Pictorial Essay pissn J Korean Soc Radiol 2012;67(3): Acute Gynecologic Disorders in Adolescents: CT Findings 청소년기의급성부인과계질환 : CT 소견 Y

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1 Pictorial Essay pissn J Korean Soc Radiol 2012;67(3): cute Gynecologic Disorders in dolescents: CT Findings 청소년기의급성부인과계질환 : CT 소견 Young Tong Kim, MD Department of Radiology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea Gynecologic disorders that cause pelvic pain in adolescents include hemorrhagic ovarian cysts, rupture or torsion of ovarian cyst or tumors, hematocolpos caused by vaginal obstruction, endometriosis, cystic uterine adenomyosis, pelvic inflammatory diseases, and pelvic inclusion cyst. The use of CT for the evaluation of pelvic pain is increasing, and CT is useful if ultrasound findings are not decisive and the lesion is extensive. Index terms dolescent Gynecologic Disease Pelvic Pain CT Received October 5, 2011; ccepted February 6, 2012 Corresponding author: Young Tong Kim, MD Department of Radiology, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan , Korea. Tel Fax ytokim@schmc.ac.kr This work was supported in part by Soonchunhyang University Research Fund. Copyrights 2012 The Korean Society of Radiology 서론 청소년기는사춘기에서성인으로가는중간과정의과도기로넓게는 10대를일컬으며좁게는 13세에서 19세사이, 즉사춘기가시작되는중학생과고등학생에해당된다. 청소년기의여아들은월경과성적활동이시작되면서소아와성인여성과는다른질환이나같은질환의다른소견을보일수있다. 사춘기이전의소아에서골반통은장관, 비뇨기계, 부인과계질환에의해유발될수있으며 (1) 청소년기에서는부인과계질환이더흔한원인이된다 (2, 3). 청소년기의여성에서골반통을일으키는주요질환은급성충수염, 장염, 요로감염, 요석, 부인과계질환등이있다. 청소년기의부인과계질환은성인여성들과유사하지만선천성기형에의한질폐색이나난소염전등은청소년기에더흔하며, 성적활동을시작하면서골반염이나자궁외임신등이골반통을유발한다. 청소년기에골반통을유발하는부인과계질환은출혈성난소낭종, 난소낭종혹은종양의파열, 난소염전, 질폐색에의한자궁질혈종, 자궁내막증, 골반염등이흔한원인질환이며, 낭성자궁선근종과복막봉입체낭포등도드문원인질환이다 (1-3). 골반통은급성과만성으로나뉘며또한생리주기에따른주기성의여부에따라나뉘기도한다. 급성골반통을일으키는질환은골반염, 자궁외임신, 난소염전, 출혈성난소낭종, 난소낭종혹은종양의파열등이며주기성을갖는만성골반통은월경통, 배란통, 자궁내막증, 난소염전, 선천성기형에의한질폐색등이며, 주기성이없는만성골반통은자궁내막증에의해유발될수있다. 골반통을호소하는환자에게가장먼저초음파가시행되고 (1) MR 과 CT는부가적으로시행한다 (2, 3). 하지만급성골반통을호소하는응급환자에서 CT가검사하기가용이하여많이시행되고있으며더증가하는추세이다. 또한초음파에서진단이명확하지않거나병변이더광범위할때진단에도움이될수있다 (2, 3). 본논문에서는청소년기의여성에서골반통을일으킬수있는부인과계질환에대해알아보고다양한 CT 소견에대해알아보고자한다. 출혈성난소낭종난소내의미성숙난포는사춘기가되면서성숙되어난자를방출하고그이후에황체가된다. 황체는배란후에프로게스테론을만들어임신을유지하는역할을하는데임신이되지않을경우에는황체가백색체 (corpus albicans) 가되어퇴행한다. 난포가난자를방출해야하는데방출하지못하고계속커지면난포낭종을형성하게되고, 황체도커지면황체낭종을형 submit.radiology.or.kr 대한영상의학회지 2012;67(3):

