Case Report pissn / eissn J Korean Soc Radiol 2016;75(4): Periureteral Varices

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Case Report pissn 1738-2637 / eissn 2288-2928 J Korean Soc Radiol 2016;75(4)

1 Case Report pissn / eissn J Korean Soc Radiol 2016;75(4): Periureteral Varices with Accompanying Pyelitis Diagnosed by 3-Dimensional Reformatted Technique of the Multidetector Row CT: A Case Report 전산화단층촬영의삼차원구성기법으로진단된신우염을동반한요관주위정맥류 : 1 예보고 Ji Hyun Yi, MD* Department of Diagnostic Radiology, College of Medicine, Yeungnam University, Daegu, Korea Periureteral varices are rare, and periureteral varices with accompanying pyelitis have been even more rarely reported. Our patient with flank pain was diagnosed with pyelitis because her CT scan showed thickening and enhancement of the ipsilateral renal pelvic wall and her clinical manifestations and laboratory results were well correlated with the diagnosis. Moreover, the author diagnosed periureteral varices because periureteral, tortuous, enhancing vascular structures were detected and 3-dimensional rendering technique of the CT scan showed that periureteral varices were connected to the ipsilateral renal vein. We experienced a case of periureteral varices with accompanying pyelitis, which was definitely confirmed by using the 3-dimensional rendering technique of the CT scan. Therefore, we report the case along with a brief review of the literatures regarding periureteral varices. Index terms Varicose Vein Ureter Pyelitis Multidetector Computed Tomography Imaging, Three-Dimensional Received November 13, 2015 Revised February 1, 2016 Accepted March 5, 2016 *Corresponding author: Ji Hyun Yi, MD Department of Diagnostic Radiology, College of Medicine, Yeungnam University, 170 Hyeonchung-ro, Nam-gu, Daegu 42415, Korea. Tel Fax ji1354@naver.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 요관주위정맥류는매우드문질환으로문맥고혈압항진, 요관양성용종, 신장혈관협착, 대동맥협착, 신장정맥혈전, 하대정맥폐쇄, 신장기형및판막의기능부전, 호두까기증후군 (nutcracker syndrome) 등에의해발생할수있다 (1-3). 요관주위정맥류의진단은과거에는경정맥요로조영술 (intravenous urography; 이하 IVU) 이나신정맥조영술 (renal venography; 이하 RV) 로진단되는경우가많았으나 (1, 4), 최근에는다중검출기전산화단층촬영 (multidetector computed tomography; 이하 MDCT) 의발달로영상의질이향상됨에따라삼차원영상과다양한재구성 CT 영상들을이용하여정맥계의해부학적위치, 주변혈관의변화, 요관의경로등을확인할수있어보다쉽고확실하게진단할수있다. 저자는신우염이동반된요관주위정맥류를다양 한 MDCT 삼차원재구성기법을이용하여진단할수있었던증례를보고하고자한다. 증례보고 70 세여자환자가좌측옆구리통증을주소로내원하였다. 과거력상에당뇨와고혈압으로진단받고약을복용중이었고가족력은특별한것이없었다. 의식은명료하고병색을보이지않았으며체온은정상이었으나늑골척추각 (costovertebral angle) 의통증과압통을호소하였다. 내원당시시행한혈액검사에서백혈구 7840/uL, 혈색소 13.4 g/dl, 혈소판 /uL였고화학검사에서총단백 7.0 g/dl, 알부민 4.0 g/dl, blood urea Copyrights 2016 The Korean Society of Radiology 327

