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文献考察：必読に値する極めて重要な文献．
Radiology. 2004 Jun;231(3):775-84.
Penetrating torso trauma: triple-contrast helical CT in peritoneal violation and organ injury--a prospective study in 200 patients.
Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ, Scalea TM.
PURPOSE: To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air. MATERIALS AND METHODS: During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15-85 years; mean age, 31 years) and 31 women (age range, 17-45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract. Sensitivity, specificity, and accuracy of CT in the diagnosis of peritoneal violation were determined. RESULTS: CT findings aided diagnosis of peritoneal violation in 34% of patients (68 of 200) and were negative for peritoneal violation in 66% of patients (132 of 200). Two patients with negative CT findings failed to improve with observation and underwent therapeutic laparotomy. CT had 97% sensitivity (66 of 68 findings), 98% specificity (130 of 132 findings), and 98% accuracy (196 of 200 findings) for peritoneal violation. CT aided diagnosis of 28 hepatic, 34 bowel or mesenteric, seven splenic, and six renal injuries. Laparotomy based on CT findings in 38 patients was considered therapeutic in 87% (33 of 38) and nontherapeutic in 8% (three of 38) and had negative results in 5% (two of 38). CONCLUSION: Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds. PMID: 15105455
要旨：penetrating torso Injury 540例中，29％は血圧不安定，明らかな腹膜炎（腹膜刺激症状：筋性防御，反跳痛と，創より離れた部位でかなり強い圧痛）のためCT検査なしに緊急手術された．200例にTriple-Contrast Helical CT検査によるprospective studyを行った．外傷機序はgunshot wound（銃創）43％，stab wound（刺創）56％，impalement（杙創：よくそう）2％．torso（胴）は5つの部位から成る．１：thoracoabdominal region（胸郭腹部，下部胸部：乳頭から肋骨弓まで，背部は肩甲骨下端まで），２：abdomen（腹部前面：両側前腋窩線間で肋骨弓より鼠径靱帯まで），３：flank（側腹部：前腋窩線と後腋窩線間で上は肋骨弓，下は腸骨稜まで），４：back（背部：肩甲骨間で上は肋骨弓，下は腸骨稜まで），５：pelvis（骨盤：腸骨稜と鼠径靱帯から大腿部上1/3まで）．撮影法は，2％の造影剤600mlを30分前に経口投与，2％の造影剤1000〜1500mlを経肛門的に投与，造影剤150mlを3ml/secで経静脈的に注入し，2〜3分後にCT撮影する．peritoneal violation（穿通性刺創）のCT所見：１．出血，ガス，弾丸や骨片により描出される刺入路が明らかに腹腔内に達する，２．腹腔内液貯留，３．遊離ガス，４．腹腔内に弾丸，５．腹腔内臓器損傷．腸間膜および腸管損傷のCT所見：１．経口的にまたは経肛門的に投与した造影剤の腸管外漏出，２．ガスや弾丸により描出される刺入路が腸管壁に達する，３．局所的な腸管壁肥厚または壁欠損像，４．腸間膜からの活動性出血（extravasation），５．腸間膜の濃度上昇または肥厚．刺創では空気が導入される，腹壁からの出血でも液貯留を認めるので遊離ガスと液貯留単独所見では消化管穿孔とは言えない．刺創部は胸郭腹部42％，腹部前面18％，側腹部15％，骨盤16％，背部16％．穿通性とCT診断されたのは34％で，66％は非穿通性と診断された．穿通性CT所見で最も多かったのは液貯留85％，順に腹腔内臓器損傷75％，”出血，ガス，弾丸や骨片により描出される刺入路が明らかに腹腔内に達する”65％，遊離ガス35％であった．Triple-contrast helical CTによるperitoneal violation（穿通性）の診断率は上記abstractのとおり．peritoneal violation（穿通性）陽性中腸間膜および腸管損傷のCT診断は47％になされた．腸管損傷のCT所見は多い順に，刺創路が腸管壁に達する77％，局所性の壁肥厚42％，造影剤の腸管外漏出18％．疑診例には4-6時間後のfollow-up CTが有用であった．
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