救急１３

【臨床症状】40代　下腹部痛　CRP:26.9　WBC:22700

【問題】画像所見と診断名は？

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➡ 冠状断

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    ▶答えはこちら
    • 膵臓は尾部で腫大しているのが確認できる
    • 同部位は造影（動脈相～静脈層）でも低吸収域を認め壊死の可能性が否定できない所見
    • 周囲（前腎傍腔）に脂肪組織濃度上昇を認めるが、結腸膜根部や腎下極以遠に炎症波及の所見はない
    • 上記より急性膵炎（グレード1）疑い
    • 治療のために他院紹介となる
    • 他、肝嚢胞、下行結腸に多数の憩室あり
    ※ 前腎傍腔レベル、結腸間膜根部レベル、腎下極以遠レベル

    【急性膵炎】

    ・急性膵炎は膵実質に壊死を伴わない「間質性浮腫性膵炎」と、壊死を伴う「壊死性膵炎」に分類される（改定アトランタ分類より）

    ・このうち8割が間質性浮腫性膵炎で、多くが1週間以内に症状が改善する

    ・壊死性膵炎は重症膵炎に分類され、これには一時的な虚血のみの膵炎も含まれる

    ・原因はアルコールと胆石によるものだけで6割近くを占める

    ・その他は特発性、医原性、腫瘍性などが続くが、割合的には上記2項目より少ない

    ・主な症状は急激な腹痛、圧痛

    ・膵アミラーゼ、リパーゼなどの血液項目の数値も参考になる

    ・急性膵炎の画像所見は次のようなものがある

    1. 膵腫大
    2. 周囲の脂肪組織濃度の上昇
    3. 筋膜の肥厚
    4. 前腎傍腔への液体貯留
    5. 造影効果の有無（造影効果がなければ虚血や壊死が疑われる）

    また重症度判定（Grade分類）があり、造影不良域と膵外進展度からGrade1～3に分類される（Grade3が最も重症）

    造影不良域/膵外進展度前腎傍腔結腸間膜根部腎下極以遠
    膵周囲のみ
    あるいは各区域に限局    		Grade1Grade1Grade2
    2つの区域にかかるGrade1Grade2Grade3
    2つの区域全体
    あるいはそれ以上    		Grade2Grade3Grade3
    ※膵を膵頭部、膵体部、膵尾部の3区域に分けて判定
    参考書籍：すぐ役立つ救急のCT・MRI 改定第2版