2 전산화단층촬영의삼차원구성기법으로진단된신우염을동반한요관주위정맥류 nitrogen 18.9 mg/dl, creatinine 0.9 mg/dl 로정상이었지만, 호중구 (neutrophil) 76%, high sensitive C reactive protein 1.6 mg/dl로증가되어있었다. 소변검사에요혈, 요단백, 요백혈구가양성이었으며, 세포병리검사상에고배율현미경시야에서적혈구와백혈구가다수관찰되었고편평세포 (squamous cell) 도관찰되었지만요세균배양검사는음성이었다. 급성신우신염의원인과그에동반된합병증여부를확인하기위해역동적조영증강 CT (dynamic contrast enhanced CT) 를시행하였으며신조영기 (nephrographic phase) 축영상 (axial image) 에서신우와요관을따라서혈관으로생각되는조영증강이잘되는병변들이관찰되었다. 신조영기시상영상 (sagittal image) 에서신우의벽이두꺼워지고조영증강되어신우염이의심되었으며신우와요관을따라구불구불하게주행하는정맥들이관찰되어요관주위정맥류를진단할수있었다 (Fig. 1A). 다평면곡선재구성영상 (multiplanar curved reconstruction image; 이하 MPCRI) 에서도시상영상과마찬가지로신우와요관을따라구불구불한비정상적인정맥들이관찰되었고 (Fig. 1B), 최대강도투사법 (maximum intensity projection; 이하 MIP) 영상에서정맥류와동측신장정맥과의연결성을확인할수있었으며 (Fig. 1C), 볼륨가시화 (volume rendering; 이하 VR) 영상에서도비정상적인요관주위정맥류를보다더입체감있게확인할수있었다 (Fig. 1D). 분비기 (excretory phase) 조영증강영상에대한 MPCRI 에서는정맥류의압박에의한신우와요관의패임현상이마치코르크따개모양으로관찰되었다. 그밖에신장동맥및정맥혈관의협착, 혈관기형이나혈전등의소견은관찰되지않았다. 환자는임상증상, 요검사및영상검사소견등을바탕으로신우염으로진단되었으며항생제치료와요관카테터를삽입하여증상이호전되었다. 그후약 10 개월뒤에시행한추적 CT 검사에서정맥류는그대로남아있었지만이전에보였던신우염소견은관찰되지않았다. 고찰 요관주위정맥류는매우드문질환으로 1922 년 Folsum 이처음보고한이래로다양한원인에의해발생한예들이보고되었다 (1). 요관주위정맥류의원인으로는문맥고혈압항진, 요관양성용종, 신장혈관협착, 대동맥협착, 신장정맥혈전, 하대정맥폐쇄, 신장기형및판막의기능부전, 호두까기증후군등이있고특별한원인없이도발생할수있다 (1-3, 5). 본증례에서도이들다양한원인들에대해조사하였으나원인이될만한특별한이상소견은관찰되지않았다. 요관주위정맥류의증상은엉덩뼈오목 (iliac fossa) 이나허리의 경미한통증, 지속되는혈뇨등이있으며특별한증상없이미세혈뇨만을일으키는경우도있으며경우에따라서는하지의정맥류가동반되기도한다 (6, 7). 본증례에서환자는옆구리통증을주소로내원하였으며요검사에서혈뇨, 농뇨 (pyuria), 단백뇨가검출되었다. 비록요세균배양검사에서세균이배양되지않았지만 CT에서신우의벽이두꺼워지고조영증강이증가되는영상소견과함께세포병리검사상에혈뇨 (hematuria), 농뇨 (pyuria) 및편평세포발견, 옆구리통증등의임상소견을종합하여신우염이동반된요관주위정맥류로진단할수있었다. 요관주위정맥류도매우드물지만신우염이동반된요관주위정맥류는아직보고된예가극히드물었다. 요관주위정맥류로인한요관압박이요로의완전폐색 (urinary tract obstruction) 을일으키지는않았지만요저류 (urinary stasis) 를일으켜신우염이발생한것으로생각되며, 환자의당뇨과거력도요로감염과신우염을일으키는데기여했을것으로생각된다. 과거에는요관주위정맥류를진단하기위해 IVU 나 RV 와같은영상검사를많이시행하였다 (1-4). 특히 IVU 에서요관주위정맥류는요관이나신우주위의확장된혈관들에의한외부압박으로인해패인모양으로보이며전체적으로요관이부채꼴의코르크따개모양 (scallpoped corkscrew-like appearance) 을보여진단에도움이되었다 (1, 4). 하지만이런요관의패임소견은다발유두종, 정맥류모양혈관종 (cricoid angioma), 낭모양신우요관염 (pyelo-ureteritis cystica), 요산돌, 결핵성요관염, 나선형꼬임, 대동맥협착, 대동맥주위림프절비대 (para-aortic lymph node enlargement) 등에서도관찰될수있기때문에진단에비특이적이다 (1). 또한 RV 는정맥류를관찰하기에는가장좋은검사법이지만정맥류와신우혹은요관과의관계를명확히관찰하기어려우며침습적인검사법으로검사의번거로움이있고합병증이생길수도있어일차적인검사로사용하기에는무리가따른다. 최근 MDCT 가눈부신발전을하면서촬영속도와해상도를향상시킴으로써어느방향으로절편영상 (slice image) 을재구성하든지질좋은영상을얻을수있게되었고이를바탕으로삼차원재구성영상도엄청난발전을가져왔다. 이러한 MDCT 삼차원재구성영상기법중 MPCRI, MIP, VR 기법은혈관영상분야에서유용하게사용되어왔으며신혈관협착, 호두까기증후군등의신혈관질환의진단에도매우중요하게사용되어왔다 (5, 6). 이처럼신혈관질환의진단에 MDCT 가유용하나 MDCT 를이용한삼차원재구성영상기법으로요관주위정맥류를진단하고기술한예는없었다. 우리는 MPCRI 를통하여요관주위의비정상적인정맥확장을관찰할수있었으며 VR, MIP 를이용하여요관주위정맥류를보다입체적으로관찰할수있었으며좌측 328 대한영상의학회지 2016;75(4): jksronline.org

이지현 A B C D Fig. 1. Periureteral varices in a 70-year-old woman. A, B.

