田中 保平

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

症例は79歳,男性。自転車走行中,ダンプカーに衝突されて受傷した。精査の結果,両側多発肋骨骨折,両側外傷性血気胸,両側肺挫傷,外傷性くも膜下出血,肝損傷,右腎損傷,多発胸腰椎骨折の診断となったが,いずれも保存的加療で改善した。また左横隔膜にBochdalek孔ヘルニアも指摘されたが,先天性か外傷による後天性かの判別は困難であった。Bochdalek孔ヘルニアは手術も考慮したが,過去症例および本人との協議により,内容物が後腹膜脂肪のみのため,症状増悪に注意しつつ経過観察とした。その後1年を経過しても絞扼を疑う症状の出現は認めていない。Bochdalek孔ヘルニアは新生児に多い疾患であるが,成人発症例も報告されている。報告された成人症例の多くは手術されており,保存的に長期間経過観察し得た症例は非常に少ない。受傷機転,症状,内容物を考慮したうえで保存加療とすることも選択肢になり得ると考えられた。(著者抄録)