2 청소년기의급성부인과계질환 Fig. 1. Hemorrhagic ovarian cyst in a 13-year-old girl who complained of abdominal pain in right lower quadrant area for one day. Precontrast axial scan shows a cystic mass with a fluid-fluid level (arrow) in right adnexa. 성하는데, 난포낭종과황체낭종은월경과정에서생기고자연소실되기때문에기능성낭종이라고한다. 기능성낭종은대부분이편측성으로보이며, 크기는 1~8 cm로다양하며, 초음파에서얇은벽을갖는저에코성낭종으로보인다. 기능성낭종의증상은무증상이거나, 둔한통증을유발할수있으며, 대부분이자연소실된다. 하지만, 낭종이갑작스럽게커지거나, 낭종내에출혈이생기거나, 낭종이파열되면급성복통을유발한다 (1). 출혈성난소낭종은급성복통을일으키는주된원인중하나로난포낭종과황체낭종에출혈이발생할수있으며황체낭종에출혈이더잘동반되는데, 그원인은황체기 (luteal phase) 때혈관들이증가하기때문이다. CT에서출혈성난소낭종은낭종내에고음영을포함한다양한감쇄지수를보이며액체액체층을보일수있다 (2, 3)(Fig. 1). Fig. 2. Hemorrhagic ovarian cyst in a 18-year-old girl who presented lower abdominal pain for one day. Precontrast axial scan shows a high attenuation cystic mass (C) in pelvic cavity. lso note high attenuation fluid collection in pelvic cavity (*), suggesting hemoperitoneum. It was proven as ruptured corpus luteal cyst of right ovary pathologically. Fig. 3. Rupture of hemorrhagic ovarian cyst in a 13-year-old girl who represented lower abdominal pain with rebound tenderness for 2 days. Postcontrast axial scan shows a irregular shaped cystic mass (C) with wall enhancement in pelvic cavity. n interruption of enhancing wall (arrow) is suggestive of rupture. lso note fluid collection in pelvic cavity. She was improved by the conservative treatment. 난소낭종및성숙기형낭종의파열단순난소낭종이파열되면골반강내에무에코성액체가보이며출혈성난소낭종이파열되면골반강내에에코가높은액체저류가보인다. 황체낭종이파열되면 CT에서낭종벽의강한조영증강, 낭종벽의불연속성혹은끊김, 두꺼워진낭종벽, 자궁과부속기에높은감쇄지수를갖는복수등이보인다 (Figs. 2, 3). 낭종벽의강한조영은혈류증가로인한소견이며낭종벽의불연속성혹은끊김은낭종파열을시사하는직접적인소견이다 (4). 파열된낭종벽은파열되지않는낭종에비해두껍다. 출혈성난소낭종이파열되면혈복막강과저혈압을유발할수있다. 자궁과부속기에높은감쇄지수를갖는복수는혈복막강 (hemoperitoneum) 을시사한다 (2, 3). 드물게조영제의유출을보일수있고지연영상에서복강내에조영제를포함한피가고여있는소견을보일수있다 (3). 난소종양중가장흔한성숙기형낭종은유피낭종 (dermoid cyst) 이라고도하는데두꺼운피막을가지고있어약 1% 에서드물게파열될수있으며 (Fig. 4), 파열은자발적으로생기거나염전, 감염등에의해생긴다 (1-3). 성숙기형낭종이복강내로파열되면급성복막염을유발하지만간혹만성적으로유출되면만성육아종성복막염을유발하기도한다. 드물게기형종이다른장기랑연결될수있는데주변의방광, 질, 소장, 대장으로파열되기도한다. 파열이되면복강내에지방액체층 (fatfluid level) 을보일수있다. 난소염전난소염전은모든연령에서생길수있지만생식기에더호발한다. 난소염전은대부분에서난소종양이나난소낭종과연관이있으며, 동반되는난소종양은대부분이양성이며성숙기형낭종 196 대한영상의학회지 2012;67(3): submit.radiology.or.kr