reformatted image (B) reveal tortuous, tubular venous structures

Mild thickening with enhancement of the left renal pelvic wall

Maximum intensity projection image shows periureteral varices

3 이지현 A B C D Fig. 1. Periureteral varices in a 70-year-old woman. A, B. Corticomedullary phase sagittal CT scan (A) and multiplanar curved reformatted image (B) reveal tortuous, tubular venous structures (arrows) along the left ureter. Mild thickening with enhancement of the left renal pelvic wall suggesting pyelitis is noted (red arrows). C. Maximum intensity projection image shows periureteral varices connected to the Lt. renal vein (arrows). D. Volume rendering image demonstrates periureteral varices (arrows). jksronline.org 대한영상의학회지 2016;75(4):

4 전산화단층촬영의삼차원구성기법으로진단된신우염을동반한요관주위정맥류 신장정맥과의연결성을관찰하는데큰도움이되었다. 또한분비기영상에서재구성된 MPCRI 를통하여정맥류에압박으로인해코르크따개모양을보이는요관의패임현상을관찰할수있어치료나예후에도움이될만한정보를더얻을수있었다. 요관주위정맥류의치료는원인질환과증상의정도에의해결정된다. 일반적으로증상이없는경우는특별한치료를요하지않으나혈뇨가심하거나요통과복통이심한경우는중재시술이나외과적처치가필요할수있다 (1, 4). 본증례에서도신우염과폐쇄성요로병증이의심되어항생제투여와함께요관카테터를삽입하였으며이와같이수술이나중재적치료가필요한경우라면 MDCT 삼차원영상기법을이용해정확한영상을얻는것은더욱중요하다할수있다. 현재까지의보고에서는요관주위정맥류를진단하기위해다른검사법을많이사용해왔다. 하지만저자는 MDCT 삼차원영상기법을이용하여요관주위정맥류를보다효과적이고확실하게진단할수있었다. 결론적으로 MDCT 삼차원영상기법은요관주위정맥류를진단하는데가장효과적인검사법으로생각된다. 아울러요관주위정맥류가신우염과동반될수있다는사실도염두에두어야겠다. REFERENCES 1. Heal MR. Ureteral varicosities--a cause of the corkscrew ureter. Br J Surg 1970;57: Weiner SN, Bernstein RG, Morehouse H, Golden RA. Hematuria secondary to left peripelvic and gonadal vein varices. Urology 1983;22: Wendel RG, Crawford ED, Hehman KN. The nutcracker phenomenon: an unusual cause for renal varicosities with hematuria. J Urol 1980;123: Kim HS, Park JW, Won IS, Shin KC, Kim S, Yang J, et al. A case of periureteral varices with nutcracker syndrome diagnosed by intravenous pyelography. Korean J Nephrol 2009;28: Trambert JJ, Rabin AM, Weiss KL, Tein AB. Pericaliceal varices due to the nutcracker phenomenon. AJR Am J Roentgenol 1990;154: Ali Khan S, Jayachandran S, Desai PG, Bonheim P. Renal colic, a presenting symptom of pelviureteric varices. Int Urol Nephrol 1985;17: Martelli A, Vitullo F. Microscopic hematuria due to periureteral varices. Urol Int 1970;25: Johnson PT, Halpern EJ, Kuszyk BS, Heath DG, Wechsler RJ, Nazarian LN, et al. Renal artery stenosis: CT angiography-- comparison of real-time volume-rendering and maximum intensity projection algorithms. Radiology 1999;211: Cuéllar i Calàbria H, Quiroga Gómez S, Sebastià Cerqueda C, Boyé de la Presa R, Miranda A, Alvarez-Castells A. Nutcracker or left renal vein compression phenomenon: multidetector computed tomography findings and clinical significance. Eur Radiol 2005;15: 대한영상의학회지 2016;75(4): jksronline.org

5 이지현 전산화단층촬영의삼차원구성기법으로진단된신우염을동반한요관주위정맥류 : 1 예보고 이지현 * 요관주위정맥류는드물고요관주위정맥류와함께신우염이동반된경우는더욱드물다. 저자는옆구리통증을주소로내 원한 70 세여자환자의전산화단층촬영에서동측신우의벽이두껍게조영증강되고임상양상과검사결과가진단과잘 부합하여신우염으로진단할수있었다. 또한요관을둘러싸는구불구불하고조영증강되는혈관구조물을확인하고요관 주위정맥류로진단할수있었으며삼차원재구성영상에서정맥류는동측신장정맥과연결되어있었다. 저자는전산화단 층촬영및삼차원재구성영상을이용하여신우염을동반한요관주위정맥류로확진할수있었던예를경험하였기에간단한 문헌고찰과함께보고하고자한다. 영남대학교의과대학영상의학과학교실 jksronline.org 대한영상의학회지 2016;75(4):

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ÀÌ±Ù¿µ 607 Table 1. Diagnostic Accuracy in the Detection of Urinary Stone Between CT Urography (CTU) and Intravenous Urography (IVU) (n=34) CTU Urinary stone (+) Urinary stone ( ) (n=27) (n=7) IVU Urinary stone