上段の来院時のCTで肝周囲に腹水（※）を認める．図４で膵前面の液貯留（↑：均一な低濃度域で境界鮮明）と，図５と図６では脂肪組織の濃度上昇（↑）を示し膵損傷の可能性を示唆する．図４と図５で膵体部の△は膵断裂を示唆するが，図３では連続しているよう（▲）で，不完全断裂のように見え，ERPの適応である．下段の翌日のCTで腹水（※）が増加している．図１０〜図１２の膵前面の液貯留（↑）も増量し，不均一な高吸収値を呈しているので血腫であろう．図１４〜図１７で前腎傍腔にも相当量の液貯留(↑）を認め膵損傷の可能性が高くなった．図１３と図１４で膵体部損傷部（△）は今度は完全断裂に見えるが，正確な診断には5mm以下のthin slice 造影CTが必須である．T：膵尾部，B：体部，H：頭部．図AのERPで膵体部から大量の造影剤の漏出（▲）を認めるが，尾部の主膵管も造影されている（↑）．手術で膵体部頭側の部分（約50％）断裂を認め，膵管も半周のみ断裂していた．膵体尾部・脾臓合併切除を行った．

文献考察：膵管損傷を伴う膵損傷に対するステント治療
J Pediatr Surg. 2001 Feb;36(2):345-8.
Treatment of pancreatic duct disruption in children by an endoscopically placed stent.
Canty TG Sr, Weinman D.

BACKGROUND: Injuries to the pancreas from blunt abdominal trauma in children are rare. Most are minor and are best treated conservatively. The mainstay for treatment of major ductal injuries has been prompt surgical resection. Diagnostic imaging modalities are the key to the accurate classification of these injuries and planning appropriate treatment. Computed tomography (CT) scan has been the major imaging modality in blunt abdominal trauma for children, but has shortcomings in the diagnosis of pancreatic ductal injury. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown recently to be superior in diagnostic accuracy. The therapeutic placement of stents in the trauma setting has not been described in children. METHODS: Two children sustained major ductal injuries from blunt abdominal trauma that were suspected, but not conclusively noted, on initial CT scan. Both underwent ERCP within hours of injury. In case 1, a stent was threaded through the disruption into the distal duct. In case 2, a similar injury, the stent could only be placed through the ampulla, thereby reducing ductal pressure. In both cases, clinical improvement was rapid with complete resolution of clinical and chemical pancreatitis, resumption of a normal diet, and discharge from the hospital. The stents were removed at 10 and 12 days postinjury, and both children have remained well. Follow-up ERCP and CT scans show complete healing of the ducts and no evidence of pseudocyst formation 1 year post injury. CONCLUSIONS: Acute ERCP should be the imaging modality of choice in suspected major pancreatic ductal injury. Successful treatment by placement of an intrapancreatic ductal stent may be possible at the same time. Surgical resection or reconstruction can then be reserved for cases in which stenting is impossible or fails.PMID: 11172431
追記：上記症例のような”side hole injury”（膵管の部分断裂）2例に膵管にステントを留置し，治療に成功した．