3 김영통 이가장흔하다 (3)(Fig. 5). 성숙기형낭종은염전, 악성으로변화, 파열, 감염등의합병증을잘동반할수있는데약 16% 에서염전을동반한다고한다. 악성종양의경우난소를고정시키기때문에염전의빈도가줄어든다고본다. 또한자궁내막증이나골반염이있는경우도난소주변에유착을일으켜염전의빈도가감소한다고한다. 정상난소가염전을일으킬수있는데청소년기에더호발한다 (5). 이는정상난소의과도한가동성 (mobility), 과도한운동, 복압의갑작스런상승. 나팔관의연축 (spasm), 길어져있는골반인대등으로설명하고있다 (1, 3, 5). 난소염전의증상은심한하복부통증, 오심, 구토, 발열등을나타내기때문에임상적으로충수돌기염과급성장염등과감별을요한다. 그리고약 50% 이상의환자에서하복부에종괴가촉지된다. 비특이적인임상소견으로인해대부분의환자 에서진단이늦기때문에난소를제거하는경우가많다 (3). 난소염전의영상소견은정상난소가염전이되었는지기존의난소종양이염전이되었느냐에따라다양하며 (2), 또나이에따라초음파소견이다를수있는데나이가어린소아나신생아에서는골반밖의낭성혹은복합성낭성종괴로보이고청소년기에는부속기에고형종괴로보인다 (6). 커져있는난소의변연부에다발성의낭포들이있는특징적인소견을보이기도하나, 대부분이비특이적인복합성낭성종괴로보인다 (6). 그리고염전이된난소내에혈류가보이기때문에, 혈류가보인다고염전의가능성을배제할수없다 (3). CT에서두꺼워진난관, 염전이된낭성종괴의벽비후, 복수, 자궁이염전이있는방향으로치우쳐져있거나, 커져있는난소가반대방향으로이동되어있는소견을보인다 (3, 5)(Figs. Fig. 4. Rupture of ovarian dermoid cyst in a 15-year-old girl who complained of lower abdominal pain with tenderness and rebound tenderness. Postcontrast axial scan shows dermoid cyst with fat-fluid level and calcification, and fat (arrow) outside the tumor is identical to intratumoral fat. There is moderate amount of pelvic free fluid (arrowheads). Fig. 5. Torsion of ovarian dermoid cyst in a 13-year-old girl who had lower abdominal pain with tenderness and rebound tenderness for three days. Precontrast axial scan shows a high attenuation mass (C) with fat and calcification containing cystic mass, suggesting torsion of underlying ovarian dermoid cyst. high attenuation nodular lesion (arrow) adjacent to cystic mass is suggestive of tubal hemorrhage. Fig. 6. Ovarian torsion in a 14-year-old girl who complained of nausea and abdominal pain in right lower quadrant area for two days.. Precontrast axial scan shows high attenuation mass (C) with cystic component in pelvic cavity.. Postcontrast axial scan shows that left ovary (arrow) is normal in position and uterus is deviated to right side. Salpingoophorectomy was done, and it was diagnosed as hemorrhagic infarction of right ovary pathologically. submit.radiology.or.kr 대한영상의학회지 2012;67(3):

4 청소년기의급성부인과계질환 6-8). CT에서염전된부속기에약 80% 에서낭성조직으로보이지만병리적으로는약 50% 에만낭성조직을보이는데이는괴사가 CT에서저음영으로보이기때문이다. 염전된부위에평균 12 cm의부속기종괴가있고대부분의종괴는지방을포함하거나포함하지않은낭성종괴로보인다. 과거에는난소염전이있을때염전을푼후의색전증때문에자궁부속기절제술 (adnexectomy) 을시행하였으나최근들어염전을푼후에색전증이없이수정능력과난소기능을유지할수있다는보고들이있어출혈성경색이보이지않으면보존적인치료를하는추세이다 (5). CT에서낭성종괴의벽은평균 11 mm로두꺼워져있거나, 낭종벽의한쪽만 10 mm 이상두꺼워져있으면출혈성경색을의미하며출혈성경색이없으면 3 mm 이하이다 (5). 부난소낭종 (paraovarian cyst) 은난소와나팔관사이의자궁광 인대에생기는낭종으로자궁부속기의낭종중에서는약 20~30% 정도발생한다 (2). 대부분이 30~40 대여성이며소아에서는드물다. 부난소낭종은경 (pedicle) 이없고광인대로퍼져나가기때문에거의합병증이없지만출혈, 천공, 염전, 종양등이생길수있다. 