来院時のCTでは，図４〜図６で右側腹壁直下に少量の液貯留がある（▲）．図３でやや壁肥厚した小腸（右下腹部だからおそらく回腸：△）があり，さらに麻痺性イレウスを示唆する，腸液を含む小腸があり（↑），回腸穿孔を疑うべきである．腹部所見で筋性防御を認めず経過観察することとなった．
下段の6時間後のCTで，図９〜図１２で麻痺性イレウスが進行し，図１３〜図１６で腹水量が増量している（▲）．遊離ガスはない（画像省略）．回腸穿孔の可能性はさらに高まり，エコーガイド下に腹水を穿刺して腹水の性状を検索すべきであった．腹部所見でまだ筋性防御ははっきりせずさらに経過観察が続けられたが，腹水の性状を確認しておけば，手術のタイミングを逸することはなく，術後の合併症を回避もしくは軽減できたであろう．

13時間後には，腹水量はさらに増量し（▲），その中に散在するガスバブルは消化管内容物または糞便を意味し，消化管穿孔が明白となった．Residentコースの症例TR１１の解答欄の「消化管穿孔のCT所見」の項目に「腸管外に腸管内容物を認める」を追加すべきである．手術で盲腸から150cmの部位で，8mm大の穿孔と大量の腸管内容物で混濁した腹水を認めた．術後は敗血症となりICU管理となった．

文献考察：鈍的外傷による小腸穿孔は受傷後8時間を過ぎると死亡率と術後合併症が急増する．
J Trauma. 2000 Mar;48(3):408-14; discussion 414-5.
Relatively short diagnostic delays (.
Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D.

OBJECTIVE: Blunt small bowel injury (SBI) is uncommon, and its timely diagnosis may be difficult. The impact of operative delays on morbidity and mortality has been unclear. The purpose of this study was to determine the relationship of diagnostic delays to morbidity and mortality in blunt SBI. METHODS: Patients with blunt SBI with perforation were identified from the registries of eight trauma centers (1989-1997). Patients with duodenal injuries were excluded. Data were extracted by individual chart review. Patients were classified as multi-trauma (group 1) or near-isolated SBI (group 2 with Abbreviated Injury Scale score within 8 hours: 2%; 8-16 hours: 9.1%; 16-24 hours: 16.7%; greater than 24 hours: 30.8%, p = 0.009) as did the incidence of complications. Delays as short as 8 hours 5 minutes and 11 hours 15 minutes were associated with mortality attributable to SBI. The rates of delay in diagnosis were not significantly associated with age, gender, intoxication, transfer status, or presence of associated injuries. CONCLUSION: Delays in the diagnosis of SBI are directly responsible for almost half the deaths in this series. Even relatively brief delays (as little as 8 hours) result in morbidity and mortality directly attributable to "missed" SBI. Further investigation into the prompt diagnosis of this injury is needed.　PMID: 10744277