消化器 / 大腸外科 / 集中治療
中毒性巨大結腸 — 管理パス
結腸径>6cm+全身毒性（Jalan）。内科外科共同管理、悪化時は緊急結腸切除。
根拠：Jalan / ACG。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 · Surgery needed?
Perforation / progressive dilation / no improvement on medical therapy?
💡 Non-obstructive colonic dilation ≥6 cm + systemic toxicity. Causes: IBD (UC > Crohn's), infectious colitis (increasingly C. diff; Salmonella/Shigella/CMV/amoebiasis), ischemia. Jalan criteria: 1) imaging colonic dilation >6 cm (typically transverse colon, highest perforation risk); 2) ≥3 of: fever >38.6°C, HR >120, WBC >10.5×10⁹, anemia; 3) ≥1 of: dehydration/altered mentation/electrolyte disturbance/hypotension. Colonoscopy is contraindicated (perforation risk); a limited sigmoidoscopy may define the cause + check C. diff; daily abdominal X-ray to measure diameter.
パス全体像
- 【判断】Surgery needed?Perforation / progressive dilation / no improvement on medical therapy?（Non-obstructive colonic dilation ≥6 cm + systemic toxicity. Causes: IBD (UC > Crohn's), infectious colitis (increasingly C. diff; Salmonella/Shigella/CMV/amoebiasis), ischemia. Jalan criteria: 1) imaging colonic dilation >6 cm (typically transverse colon, highest perforation risk); 2) ≥3 of: fever >38.6°C, HR >120, WBC >10.5×10⁹, anemia; 3) ≥1 of: dehydration/altered mentation/electrolyte disturbance/hypotension. Colonoscopy is contraindicated (perforation risk); a limited sigmoidoscopy may define the cause + check C. diff; daily abdominal X-ray to measure diameter.）
- Perforation/progressive dilation/no improvement at 24–72 h/worsening → Surgery needed → colectomy
- Initial, responding to treatment → Initial · medical + co-management
- 【終点】Initial · medical + co-managementInitial, respondingへ薬物療法 (medical-surgical co-management): nilによりmouth/NG 減圧, 輸液・electrolyte correction (potassium), stop antimotility/opioid/anticholinergic drugs, broad-spectrum 抗菌薬; treat the cause — IBD → IV corticoステロイド (第一選択), C. diff → oral vancomycin/IV metronidazole (stop the inciting antibiotic); daily abdominal X-ray + exam; early surgical involvement on standby.
- 【終点】Surgery needed → colectomyPerforation / progressive dilation / no improvement on 薬物療法 at 24–72 h / worsening toxicity / major 出血: 緊急手術 (subtotal colectomy + end ileostomy); delayへ穿孔 has high mortality. Concurrently aggressive 蘇生, broad-spectrum 抗菌薬, correct electrolytes; ステロイド can mask 穿孔 (check the liver dullness daily).
よくある質問
- 中毒性巨大結腸 — 管理パスはどの臨床課題を扱う診療パスですか？
- 結腸径>6cm+全身毒性（Jalan）。内科外科共同管理、悪化時は緊急結腸切除。
- 中毒性巨大結腸 — 管理パスの主要な意思決定ステップは何ですか？
- Surgery needed?
- 中毒性巨大結腸 — 管理パスはどのような対応方針を示しますか？
- Initial · medical + co-management：Initial, respondingへ薬物療法 (medical-surgical co-management): nilによりmouth/NG 減圧, 輸液・electrolyte correction (potassium), stop antimotility/opioid/anticholinergic drugs, broad-spectrum 抗菌薬; treat the cause — IBD → IV corticoステロイド (第一選択), C. diff → oral vancomycin/IV metronidazole (stop the inciting antibiotic); daily abdominal X-ray + exam; early surgical involvement on standby.；Surgery needed → colectomy：Perforation / progressive dilation / no improvement on 薬物療法 at 24–72 h / worsening toxicity / major 出血: 緊急手術 (subtotal colectomy + end ileostomy); delayへ穿孔 has high mortality. Concurrently aggressive 蘇生, broad-spectrum 抗菌薬, correct electrolytes; ステロイド can mask …
- 中毒性巨大結腸 — 管理パスのうち直ちに対応が必要な状況はどれですか？
- Surgery needed → colectomy：Perforation / progressive dilation / no improvement on 薬物療法 at 24–72 h / worsening toxicity / major 出血: 緊急手術 (subtotal colectomy + end ileostomy); delayへ穿孔 has high mortality. Concurrently aggressive 蘇生, broad-spectrum 抗菌薬, correct electrolytes; ステロイド can mask 穿孔 (check the liver dullness daily).
- 中毒性巨大結腸 — 管理パスはどのガイドラインに基づいていますか？
- Toxic megacolon (Jalan criteria; ACG IBD and C. difficile guidelines) · 準拠：Jalan / ACG
出典
- Toxic megacolon (Jalan criteria; ACG IBD and C. difficile guidelines)