부난소낭종의약 2~16% 에서염전이발생할수있는데대부분이임신한여성에서호발하며소아에서는드물게보고되고있다. 수술전에진단이어렵지만난소가정상이면서자궁과인접한부위에낭종이있을때진단이가능하며복통을호소하는환아에서초음파에서고에코성종괴로보이면염전의가능성을생각할수있다 (7)(Fig. 9). 자궁질혈종사춘기가되어월경이시작되면서횡질중격과무공처녀막에 Fig. 7. Ovarian torsion with hematosalpinx in a 11-year-old girl.,. Postcontrast axial scans show large low attenuation mass-like lesion (arrowheads) with small cystic lesion (arrows) in anterior portion of lower abdominal and pelvic cavity, suggesting torsed left ovary. Uterus is deviated to left side. large cystic mass (C) with wall enhancement is in pelvic cavity. It was diagnosed as left ovarian torsion and hematosalpinx surgically, so detorsion of twisted left ovary and cystectomy of left adnexa were done. The cystic lesion was confirmed as hemorrhagic necrosis of fallopian tube pathologically. Fig. 8. Ovarian torsion in a 10-year-old girl who complained of fever and low abdominal pain for four days.,. Postcontrast axial scans show enhancing soft tissue mass-like lesion (arrowheads) connecting to torsed enlarged left ovary (O). It represents a twisted thickened fallopian tube. Detorsion of left adnexal torsion was done. 198 대한영상의학회지 2012;67(3): submit.radiology.or.kr

5 김영통 의한질폐색으로자궁질혈종 (hematometrocolpos) 이유발되며이는급성골반통의한원인이된다 (1, 8). 횡질중격은뭘러기형의일부이며뭘러기형은무증상이거나불임과관련이있으며일부에서폐색이동반되면월경통이나복부종괴로나타날수있다 (1, 8). 뭘러기형은크게뭘러관이형성, 측융합 (lateral fusion) 이상, 수직융합 (vertical fusion) 이상, 혹은여러가지결합이같이있는것으로나뉠수있다 (1). 측융합이상은단각 (unicornuate) 자궁, 양각 (bicornuate) 자궁, 중복 (didelphic) 자궁, 중격 (septate) 자궁, Diethylstilbestrol (DES) 과관련된자궁기형등으로나뉘며, 수직융합이상은자궁경부이형성, 횡질중격 (transverse vaginal septum) 으로나뉜다. 뭘러관이상은발생학적으로신장기형을잘동반하는데, 이때동반되는신장기형은신장무형성, 이소성신장, 낭성이형성, 중복성집합관등 이다 (1, 8). 중복자궁의약 75% 에서수직격막과연관이있으며횡질중격도동반할수있으며, 편측성질폐색과신장무형성을동반하는증후군을만들기도하는데이를 Herlyn-Werner- Wunderlich 증후군이라고하기도한다 (8)(Figs. 10, 11). 질폐색과신장무형성을동반한중복자궁을가진환자의평균연령이 17.4 세이며대부분이복통을호소하였다. 횡질중격은어디에나생길수있으며, 상부와중부사이에잘발생하여자궁질혈종을형성하며 (Fig. 11) 심한경우는난관혈종 (hematosalpinx) 을유발할수있다 (8)(Fig. 10). 이러한질폐색은월경때역행흐름을일으켜자궁내막증식증과골반내유착의빈도를증가시킬수있다 (8)(Fig. 12). 영상소견은늘어난질내에혈액이고여있는소견을보이는데 MRI 가격막의두께를보는데더도움이된다. 