犬の大動脈血栓塞栓症 診断編
TRANSCRIPT
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犬の大動脈血栓塞栓症 診断編
Masanao.Ichimata
Emergency Diseases of Veterinary Medicine
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Thrombus/embolus
May not be copied or reprinted without Author’s approval http://rebelem.com/age-adjusted-d-
dimer-testing/より引用・改変
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Thrombus/embolus • Thrombus
– 血管内で血小板などの血液成分が凝集した塊(局所的に形成されたもの)
• Embolus(Emboli:複数形) – 凝集塊が元々形成された場所から血流に乗って別の場所に運ばれたもの
May not be copied or reprinted without Author’s approval
Hall JE, Guyton and Hall Textbook of Medical Physiology,Saunders,12e
Nelson RW, Small Animal Internal Medicine,Mosby, 5e
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Pathophysiology
May not be copied or reprinted without Author’s approval
血栓形成
血管壁の性状の変化
血流の変化 血液性状の変化
Virchow Triad
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Histopathology
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 より引用・改変
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Epidemiology • Prevalence
– 来院症例の0.05%(31例:10年間中)
– 36症例(剖検にて:16年間中)
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
Winkle TJ. JVECC, 1993
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Epidemiology • Case Report(ATE in Canine Patient)
– J−GROVALで検索 (犬 動脈血栓で検索して内容を精査 日本の文献のみ)
• Hit数:21
• 症例数:28例
• 1991年~
May not be copied or reprinted without Author’s approval
Not Published Date
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Signalment • Year
– 中高齢での発症が多い • Median:8 ~10 years
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Winter RL. Vet Cardiol, 2012
Winkle TJ. JVECC, 1993 Gonclaves. JSAP, 2008
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Signalment • Sex
– 特に差はない?
• M > F
• F > M
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
Winter RL. Vet Cardiol, 2012 Gonclaves. JSAP, 2008 Baswood. JSAP, 2000
Winkle TJ. JVECC, 1993
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Clinical Signs • Episode
– Acute vs Chronic(Acute:発生から1日以内に悪化した症例)
• ほぼ半々
• Acute→Chronic:全例(n=4)
• Acute→Chronic:全体の1/3
• Chronic
May not be copied or reprinted without Author’s approval
Winter RL. Vet Cardiol, 2012
Lake-Bakaar GA. JAVMA, 2012
Baswood. JSAP, 2000
Gonclaves. JSAP, 2008 Morris. IVECCS, 2012
Kuniya T. JVMA, 2014
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Clinical Signs
May not be copied or reprinted without Author’s approval Miyabi T. 血栓症の診断と治療, CAP, 2010
より引用・改変
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Clinical Signs • Pathognomonic Signs 5P
1. Pain:疼痛
2. Pallor:蒼白
3. Pluseleness:脈圧消失
4. Parasthesia:感覚異常
5. Paralysis:運動麻痺
May not be copied or reprinted without Author’s approval
Shigeki Y. 血栓症の診断と治療, CAP, 2010
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Clinical Signs • Client Complaint
– 不全麻痺 or 完全麻痺(片 or 両後肢) • 54~90%
– 診断時には歩行可能 • 81%
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
Winter RL. Vet Cardiol, 2012
Winter RL. Vet Cardiol, 2012
Gonclaves. JSAP, 2008
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Physical Examination • Temperature(Rectal)
– 38.4 ± 1.8 ℃
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Physical Examination • Pluseleness
– 55~100%
• Coldness of limbs:四肢冷感 – 35~65%
• Pain(include CC)
– 29~65%
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Winter RL. Vet Cardiol, 2012
Winkle TJ. JVECC, 1993 Gonclaves. JSAP, 2008
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Clinical Signs
May not be copied or reprinted without Author’s approval Haruka W, Case Study ,Sysmec , 2012
より引用・改変
大動脈血栓症に関連した後肢壊死
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Physical Examination • 心雑音
– 29%
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Summary 1 • 中高齢犬、後肢の麻痺で来院することが多い
• 診察時には歩行が可能となっていることも多い
• 疼痛反応・冷感は時々みられる程度
• 股圧の触知は鑑別に重要
May not be copied or reprinted without Author’s approval
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CBC • WBC
– ストレスパターン
– Neutrophil:上昇:6/31
• Thrombocyte – 上昇:4/31(Acute:3)
– 減少:3/31(All Chronic)
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Blood Chemistry • Azotemia:68%
– BUN:上昇 • Median:41.0 ± 38.2
– Creatinine:上昇 • Median:2.2 ± 2.6
• CPK:上昇
– Median:384
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Blood Chemistry • Alb:減少
– Median:2.8 ± 0.7(正常値:3.0~4.4)
– 約50%の症例で認められた
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Gonclaves. JSAP, 2008
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Urine Test • Proteinurea(n:18/19)
• UPC(n=12)
– Median:5.7 ± 4.8
– 10/12で血清Alb減少
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Blood Coagulation Test • PT
– 約30%の症例で延長(5/17)
