図１〜図８で急性膵炎の診断で問題はなく，血管の合併症も認めない．

下段の翌日のCTで大量の腹水を認めるが，重症膵炎でもこれほど大量の腹水が１日で発生するとは思われず，急性膵炎のなんらかの合併症を考慮すべきである．図２０でdensityが計測されており，血腫は50〜60HU以上を示すと言われ，65HUだから血腫の可能性が高い．腹水のdensityも必ず計測すべきであり，おそらく30HU以上を示し容易に出血性合併症を疑えたであろう．図１５の１〜図１０の６は脾動脈だから図１３〜図１９の↑は動脈瘤かまたはextravasation（造影剤の血管外漏出）である．Delayed phaseの図A〜図Dで白矢印は同部位の↑と同じ大きさ・形態で残っているので動脈瘤である．ExtravasationならDelayed phaseで大きくなり周囲に広がる所見を呈する．血管造影で脾動脈瘤を認め（図E：▲），コイルで脾動脈を塞栓し（図F）止血に成功した．図Gは6週間後のCTで液化した血腫（△）を示す．

文献考察：膵炎に伴う仮性動脈瘤破裂の治療のfirst choiceは血管造影・TAEである．
１）Surgery. 2005 Mar;137(3):323-8.
Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis.
Bergert H, Hinterseher I, Kersting S, Leonhardt J, Bloomenthal A, Saeger HD.

BACKGROUND: Arterial pseudoaneurysm formation in pancreatitis is a rare complication. The optimal treatment modality is controversial. Operative treatment and interventional treatment, either alone or as a temporizing method with a later operation, are options. METHODS: In this single-center, patient-based cohort study, we managed 35 patients (8 with necrotizing pancreatitis and 27 with chronic pancreatitis) with bleeding pseudoaneurysms treated over a period of 10.5 years with a median follow-up of 4.6 years. Angiography was performed depending on the patient's hemodynamic condition. RESULTS: Angiography had a sensitivity of 96% for 26 patients. Angiographic embolization as primary treatment was performed in 16 patients (61% embolization rate); there were 2 rebleeding complications. No patients required intervention for embolization complications after discharge. Nineteen patients (54%) underwent an operation, 9 urgently without angiographic evaluation. The overall mortality rate for the 35 patients was 20% (19% for embolization, 21% after an operation). For necrotizing pancreatitis, an advantage of angiographic embolization was observed (mortality in 2/5 vs 2/3 after surgery). Ligation or repair of the bleeding vessel was complicated by higher rebleeding rates (6/13) than partial pancreatectomy (1/6). CONCLUSIONS: Concerns that angiographic embolization is unable to provide definitive hemostasis in both acute and chronic pancreatitis are unfounded. In the operative treatment of chronic pancreatitis, partial pancreatectomy is superior to vessel ligation, depending on the patient's general condition and degree of pancreatic inflammation. We propose an algorithm for the management of arterial pseudoaneurysms in the setting of pancreatitis.PMID: 15746787

２）Am J Surg. 2005 Sep;190(3):489-95.
Systematic appraisal of the management of the major vascular complications of pancreatitis.
Balachandra S, Siriwardena AK.

BACKGROUND: This study is a systematic appraisal of the management of major vascular complications of pancreatitis conducted by collating individual patient-episode data from published literature. METHODS: Searches identified 79 papers of which 62 provided detailed information on the clinical course of 214 patients. Principal outcomes were modes of presentation, results of diagnostic angiography, and embolization and overall outcome. RESULTS: There were 160 "spontaneous" and 40 postoperative episodes of hemorrhage. Underlying pancreatic disease was chronic pancreatitis (40), pseudocyst (135), and acute pancreatitis in 39. Angiography was undertaken in 173 (81%) with embolization attempted in 115 and achieving hemostasis in 85 (75%). There were 40 (19%) deaths. Mortality was greater in patients undergoing surgery as first intervention compared with angiography first (P = .01, Fisher exact test). CONCLUSION: This analysis of pooled data provides evidence of a central role for mesenteric angiography in the diagnosis of major vascular complications of pancreatitis and for angiographic embolization as a powerful tool for achieving hemostasis.PMID: 16105542