수직격막은자궁기형과관련이있는데대부분이 Fig. 9. Torsion of paratubal cyst in a 14-year-old girl who had lower abdominal pain with tenderness and rebound tenderness for three days.. Transabdominal ultrasonography shows echogenic mass (M) near normal right ovary (arrow).. Postcontrast axial CT scan shows normal ovary (arrow) and cystic mass (M) in right adnexa. It was confirmed by torsion of paratubal cyst at surgery. Fig. 10. Didelphic uterus and obstructed hemivagina-ipsilateral renal agenesis anomaly in a 18-year-old girl who presented with abdominal pain and tenderness in right lower quadrant pain for one day.,. Postcontrast axial () and coronal () images show multiple cystic and tubular structures (arrowheads) with enhancing wall in right lower quadrant abdomen, suggesting hematosalpinx. lso note didelphic uterus (U) and fluid collection in dilated right hemiuterus and dilated right hemivagina (V) on coronal image (). submit.radiology.or.kr 대한영상의학회지 2012;67(3):

6 청소년기의급성부인과계질환 C Fig. 11. Transvaginal septum in a 10-year-old girl who presented as lower abdominal pain and hypermenorrhea.. Postcontrast axial scan shows fluid collection in uterine cavity (U) and vagina (V)., C. Postcontrast coronal () and sagittal (C) images shows thin horizontal septum (arrow) in the midportion of dilated vagina (V). lso note fluid collection in endometrial cavity (arrowhead). On coronal image, right kidney is absent. Fig. 12. Hematocolpos caused by imperforate hymen in a 14-year-old girl. She had lower abdominal pain for two weeks, and abdominal pain was progressed.. Postcontrast sagittal image shows fluid collection in markedly dilated vagina (V) and slightly dilated endometrial cavity.. Precontrast axial scan shows high attenuation fluid collection in dilated vagina (V) and high attenuation fluid in right anterior pelvic cavity (arrowhead). It was confirmed as hemoperitoneum by endometriosis at laparoscopic biopsy. 중복자궁이다. 일부에서정상자궁에서도보일수있다 (8). 정상적인처녀막은대부분에서천공이되어있지만완전하게막혀있는무공처녀막 (imperforate hymen) 은 0.1% 에서발생하며자궁질혈종을형성해서주기적인골반통이나복부종괴로나타난다. 무공처녀막은초경을시작하기전에는증상이없다가초경이시작된후에주기적인골반통과일차성무월경증으로나타난다. 무공처녀막은뭘러관이상과는무관하여동반된자궁기형없이나타나지만영상소견이나임상증상은질의하부에생긴횡질중격과유사하다 (Figs. 12, 13). 육안으로관찰하면횡질중격은두껍고분홍색이며투과조명성이없는반면에무공처녀막은투과조명성이있다 (8). 자궁내막증자궁내막증 (endometriosis) 은월경을하고있는여성의약 30% 에서보이는흔한질환으로, 자궁내막세포가자궁밖으로나와다른장기에부착해서호르몬의영향을받는질환으로몸전체어느부위에도있을수있는데, 난소, 자궁인대, 골반강, 나팔관등에가장흔히발생한다 (2, 3). 과거에는청소년기에는자궁내막증이거의생기지않는다고하였지만최근들어서는청소년기에도자궁내막증이만성골반통과연관이있으며복강경수술을시행한환자에서증상없이우연히발견된다고보고하고있다 (9). 청소년기에자궁내막증의빈도는정확히알수없지만만성적인복통을주소로복강경수술을시행한 105 명중약 35% 인 37 명에서자궁내막증이있었고병변은대부분이쌀알보다작았고 1명에콩알만하다고하였다. 이중 8명에서우측복통혹은급성골반통을호소하였다고한다 (9). 비스테로이드성항염제에반응하지않는골반통을가진청소년에서복강경수술에서약 50~70% 에서자궁내막증이있었다고보고 200 대한영상의학회지 2012;67(3): submit.radiology.or.kr

