超音波検査技術

ISSN: 1881-4506
一般社団法人日本超音波検査学会
〒162-0801 東京都新宿区山吹町358-5
Japanese Journal of Medical Ultrasound Technology 46(4): 317-329 (2021)
doi:10.11272/jss.333

原著Original Article

腸閉塞における超音波パルスドプラ法の有用性―病変局所壁血流のresistive index計測による虚血進展予測―Pulsed Doppler Ultrasound Utility for Intestinal Obstruction: Prediction of Ischemic Progression by Measurement of the Resistive Index of the Lesion

森 貞浩1，藤浪 麻衣1，矢島 麻里絵1，森 夕佳1，町田 直子1，井上 知彦1，箭内 紀史1，小野 嘉文2，高佐 顕之2，渡久山 哲男2，中川 潤一2，小川 恭史3，中山 伸一3，西山 保比古3，西 八嗣3Sadahiro Mori1, Mai Fujinami1, Marie Yajima1, Yuka Mori1, Naoko Machida1, Tomohiko Inoue1, Norifumi Yanai1, Yoshifumi Ono2, Akiyuki Takasa2, Tetsuo Tokuyama2, Junichi Nakagawa2, Yasufumi Ogawa3, Nobukazu Nakayama3, Yasuhiko Nishiyama3, Yatsushi Nishi3

1 相模原赤十字病院臨床検査部Department of Clinical Laboratory, Sagamihara Red Cross Hospital

2 相模原赤十字病院内科Department of Internal Medicine, Sagamihara Red Cross Hospital

3 相模原赤十字病院外科Department of Surgery, Sagamihara Red Cross Hospital

受付日：2020年7月2日Received: July 2, 2020
受理日：2021年2月19日Accepted: February 19, 2021
発行日：2021年8月1日Published: August 1, 2021
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目的：腸閉塞機転でパルスドプラ法を使用し得られたresistive index（RI）によって虚血進展予測と層別が可能かを検討すること．

対象と方法：対象は腹痛精査目的のUSで腸閉塞機転を同定しえた64例である．保存的治療群と手術群でRIを比較し，receiver operating characteristics curve（ROC）で手術・腸切除要否のカットオフ値を算出した．さらに腸切除要否について多変量解析で血液検査データ，腹水，発症からの時間区分各因子のオッズ比を算出した．

結果と考察：RIは保存的治療群に比し手術群で有意に高値で（0.73±0.06 vs.0.89±0.09, p＜0.01），腸温存群に比し腸切除群で有意に高値であった（0.80±0.10 vs.0.94±0.06, p＜0.01）．RIの手術要否カットオフ値は0.79（感度87.5%，特異度91.7%），腸切除要否カットオフ値は0.85（感度100%，特異度72.5%）であった．多変量解析では発症からの時間区分とRI高値が腸切除に関連した．パルスドプラ法で拍動血流を認めてもRI高値の場合には静脈の絞扼，うっ血に伴う末梢動脈灌流の低下を示唆し静脈絞扼時期を示すものと思われ，この段階の手術で腸管を温存できる可能性があった．

結語：腸閉塞例では閉塞機転局所のRI計測により静脈絞扼状態の評価が可能となり，RIが0.85を超える場合には絞扼性の可能性が高く腸温存のために緊急手術の検討が望まれる．

Purpose: This study aimed to determine the usefulness of the resistive index (RI), measured with pulsed wave Doppler (PW-Doppler), to predict and stratify ischemic progression in intestinal obstruction.

Subjects and Methods: We included 64 patients diagnosed with intestinal obstruction using abdominal ultrasonography. We compared the RI values between patients who required surgery and those managed conservatively. Using receiver operating characteristics curves, we determined the RI cut-off value to predict surgery and bowel resection. We also assessed the association to other factors such as blood tests, biochemical markers, ascites, time from onset of symptoms, and bowel resection requirement.

Results and Discussion: The RI was significantly higher in the surgical group than in the conservative treatment group (0.73±0.06 vs. 0.89±0.09, p＜.01). Among the surgical cases, the RI was significantly higher in patients requiring bowel resection (0.80±0.10 vs. 0.94±0.06, p＜.01). The RI cut-off value for surgery and bowel resection was 0.79 (sensitivity 87.5%, specificity 91.7%) and 0.85 (sensitivity 100%, specificity 72.5%), respectively. Multivariate analysis showed that both the time of onset and a high RI were associated with bowel resection. If pulsatile blood flow with a high RI is observed on PW-Doppler arterial perfusion is considered to be decreased due to venous congestion, suggesting venous strangulation. Timely surgical intervention may prevent bowel resection at this stage.

Conclusion: In intestinal obstruction, the venous constriction status can be evaluated with pulsed wave Doppler ultrasonography by assessing the RI of blood flow to the intestinal wall. Immediate surgery should be considered if the RI exceeds 0.85 due to strangulated intestinal obstruction.

Key words: Intestinal obstruction; pulsed Doppler sonography; resistive index; intestinal ischemia; venous strangulation

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