来院時のCTで肝損傷（図２〜図４：▲）を示しているが，周囲に腹水や血腫を認めず日本外傷学会肝損傷分類 Ib である．図３と図４で膵尾部損傷（△）を認めるが，図２で膵組織の一部（白矢印）は繋がっており部分断裂である．翌日の5mmスライスCTでは図１０〜図１４の5スライスで断裂（△）を示し，図７〜図９の3スライスで膵組織の連続性（白矢印）を認め50％以上の部分断裂である．5mmスライスCTで確信を持って膵組織50％以上の断裂と診断できれば主膵管損傷の可能性は極めて高い．ERPで膵尾部での造影剤漏出を認めた（図A：↑）．手術では膵尾部の完全断裂を認め（図B：△），膵尾部・脾臓合併切除が施行された．CT所見と手術所見は100％一致しないこともあるが，5mmスライスCTで8スライス中5スライスで断裂を認めれば主膵管損傷を意味することは証明された．

文献考察：ERPの膵管損傷所見で治療法を選択．
J Trauma. 2000 Apr;48(4):745-51; discussion 751-2.
Pancreatographic classification of pancreatic ductal injuries caused by blunt injury to the pancreas.
Takishima T, Hirata M, Kataoka Y, Asari Y, Sato K, Ohwada T, Kakita A.

BACKGROUND: In the treatment of patients with pancreatic injury, the focus of attention is usually on main ductal injuries. METHODS: To develop a classification system for pancreatic ductal injuries, we retrospectively analyzed blunt pancreatic injuries in 40 patients. We assessed the relationships between findings on pancreatography (36 endoscopic retrograde procedures and 4 transduodenal procedures), the treatment modality, and the clinical course. RESULTS: Patients with class 1 injuries (radiographically normal ducts, n = 13) could be treated nonsurgically without major complications. Patients with class 2 injuries (branch injuries, n = 7), in whom contrast medium from ductal branches did not leak from the pancreatic parenchyma (class 2a, n = 3), could be treated nonsurgically. Patients with leaks into the retroperitoneal space (class 2b, n = 4) required at least a drainage laparotomy. Patients with class 3 injuries (main duct injuries, n = 20), including two patients in whom conservative treatment resulted in severe complications, required laparotomy. CONCLUSION: This classification system for pancreatic ductal injuries may facilitate the selection of appropriate therapeutic modalities for patients with blunt pancreatic injury.PMID: 10780612