7 김영통 하였다. 자궁내막증에의한골반통은생리주기에따라주기적인데반해청소년기는대부분에서주기적이거나비주기적인골반통을호소한다. 자궁내막증은자궁내막세포가월경주기에따라호르몬영향을받아주위에유착을일으키는데병변이작을때는초음파와 MRI 와같은영상기법이자궁내막증을진단하는데제한적이며복강경술이진단에더도움이된다 (2, 3). 난소의자궁내막종은청소년기에는형성되지않고 20대중반부터생성되는데난소에자궁내막종이형성이되면영상기법이진단에도움이된다. 영상소견은난소와골반강에출혈성낭성종괴로보이는데초음파에서출혈의시기에따라다양한내부에코를갖는낭성종괴로보인다. 출혈성난소낭종과같이혈류가없는미세한선들을보이지만만성혈종의경우는두꺼워진격막내부에혈류를보일수있다. 자궁내막종의초음파소견은비특이적이기때문에다른원인의난소종괴들과감별이필요하다 (2). 6주후에초음파를시행하면자궁내막종의크기와출혈의시기에따라내부에코가변하기때문에진단에도움이된다. 초음파소견이애매할때 MRI 가도움이될수있다 (2, 3). MRI 에서자궁내막종의진단율은 90% 이상으로특징적인소견은 T1 강조영상에서고신호강도, T2 강조영상에서저신호강도를보이는낭성종괴이다. 반복되는출혈에의해단백질과철성분의농도가높아짐에따라 T2 강조영상에서점점저신호강도를보이는현상을 shading 이라하며자궁내막종을진단할수있는특징적인소견이다 (3). CT에서는자궁내막종이비특이적인출혈성낭종으로보이기때문에일차적인진단방법으로고려되지않는다. 출혈성난소낭종은주로일측성인데반해자궁내막종은주로양측성혹은다방성 (multilocular) 이며난소간의유착으로인해난소의자궁내막종이인접해서붙어있는모양을보일수있는데이를 kissing ovary sign 이라고한다 (Fig. 14). 낭종들이다발성이거나양측성이며두꺼운벽을가지면서골반강에지방침윤이있으면출혈성난소낭종보다는자궁내막종으로진단할수있다 (2, 3)(Fig. 15). Fig. 13. Hematometrocolpos of double vagina caused by imperforate hymen associated with longitudinal vaginal septum and uterine didelphys. 13-year-old girl presented with lower abdominal pain for 2 days. Oblique coronal postcontrast image shows markedly distended vagina. longitudinal septum (open arrowheads) splits the vagina into two compartments. Fig. 14. Endometriomas in a 19-year-old girl. Postcontrast axial scan shows multiple cystic lesions (C) of both ovaries with kissing ovary sign. 낭성자궁선근종자궁선근종은자궁근층에자궁내막의양성증식으로, 근육의미만성과다증식으로자궁근의비대를동반하며전반적으로자궁이커지는질환이다 (3). 자궁적출술을시행한약 20% 에서자궁선근종이있을정도로흔한질환이며월경통, 월경과다의증상을보인다. 자궁선근종의영상소견은이소성자궁내막의비율에따라다양하게보이는데이소성자궁내막내에출혈혹은늘어난낭성선 (cystic gland) 에의해자궁근층내에작은낭성조직들이보인다 (3). 대부분이 5 mm 이하의낭종으로보이는데드물게이소성자궁내막에과다한출혈이생기면 Fig. 15. Endometriomas in a 19-year-old girl. She complained of lower abdominal pain and fever for 10 days, and she had severe dysmenorrhea. Postcontrast axial scan shows two thin walled cystic masses (C) in pelvic cavity. ilaterality and multiple lesions supported the diagnosis of endometriosis rather than hemorrhagic ovarian cyst. submit.radiology.or.kr 대한영상의학회지 2012;67(3):

