井戸 弘毅¹, 磯部 紅仁子², 木村 圭一¹, 足立 正純², 鶴田 隆一², 小野 景子¹, 北村 直美¹, 利光 鏡太郎¹, 横田 徹¹

Kouki IDO¹, Kuniko ISOBE², Keiichi KIMURA¹, Masazumi ADACHI², Ryuichi TSURUTA², Keiko ONO¹, Naomi KITAMURA¹, Kyotaro TOSHIMITSU¹, Toru YOKOTA¹

¹名古屋徳洲会総合病院外科, ²名古屋徳洲会総合病院超音波検査室

¹Department of Surgery, Nagoya Tokushukai General Hospital, ²Ultrasonic Laboratory, Nagoya Tokushukai General Hospital

キーワード : bleeding pseudocyst, chronic pancreatitis, Doppler, ultrasonography

症例は50歳, 男性. 腹痛を主訴に当院に入院. 約1年半前, 慢性膵炎と診断, 腹部超音波検査で膵頭部に直径3 cm大の仮性嚢胞を指摘されていた. 今回来院時の超音波検査では膵頭部に直径5 cm大の腫瘤が認められ, 腫瘤内は外側の低エコー域, 中間層の流動性のある高エコー域, 内側のドプラで拍動波を示す嚢胞域で形成されていた. CTでは膵頭部に出血塊と思われる高吸収域がみられ, dynamic CTにてその内部に造影剤の漏出が認められた. 出血性膵仮性嚢胞と診断し経過観察したところ, 入院後11日目に突然吐血, 出血性ショックとなった. 出血性膵仮性嚢胞の十二指腸への穿破と診断し, 緊急血管造影検査を施行, 金属コイルによるTAEにて止血した. 止血術後, 膵頭部腫瘤は縮小し, 拍動波を示す嚢胞域は消失した. 出血性膵仮性嚢胞は頻度は少ないが, 慢性膵炎においてもっとも重篤な合併症の一つであり, 早期診断, 早期治療が重要である. ドプラを併用した超音波検査は本疾患の診断に有用であり, 慢性膵炎の腹痛, または消化管出血の患者を診る際は常に本疾患を念頭に入れた超音波検査をすべきであり, 診断されれば早期に血管造影, TAEを行うべきと考えられた.

A 50-year-old man was admitted to our institution for upper abdominal pain. The diagnosis was chronic pancreatitis. A pseudocyst 3 cm in diameter had been detected in the head of the pancreas by ultrasonography a year and a half earlier. At the current hospitalization, ultrasound examination showed a mass 5 cm in diameter where the pseudocyst had been seen. This mass comprised an external hypoechoic lesion, a middle movable hyperechoic lesion, and an internal cystic lesion showing an arterial signal on Doppler ultrasound examination. Computed tomography showed a high-density area thought to be a hematoma in the head of the pancreas, and extravasation in the mass was demonstrated by rapid injection of a contrast medium. Our diagnosis was a bleeding pseudocyst. The patient suddenly vomited fresh blood and went into hypovolemic shock on the 11th hospital day. Emergency angiography and transcatheter embolization with steel coils was accomplished under a diagnosis of rupture of the bleeding pseudocyst into the duodenum. Ultrasonographic examination showed that the mass had decreased in size and the cystic lesion, showing an arterial signal, had disappeared after embolization. Although bleeding pseudocysts occur infrequently, they are a life-threatening complication of chronic pancreatitis. Early diagnosis and treatment are thus essential. Ultrasound examination with Doppler ultrasonography is strongly indicated when diagnosing bleeding pseudocysts and examining patients with chronic pancreatitis accompanied by abdominal pain, gastrointestinal bleeding, or both. Early treatment by transcatheter embolization should be used to avoid this potentially lethal complication.