Ogilvie) = massive colonic dilation (especially cecum/right colon) without mechanical obstruction, from autonomic imbalance; common in hospitalized/postoperative (cesarean, orthopedic)/critically ill/electrolyte disturbance/drugs (opioids, anticholinergics). Perforation risk rises with cecal diameter: <12 cm ~0%, 12–14 cm ~7%, >14 cm ~23%. Diagnosis: plain film (cecal dilation), CT + oral/rectal contrast to exclude mechanical obstruction, check for ischemia/perforation.）
- Ischemia/perforation/peritonitis or all measures failed → Ischemia/perforation/failure → surgery
- いいえ ischemia/perforation (conservative/neostigmine first) → No ischemia/perforation · conservative + neostigmine
- 【終点】No ischemia/perforation · conservative + neostigmineNo 虚血/穿孔: conservativeに対し24–48 h first — NPO, NG + rectal tube 減圧, correct electrolytes (potassium/magnesium/calcium/phosphate), stop opioids/anticholinergics, position changes, avoid osmotic laxatives (lactulose worsens it); no improvementまたはcecum ≥10–12 cm → neostigmine 2–2.5 mg IV (cardiac monitoring, atropine ready; 禁忌でbradycardia/hypotension/asthma/mechanical 閉塞/虚血-穿孔/urinary 閉塞); still not resolving → colonoscopic 減圧 (unprepped, place a 減圧 tube),次いでPEGへprevent recurrence.
- 【終点】Ischemia/perforation/failure → surgeryIschemia/穿孔/peritonitisまたはfailureのconservative + neostigmine + colonoscopy: 手術 (cecostomy/percutaneous cecostomyまたはsubtotal colectomy); cecal diameter >12–14 cm sharply raises 穿孔 risk (>14 cm ~23%), 穿孔 死亡率 is high, timely 減圧 is key.
よくある質問
- 急性結腸偽閉塞（Ogilvie）はどの臨床課題を扱う診療パスですか？
- 機械的閉塞なしの結腸拡張。保存無効や盲腸径大ならネオスチグミン/減圧。
- 急性結腸偽閉塞（Ogilvie）の主要な意思決定ステップは何ですか？
- Ischemia/perforation?
- 急性結腸偽閉塞（Ogilvie）はどのような対応方針を示しますか？
- No ischemia/perforation · conservative + neostigmine：No 虚血/穿孔: conservativeに対し24–48 h first — NPO, NG + rectal tube 減圧, correct electrolytes (potassium/magnesium/calcium/phosphate), stop opioids/anticholinergics, position changes, avoid osmotic laxatives (lactulose worsens it); no improvementまたはcecum ≥10–12 cm → neostigmine 2–2.5 mg IV (cardiac monitoring, atropine ready; 禁忌でbradycardia/hypotension/asthma/mechanical 閉塞/虚血-穿孔/urinary 閉塞); still not resolving → colonoscopic 減圧 (unprepped, place a 減圧 tube),次いでPEGへprevent recurrence.；Ischemia/perforation/failure → surgery：Ischemia/穿孔/peritonitisまたはfailureのconservative + neostigmine + colonoscopy: 手術 (cecostomy/percutaneous cecostomyまたはsubtotal …
- 急性結腸偽閉塞（Ogilvie）のうち直ちに対応が必要な状況はどれですか？
- Ischemia/perforation/failure → surgery：Ischemia/穿孔/peritonitisまたはfailureのconservative + neostigmine + colonoscopy: 手術 (cecostomy/percutaneous cecostomyまたはsubtotal colectomy); cecal diameter >12–14 cm sharply raises 穿孔 risk (>14 cm ~23%), 穿孔 死亡率 is high, timely 減圧 is key.
- 急性結腸偽閉塞（Ogilvie）はどのガイドラインに基づいていますか？
- Acute colonic pseudo-obstruction Ogilvie (ASGE/ESGE; NEJM neostigmine RCT; ASCRS) · 準拠：ASGE / NEJM
出典
- Acute colonic pseudo-obstruction Ogilvie (ASGE/ESGE; NEJM neostigmine RCT; ASCRS)