経口抗凝固薬を直接服用している患者さんの大腸内視鏡的粘膜切除術後のまれな合併症としての腹腔内出血

Intra-abdominal bleeding as a rare complication after colonic endoscopic mucosal resection in a patient taking direct oral anticoagulants.

• Yoshinori Sato
• Yusuke Satta
• Hiroshi Yasuda
• Hirofumi Kiyokawa
• Masaki Yamashita
• Yasumasa Matsuo
• Fumio Itoh

抄録

心房細動の既往歴があり，リバロキサバン30mg/日を服用していた84歳女性の症例を紹介する．横結腸の肝屈曲部に位置する5mmの腺腫を内視鏡的粘膜切除術で切除した．術後，徐々に激しくなる腹痛と少量の血便を伴う腹痛を呈した。そのため内視鏡的粘膜切除術後5日目に来院された。来院時の腹部造影CT検査では空気の滲出や遊離は認められなかったが，腹膜腔内に血便が確認された。このため，内視鏡的粘膜切除術後の腹腔内出血と診断され，同日入院した。入院後，リバロキサバンを中止し，患者の状態を観察した。その後の腹部CT検査で明らかな血性腹水の増加が認められなかったため，放射線学的介入や外科的処置は行わず，保存的治療のみを行って退院した。大腸内視鏡的粘膜切除術後の主な合併症は出血と穿孔であるが、内視鏡的粘膜切除術後に腹腔内出血が発生した症例はこれまでに数例しか報告されていない。腹腔内出血を起こした患者さんには、時に緊急治療が必要となることがあります。この合併症は非常にまれではあるが、特に抗凝固剤を服用している患者さんで発生する可能性があることを念頭に置いておくことが重要である。

We describe the case of an 84-year old female who was taking rivaroxaban 30 mg/day and had a medical history of atrial fibrillation. She underwent endoscopic mucosal resection of a 5-mm adenoma located in the hepatic flexure of the transverse colon. Following the procedure, she developed gradually intensifying abdominal pain, with the appearance of small amount of blood in the feces. For that reason, she visited our facility on the 5th day post-endoscopic mucosal resection. At the time of the visit, contrast-enhanced abdominal computed tomography revealed no extravasation or free air; however, bloody ascites was confirmed in the peritoneal cavity. Thus, the patient was diagnosed with post-endoscopic mucosal resection intra-abdominal hemorrhage and hospitalized the same day. After admission, rivaroxaban was discontinued and patient condition monitored. Because subsequent abdominal computed tomography revealed no distinct increase in bloody ascites, no interventional radiological or surgical procedure was performed, and the patient was discharged after providing only conservative treatment. While hemorrhage and perforation are the main complications after colonic endoscopic mucosal resection, so far, there have been a few reports on the occurrence of intra-abdominal hemorrhage following endoscopic mucosal resection. Emergency treatment is sometimes required in patients with intra-abdominal hemorrhage. It is important to keep in mind that this complication, although very rare, may occur, particularly in patients taking anticoagulants.