8 청소년기의급성부인과계질환 자궁근층내에경계가분명한출혈을동반한낭성자궁선근종을만들수있다 (10)(Fig. 16). 낭성자궁선근종은초음파와 CT에서내부에불규칙한벽을보이는낭성병변으로보이고 MRI 에서출혈을동반한낭성종괴로보여, 출혈성병변혹은괴사를동반한자궁근종이나자궁의기형과감별이필요하다 (3). 또한병변이외측으로돌출하면난소종양과도감별을해야한다. 10대에서생기는낭성자궁선근종은드물지만그빈도가점차증가하고있는추세이다. 주로심한월경통을호소하는환아에서자궁에저음영의종괴가보이면낭성자궁선근종의가능성을생각해볼수있다. 치료는환자의나이, 증상의정도, 낭종의크기와위치에따라달라지는데나이가어린경우는수술을최소화하는치료를시행한다. 골반통을주소로한청소년기의여아에서자궁근층에낭성종괴가보이면드물지만낭성자궁선근종으로진단할수있다 (10). Fig. 16. Cystic uterine adenomyosis in a 14-year-old girl who presented with lower abdominal pain for two days. She had also presented with severe dysmenorrhea.. Precontrast axial scan shows low attenuation mass (arrow) in uterine myometrium.. Postcontrast sagittal image shows low attenuation mass (arrow) with irregular enhanced wall in uterine myometrium. 골반염사춘기이후에성적활동의증가로청소년기의여성에서골반염은골반통의한원인이된다 (1-3). 골반염은자궁, 난관, 난소, 복막및인접조직등을침범하는염증성질환을말하며하부성기에침입한각종세균이상향이동해발생하는속발성질환이다. 임질혹은클라미디아에의한감염에의해발생하며, 염증은자궁경부에서시작해서상부로이동한다. 골반염의진단에초음파가일차적인진단방법이지만 CT는병변의범위와합병증을보는데도움이된다 (2, 3). 골반염의 CT 소견은질환의정도에따라다양한데, 감염이경하면정상이거나맹낭 (cul-de-sac) 에소량의복수가보일수있다. 난소염은초기에난소가약간커져있으면서다낭으로 (polycystic) 보인다. 자궁내막염은초기에자궁이커져있으면서자궁내막이조영증강이되면서액체저류를보인다. 염증이심해지면난소난관농양, 난관유농증 (pyosalpinx), 복막염으로나타난다 (2, 3)(Fig. 17). 난소난관농양은양측에두꺼운벽을갖는저음영의부속기종괴로보이며두꺼운격막을가지기도한다. 난관유농증은난관이늘어나있고난관내에농이차서늘어난두꺼운벽을갖는낭성조직혹은관상모양의조직들로보인다 (2). Fig. 17. ilateral pyosalpinx in a 19-year-old girl. Postcontrast axial scan shows dilated thickened enhancing fallopian tubes (arrows) containing fluid, suggesting pyosalpinx. 난관수종나팔관의끝이막혀서액체가차서늘어나는데다른질환의일부로나타나기도하고단독으로생길수도있다 (2). 원인에따라나팔관애에장액, 출혈, 농이찰수있다. 원인으로는골반염이가장흔하고자궁내막증, 이전수술에의한유착, 나팔관암, 나팔관임신등이다 (2). 청소년기에는자궁기형에의한질폐색이원인이되기도한다 (8). 질폐색과신장무형성을동반 202 대한영상의학회지 2012;67(3): submit.radiology.or.kr

9 김영통 Fig. 18. Pelvic inclusion cyst in a 15-year-old girl. She had the history of operation of ileal atresia at neonatal period. Ileoileal anastomosis was also done due to foreign body lodging at the anastomotic site when she was 8 years old. t that time, there was no fluid collection in abdominal and pelvic cavity on abdominal CT.,. Postcontrast axial () and coronal () images show irregular shaped fluid collection in right lower abdominal and pelvic cavity, conforming to the borders of adjacent organs or the peritoneal wall. normal-appearing ovary (arrow) is surrounded by loculated fluid. t pathologic examination, mesothelial cells were lined on some portion of cystic wall. 한중복자궁의 7예중 2예에서는난관혈종이있었다고한다. 난관수종의증상은다양한데반복되는하복부동통이나골반통으로나타나거나무증상일수있다. 난관수종의영상소견은소시지같이생긴 C자혹은 S자형태의낭성조직으로보인다 (Figs. 10, 17). 나팔관의직경이 10 mm까지늘어날수있어난소낭종이나늘어난장으로오인할수있다 (2)(Fig. 7). 