図１６の円形の低濃度部分（白矢印）が膀胱でFoleyカテーテルが挿入され虚脱しているので，図１５の※は腹水である．全画像で腹水（※）があり，図２〜図１２の↑は遊離ガスを示しているので消化管穿孔の可能性が極めて高い．直腸からＳ状結腸は図１２の1から図のごとく数字順に展開するので，図６〜図１１の壁肥厚を呈する▲は空腸であろう（右上腹部から左下腹部への斜線を境に空腸は左側に回腸は右側に位置する傾向にある）．従って空腸穿孔と診断する．手術でTreitz靱帯から約100cmの部位で2cm大の穿孔を認めた．

参考症例（空腸穿孔 IIa）：51歳男性．停車中の車に衝突し，ハンドルで腹部を打撲した．腹部全体に圧痛と反跳痛を認めた．

図１〜図４で遊離ガス（↑）を認める．腹水を伴わない遊離ガスは消化管穿孔以外の原因も考慮するが，図６のMorison窩と図１２の骨盤腔に腹水（※）を認めるので，消化管穿孔の可能性は極めて高い．図５〜図７で液貯留（△）を認め，図７〜図９の空腸（▲）は壁肥厚を示し，図１０と図１１の液状内容物（白矢印）は麻痺性イレウスを示唆するので，空腸穿孔と診断する．手術でTreitz靱帯から100cmの部位で空腸穿孔（図１３：↑）が確認された．

文献考察：pan scan（頭部，頸椎，胸部と腹部をCT検査）．高エネルギー外傷（1：時速56km/h以上の自動車事故，2：4,7m以上の高さからの墜落，3：車にはねられ3m以上飛ばされた，4:意識レベル低下状態で暴行された）例で，主訴と身体所見で明らかな外傷の徴候がない（1：胸部と腹部に外傷痕を認めない，2：循環動態が安定，3：腹部所見が陰性）にpan scanを行うと，頭部3.5%，頸椎5.1%，胸部19.6%，腹部7.1%に異常所見が発見され，全症例の19％に治療方針が変更された．
Arch Surg. 2006 May;141(5):468-73; discussion 473-5.
Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study.
Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D.

HYPOTHESIS: The use of liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS: All patients admitted following blunt multisystem trauma. INTERVENTION: Pan scan, including computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis, with the following inclusion criteria: (1) no visible evidence of chest or abdominal injury, (2) hemodynamically stable, (3) normal abdominal examination results in a neurologically intact patient or unevaluable abdominal examination results secondary to a depressed level of consciousness, and (4) significant mechanisms of injury. Radiological findings and changes in treatment based on these findings were recorded. MAIN OUTCOME MEASURE: Any alteration in the normal treatment plan as a direct result of CT scan findings. These alterations include early hospital discharge, admission for observation, operative intervention, and additional diagnostic studies or interventions. RESULTS: One thousand patients underwent pan scan during the 18-month observation period, of which 592 were evaluable patients with no obvious signs of abdominal injury. Clinically significant abnormalities were found in 3.5% of head CT scans, 5.1% of cervical spine CT scans, 19.6% of chest CT scans, and 7.1% of abdominal CT scans. Overall treatment was changed in 18.9% of patients based on abnormal CT scan findings. CONCLUSIONS: The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.PMID: 16702518（full text）