• APTT – 約60%の症例で延長(10/17)
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Gonclaves. JSAP, 2008
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Blood Coagulation Test • Fibrinogen
– 約67%の症例で増加
• D-dimer – 約80~100%の症例で増加
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Winter RL. Vet Cardiol, 2012
Kuniya T. JVMA, 2014
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Blood Coagulation Test • Thromboelastography
– 4/5 で凝固亢進 (1例がAcute、他Chronic)
• K動態:減少
• α角度:増加
• Maximum amplitude:増加
• G(Clot strength):増加
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Summary 2 • 血液化学検査
– 高窒素血症や低アルブミン血症など、診断特定のヒントになる項目も多い
• 尿検査 – 蛋白尿に注意
• 血液凝固検査 – D-ダイマーは診断の有用な判断材料となる
May not be copied or reprinted without Author’s approval
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Radiography • 跛行や疼痛などの除外診断として
• 肺野に病変を認めたりなど、併発疾患(原因疾患も含め)が確認されることもある
May not be copied or reprinted without Author’s approval
Baswood. JSAP, 2000
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Ultrasonography
May not be copied or reprinted without Author’s approval
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Ultrasonography
May not be copied or reprinted without Author’s approval
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Ultrasonography
May not be copied or reprinted without Author’s approval
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Ultrasonography • 部位
– 大動脈のみ • 16%
– 大動脈&外 or/and 内腸骨動脈を巻き込む • 73~76%
– 腎動脈を巻きこむ • 4~8%
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Winter RL. Vet Cardiol, 2012
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Ultrasonography • 血流
– 40%の症例で血栓もしくは塞栓部にドップラーが乗らなかった
• Echogenicity – 隣接した筋肉との比較
– 高エコー性から低エコー性まで様々
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012
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Echocardiography
May not be copied or reprinted without Author’s approval
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Echocardiography • 心臓病
– 粘液腫様変性性僧帽弁疾患 • 20%
– 心内膜炎 • 6~30%
May not be copied or reprinted without Author’s approval
Lake-Bakaar GA. JAVMA, 2012 Gonclaves. JSAP, 2008
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CT / MRI • 血栓塞栓症の確認
• 病変部位、病変の広がりを確認
• その他の疾患の除外に有用
May not be copied or reprinted without Author’s approval Kuniya T. JVMA, 2014 より引用・改変
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Summary 3 • 画像検査は、他疾患との鑑別と原因特定に有用である
– X線検査は主に他疾患との鑑別に
– 腹部超音波検査にて、確定診断
– 心臓・腹部超音波検査で血栓塞栓症の原因になっている疾患の探索をおこなう
May not be copied or reprinted without Author’s approval
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Concurrent Diseases
May not be copied or reprinted without Author’s approval
Cardiac Disease
33%
Renal Disease
33%
Atherosclerosis by Thyroid Disease
19%
Neoplasma 15%
Winkle TJ. JVECC, 1993
n=31
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Concurrent Diseases
May not be copied or reprinted without Author’s approval
Cardic Disease
39%
Protein Losing Disease
8%
No identify 38%
Neoplasma 15%
Gonclaves. JSAP, 2008
n=13
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Concurrent Diseases
May not be copied or reprinted without Author’s approval
No identifying
49% Protein Losing Nephopathy
29%
Hypothyroid 13%
Neoplasma 3%
Diabetes mellitus
3%
Hyperadenocoltism 3%
Winter RL. Vet Cardiol, 2012
n=26
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Concurrent Diseases
May not be copied or reprinted without Author’s approval
Cardiac Disease
23%
Renal Disease 26%
No identifying 13%
Neoplasma 23%
Immun-mediated
thombopenia 6%
Hyperadenocoltism 3%
Diabetes mellitus
3%
Hypoadenocorticism 3%
Lake-Bakaar GA. JAVMA, 2012
n=36
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Concurrent Diseases • Baswood. JSAP, 2000 (n=6)
– Hyperadenocorticism:2例 • Adrenal Tumor:1例
• Pituitary :1例
– Cardiac Disease:1例
– Neoplasma:1例
– No identify:1例
May not be copied or reprinted without Author’s approval
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Others • ステロイド治療
– 凝固に関する報告 • 副腎皮質機能亢進症に罹患した犬の塞栓症のリスクや凝固系の亢進は以前より報告されていた
• 近年ステロイドの使用による凝固系の亢進がランダム化比較試験により報告された
May not be copied or reprinted without Author’s approval
Klose TC. JVECC, 2011
Romão. BMC Vet Res, 2013
Rose L. JVIM, 2013
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Others • ATE診断時におけるステロイド治療あり
– 14~20%
• +α 門脈血栓症診断時におけるステロイド治療あり
– 42%
May not be copied or reprinted without Author’s approval
Winkle TJ. JVECC, 1993 Lake-Bakaar GA. JAVMA, 2012
Respess M. JAVMA, 2012
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Summary 4 • 併発(原発)疾患 ー Top4
1. 心臓病(による血流の変化)
2. 腎臓病(による凝固亢進状態?)
3. 内分泌疾患
4. 腫瘍性疾患
• ステロイド治療はATEの発症リスクにつながる可能性がある
May not be copied or reprinted without Author’s approval