ニボーを形成する大量の腹水（※）と遊離ガス（G）は，かなり長時間前の消化管穿孔を示唆する．△は腸間膜間に存在する遊離ガスであるが，図３と図４の十二指腸（Du）周辺の▲は後腹膜に存在する遊離ガスであり，十二指腸の後腹膜穿孔を強く示唆する．図２〜図５の↑はextravasationではなく，図１の上腸間膜静脈（SMV）に連続するので正常な静脈である．A：上行結腸，T：横行結腸．手術で十二指腸水平部に2cm大の穿孔を認めた．

参考症例（十二指腸下行部離断）：24歳男性．牧場で馬に右上腹部を蹴られた．右上腹部に馬蹄痕を認め，腹膜刺激症状を呈していた．ガストログラフィン原液を服用させた後の造影CTである．

十二指腸は図３の1から数字順に展開するものと思われる．図３〜図１２の↑は腸管外に漏出したガストログラフィンであり，十二指腸下行部の穿孔を意味する所見である．図１０〜図１２の▲は腸管外ガスの可能性が高い．十二指腸水平部（図１０の9〜図１０の13）と上部空腸内に造影剤を認めないので，穿孔（IIa：周径の1/3未満）や破裂（IIb：周径の1/3以上で腸管壁の連続性が保たれているもの）ではなく，離断（IIc：腸管壁の連続性が完全に断たれているもの）であることを示唆する．手術で十二指腸下行部の離断を認めた．

文献考察：１）十二指腸損傷のCT所見
Jayaraman MV, Mayo-Smith WW, Movson JS, Dupuy DE, Wallach MT.
CT of the duodenum: an overlooked segment gets its due.
Radiographics. 2001 Oct;21 Spec No:S147-60. Review.　PMID: 11598254
追記：十二指腸損傷のCT所見．１：後腹膜腔内で十二指腸周囲に遊離ガス，２：経口的に投与した造影剤の腸管外漏出，３：後腹膜腔内の液貯留，４：十二指腸壁の浮腫または壁肥厚，５：周囲脂肪組織の濃度上昇，６：膵損傷．

文献考察：２）child abuse（乳幼児虐待）
J Pediatr Surg. 2004 Apr;39(4):600-2.
Duodenal injuries in children: beware of child abuse.
Gaines BA, Shultz BS, Morrison K, Ford HR.

PURPOSE: It is frequently overlooked that child abuse may result in significant intraabdominal injury, particularly to the duodenum. The authors hypothesized that a significant number of duodenal injuries in young children would be the result of nonaccidental trauma. METHODS: An 8-year (1995 through 2002) retrospective review of a pediatric level I trauma center database was performed after Institutional Review Board approval was obtained, and information regarding patients with duodenal injury was abstracted. Demographic variables, injury severity, length of stay, mortality rate, and mechanism of injury were examined. Statistical analysis was performed using descriptive statistics and Student's t test. Statistical significance was defined as P less than.05. RESULTS: Over the 8-year study period, 8,968 patients were admitted, 2,179 (24%) were less than 3 years of age. Thirty children (0.3%) suffered injury to the duodenum, with 20 hematomas and 10 perforations. Patients were overwhelmingly boys (80%), with an average age of 7.6 +/- 4.4 years and Injury Severity Score (ISS) of 14 +/- 10. No patients died. Children were injured by a variety of mechanisms, including collisions involving motor vehicles (n = 9), bicycles (n = 4), and ATVs (n = 2). However, all children less than 4 years of age (n = 8) were victims of nonaccidental trauma, 2.8% of all child abuse admissions. Three of these children suffered perforations of the duodenum. Among the entire population, those children who suffered perforations had a significantly higher ISS (23.7 +/- 7.2 v 9.6 +/- 7.3; P <.0003 and longer length of stay v p than those with hematomas conclusions: injury to the duodenum is unusual in pediatric trauma patient but does result significant severity prolonged hospitalization. young child one must maintain a high index suspicion regarding etiology because large percentage potentially abuse.>追記：十二指腸損傷30例（穿孔10例，壁内血腫20例）中child abuseによる外傷例は8例と高率であった．