복막봉입체낭포복막봉입체낭포 (pelvic inclusion cyst) 는배란때흘러나온난포액이감염이나수술로인해손상된복막에의해흡수되지못하고골반강내에낭성종괴로보이는질환으로, 주로 20~40 대여성에서호발하지만배란이시작되는청소년기에도보일수있다 (2). 수술이나감염후 6개월에서 20년후에생길수있고크기가약 20 cm까지커질수있다. 환자들은하복부동통, 골반팽만감, 촉지되는종괴를증상으로한다. 복막봉입체낭포는복막의염증성낭종, 복막가성낭종, 다방성복막낭종등다양하게불린다. 복막봉입체낭포는대부분이단방성이며중피성조직에서기원하며평활근이거의없다. 복막봉입체낭포는부난소낭종, 난관수종, 그리고낭종성임파관종등과감별해야한다. 이들낭종들은정상난소와가깝게붙어서발생하는데낭종내외부의정상난소위치에따라, 낭종의형태에따라감별할수있다. 복막봉입체낭포는정상난소가낭종근처에서발견되거나, 낭종내부에난소가존재하고, 낭종벽에난소가부착되어있다. 복막봉입체낭포는수술후재발률이높아수술적치료보다는보완적내과치료를선호하고있다. 가장중요한초음파소견은낭종격막과낭종액에둘러싸여 있는난소를볼수있으며 CT에서는불규칙하며복벽이나주변장기의경계에의해경계가이루어지는액체저류로보이며 (Fig. 18) 부난소낭종과는감별점은액체저류의벽비후가부난소낭종에비해더두껍다 (2). 결론 골반통을호소하는청소년기의여성에서부인과계질환의다양한 CT 소견을아는것은골반통을유발할수있는여러질환들로부터부인과계질환을감별하는데많은도움이될것으로사료된다. 참고문헌 1. Garel L, Dubois J, Grignon, Filiatrault D, Van Vliet G. US of the pediatric female pelvis: a clinical perspective. Radiographics 2001;21: Potter W, Chandrasekhar C. US and CT evaluation of acute pelvic pain of gynecologic origin in nonpregnant premenopausal patients. Radiographics 2008;28: ennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. Radiographics 2002;22: Choi HJ, Kim SH, Kim SH, Kim HC, Park CM, Lee HJ, et al. Ruptured corpus luteal cyst: CT findings. Korean J Radiol submit.radiology.or.kr 대한영상의학회지 2012;67(3):

10 청소년기의급성부인과계질환 2003;4: Rha SE, yun JY, Jung SE, Jung JI, Choi G, Kim S, et al. CT and MR imaging features of adnexal torsion. Radiographics 2002;22: Stark JE, Siegel MJ. Ovarian torsion in prepubertal and pubertal girls: sonographic findings. JR m J Roentgenol 1994;163: Okada T, Yoshida H, Matsunaga T, Kouchi K, Ohtsuka Y, Takano H, et al. Paraovarian cyst with torsion in children. J Pediatr Surg 2002;37: Junqueira L, llen LM, Spitzer RF, Lucco KL, abyn PS, Doria S. Müllerian duct anomalies and mimics in children and adolescents: correlative intraoperative assessment with clinical imaging. Radiographics 2009;29: Emmert C, Romann D, Riedel HH. Endometriosis diagnosed by laparoscopy in adolescent girls. rch Gynecol Obstet 1998;261: Ho ML, Raptis C, Hulett R, Mclister WH, Moran K, halla S. denomyotic cyst of the uterus in an adolescent. Pediatr Radiol 2008;38: 청소년기의급성부인과계질환 : CT 소견 김영통 청소년기에골반통을유발하는부인과계질환은출혈성난소낭종, 난소낭종혹은종양의파열및염전, 질폐색에의한자 궁질혈종, 자궁내막증, 낭성자궁선근종, 골반염, 그리고복막봉입체낭포가있다. 골반통을평가하기위해 CT 의이용이 증가하고있으며, 초음파소견이명확하지않거나병변이광범위할때 CT 가도움이될수있다. 순천향대학교의과대학천안병원영상의학과 204 대한영상의학회지 2012;67(3): submit.radiology.or.kr