内容紹介
Summary
A 70-year-old man underwent a colonoscopy and enhanced CT for scrutiny of his anemia. These examinations revealed rectal cancer(cT4b[rectal mesenteric infiltration], N3M0, cStage Ⅲc). We introduced neoadjuvant chemotherapy(NAC)(cetuximab plus oxaliplatin plus S-1, 4 courses)for this patient and diagnosed ycStage Ⅲc(ycT4bN3M0)after the therapy. We performed laparoscopic total pelvic exenteration with bilateral pelvic lymph node dissection. Cefmetazole was administered as a preventive antibiotic in the perioperative period(intraoperatively to postoperative day 3). On postoperative day 4, intra-abdominal heavy bleeding occurred. Blood examination revealed remarkable coagulation disorder with parameters such as APTT 58.9 sec, PT-INR 3.33, and a remarkably high PIVKA-Ⅱ score of 11,754 mAU/mL. Based on these findings, the patient was diagnosed with complicated vitamin K(VK)deficiency. The coagulation disorders improved following the administration of VK. VK is a fat-soluble vitamin, and the main absorption pathways are dietary, intestinal bacterial production, and recycling in the VK metabolic cycle. In our case, it was considered that the causes of VK deficiency were a marked decrease in VK intake, impairment of the VK metabolic cycle due to taking antibiotics with a N -methyl-thiotetrazole group, and deficiency of VK accompanying suppression of the intestinal flora by antibiotics. We should also consider VK deficiency when patients are diagnosed with postoperative bleeding.
要旨
症例は70歳,男性。貧血精査目的の大腸内視鏡検査,腹部造影CTより直腸癌,Rb,cT4b(膀胱,精嚢),N3M0,cStage Ⅲcと診断した。術前化学療法としてcetuximab+oxaliplatin+S-1を4コース施行し,ycStage Ⅲc(ycT4bN3M0)と診断した。根治手術として腹腔鏡下骨盤内臓全摘術,両側側方リンパ節郭清,回腸導管造設術を施行した。術中より予防的抗菌薬としてセフメタゾンを2 g/日を4日間投与した。術後4日目にドレーンより血性排液を認め,APTT 58.9秒,PT-INR 3.33と凝固能異常所見を認めた。PIVKA-Ⅱを測定し11,754 mAU/mLと著明な高値を呈したため,ビタミンK(VK)欠乏症と診断した。VK製剤を投与し凝固能は改善した。VKの主な吸収経路は食事,腸内細菌での産生,VK代謝サイクルでの再利用である。本症例では,① VK摂取量の著しい減少,② N -methyl-thiotetrazole基を有する抗菌薬によるVK代謝サイクルの障害,③ 抗菌薬による腸内細菌叢の抑制に伴うVKの不足が原因として考えられた。術後出血の原因として,VK欠乏症併発も念頭に置く必要がある。
目次
A 70-year-old man underwent a colonoscopy and enhanced CT for scrutiny of his anemia. These examinations revealed rectal cancer(cT4b[rectal mesenteric infiltration], N3M0, cStage Ⅲc). We introduced neoadjuvant chemotherapy(NAC)(cetuximab plus oxaliplatin plus S-1, 4 courses)for this patient and diagnosed ycStage Ⅲc(ycT4bN3M0)after the therapy. We performed laparoscopic total pelvic exenteration with bilateral pelvic lymph node dissection. Cefmetazole was administered as a preventive antibiotic in the perioperative period(intraoperatively to postoperative day 3). On postoperative day 4, intra-abdominal heavy bleeding occurred. Blood examination revealed remarkable coagulation disorder with parameters such as APTT 58.9 sec, PT-INR 3.33, and a remarkably high PIVKA-Ⅱ score of 11,754 mAU/mL. Based on these findings, the patient was diagnosed with complicated vitamin K(VK)deficiency. The coagulation disorders improved following the administration of VK. VK is a fat-soluble vitamin, and the main absorption pathways are dietary, intestinal bacterial production, and recycling in the VK metabolic cycle. In our case, it was considered that the causes of VK deficiency were a marked decrease in VK intake, impairment of the VK metabolic cycle due to taking antibiotics with a N -methyl-thiotetrazole group, and deficiency of VK accompanying suppression of the intestinal flora by antibiotics. We should also consider VK deficiency when patients are diagnosed with postoperative bleeding.
要旨
症例は70歳,男性。貧血精査目的の大腸内視鏡検査,腹部造影CTより直腸癌,Rb,cT4b(膀胱,精嚢),N3M0,cStage Ⅲcと診断した。術前化学療法としてcetuximab+oxaliplatin+S-1を4コース施行し,ycStage Ⅲc(ycT4bN3M0)と診断した。根治手術として腹腔鏡下骨盤内臓全摘術,両側側方リンパ節郭清,回腸導管造設術を施行した。術中より予防的抗菌薬としてセフメタゾンを2 g/日を4日間投与した。術後4日目にドレーンより血性排液を認め,APTT 58.9秒,PT-INR 3.33と凝固能異常所見を認めた。PIVKA-Ⅱを測定し11,754 mAU/mLと著明な高値を呈したため,ビタミンK(VK)欠乏症と診断した。VK製剤を投与し凝固能は改善した。VKの主な吸収経路は食事,腸内細菌での産生,VK代謝サイクルでの再利用である。本症例では,① VK摂取量の著しい減少,② N -methyl-thiotetrazole基を有する抗菌薬によるVK代謝サイクルの障害,③ 抗菌薬による腸内細菌叢の抑制に伴うVKの不足が原因として考えられた。術後出血の原因として,VK欠乏症併発も念頭に置く必要がある。