Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 (stricturoplasty) 를시행하여야하기때문에영상소견에서이를 감별하는것이중요하며, Crohn 병의합병증으로누공이발생 하였을경우에도, 복합누공의경우는수술적치료를요하지 만

Size: px

Start display at page:

Download "Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 (stricturoplasty) 를시행하여야하기때문에영상소견에서이를 감별하는것이중요하며, Crohn 병의합병증으로누공이발생 하였을경우에도, 복합누공의경우는수술적치료를요하지 만"

하뉘 부
6 years ago
Views:

1 Original Article pissn J Korean Soc Radiol 2013;68(2): Comparative Study between Axial and Coronal Planes of CT Enterography in Evaluation of Disease Activity and Complications of Crohn Disease 1 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 1 Sung Eun Ahn, MD 1, Seong Jin Park, MD 1, Soung Kyung Moon, MD 1, Joo Won Lim, MD 1, Dong Ho Lee, MD 1, Young Tae Ko, MD 1, Hyo Jong Kim, MD 2 Departments of 1 Diagnostic Radiology, 2 Gastroenterology, Kyung Hee University Hospital, Seoul, Korea Purpose: To retrospectively compare the accuracy of axial and coronal planes of CT enterography for detection of pathologic findings of Crohn disease. Materials and Methods: 168 patients who were suspected of having Crohn disease underwent CT enterography. 66 patients who were diagnosed Crohn disease were retrospectively evaluated (endoscopic biopsy of terminal ileum: 12 patients, segmental resection of small bowel: 6 patients, diagnosed based on a combination of clinical, histopathological and imaging findings: 48 patients). 2 radiologists reviewed axial planes of CT enterography and one month later reviewed coronal planes. CT enterography findings of active phase, chronic phase and complications of Crohn disease were evaluated and then compared with axial and coronal planes by using chi-square test. Results: Mucosal hyperenhancement, wall thickening, and mesenteric fat stranding were more detected on axial planes, which were CT findings of active Crohn disease. Pseudosacculation, fibrotic strictures, fistulas, abscesses were more detected on coronal planes, which were CT findings of chronic Crohn disease or complications. In particular, pseudosacculation and fibrotic strictures were significantly more detected on coronal planes. Conclusion: When evaluating CT enterography in Crohn disease, coronal planes provide more useful diagnostic information of pseudosacculation and fibrotic strictures. Index terms Crohn Disease CT CT Enterography Received August 20, 2012; Accepted November 1, 2012 Corresponding author: Seong Jin Park, MD Department of Diagnostic Radiology, Kyung Hee University Hospital, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul , Korea. Tel Fax indawn@hanafos.com Copyrights 2013 The Korean Society of Radiology 서론 Crohn 병은장벽전층을침범하는만성육아종성염증으로구강에서항문까지소화관의어떤부위에서도발생할수있으나, 환자의 80% 정도가소장에병변을보이며, 그중에서도말단회장이가장호발부위이다. 침범부위는다발성이며, 침범부위사이에정상부위가끼여있는형태로분포한다 (1). Crohn 병을처음진단할때에는환자의임상증상, 혈액학적검사소견, 병리조직학적소견, 영상의학적소견을모두종합하여판단하게되며특히, 영상소견의특징이나분포가진단과치료에매우중요한역할을하게된다 년에발표된 American College of Radiology (ACR) 에따르면 CT 소장조영술은 Crohn 병을진단받은환자에서급성악화나합병증이의심되는상황에서평가하는데현재까지알려진영상의학검사중가장좋은검사로알려져있다. Crohn 병치료의성공여부는질병의활성도나침범정도에달려있으며, 따라서 Crohn 병이의심되는환자의영상소견을분석할때에는 Crohn 병의진단뿐아니라질병의활성도, 침범정도, 중증도를평가하는것이매우중요하다. 즉, Crohn 병으로인한소장내경의감소가있을경우에, 급성기염증소견으로인한분절성소장내경감소인경우는약물치료에도잘반응하지만, 섬유성협착에의한소장내경이감소한경우수술적치료 submit.radiology.or.kr 대한영상의학회지 2013;68(2):

2 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 (stricturoplasty) 를시행하여야하기때문에영상소견에서이를 감별하는것이중요하며, Crohn 병의합병증으로누공이발생 하였을경우에도, 복합누공의경우는수술적치료를요하지 만, 단순누공은 infliximab (inhibit tumor necrosis factor) 을 이용한약물치료에도잘반응하기때문에감별을요한다. Crohn 병의진단, 질병활성도, 합병증과관련된여러가지 CT 소장조영술의소견이보고되었으나, 현재까지보고된문헌 에서 Crohn 병으로진단된환자들의 CT 소장조영술의횡단영 상과관상영상에비교연구는없었다. 또한복부 CT 의횡단영상과관상영상을비교한논문은있었 으나, 소장폐쇄가의심되는환자들의횡단영상과관상영상을 비교한논문이거나 (2), 복통을주소로촬영한환자들의횡단영 상과관상영상을비교한논문이었으며 (3), Crohn 병으로진단 받은환자들을대상으로한비교연구는없었다. 이에저자들은두영상간의비교연구를통해어떠한영상에 서 Crohn 병의급성기혹은만성기소견이나합병증동반여부가 잘관찰되는지를알고있다면, Crohn 병의진단과치료계획수 립에도움이될수있을것으로생각하였다. 본연구에서는 Crohn 병환자의 CT 소장조영술의횡단영상과관상영상을비 교, 분석하고, 두영상에서 Crohn 병의진단과질병활성도, 합 병증평가에있어서유용성을비교하고자하였다. Patients who were suspected of having Crohn disease underwent CT enterography (n = 168) Excluded (n = 102) Patients with proven diagnosis of Crohn s disease underwent CT enterography (n = 66, study population) Patients with did not undergo ileocoloscopy with biopsy within 30 days (n = 87) Patients with proven diagnosis of other disease (n = 9): Tb enteritis (n = 3), Behcet's disease (n =2), UC (n = 1), P-J syndrome (n = 1), lipoma (n = 1), GIST (n = 1) Patients with did not reconstructed coronal planes (n = 6) Endoscopic biopsy of terminal ileum (n = 12) Segmental resection of small bowel (n = 6) Diagnosed base on a combination of clinical, histopathological and imaging finding (n = 48) Fig. 1. Flowchart of the selection of patients for retrospective study, with all patients undergoing CT enterography and ileocoloscopy with biopsy within 30 days. Note.-GIST = gastrointestinal stromal tumor, P-J syndrome = Peutz- Jegher syndrome, Tb enteritis = Tuberculous enteritis, UC = ulcerative colitis 대상과방법 환자 2010 년 11월부터 2011 년 12월까지본원에서소장의 Crohn 병이의심되어 CT 소장조영술을시행한 168 명의환자를대상으로하였다 (Fig. 1). 168 명의환자중연구에포함된환자의포함기준은다음과같았다. 1) CT 소장조영술을시행한 30 일이내에대장내시경과생검을시행한환자, 2) 수술혹은내시경생검을통한병리조직소견으로 Crohn 병으로확진된환자나환자의임상증상, 내시경생검을통한병리조직학적소견, 영상의학적소견을모두종합하여판단하여 Crohn 병으로진단된환자, 3) CT 소장조영술의관상영상이재구성된환자를연구의포함기준으로하였다. 168 명의환자중 102 명의환자가다음과같은이유로조사에서제외되었다. CT 소장조영술을시행한 30일이내에대장내시경과생검을시행하지않은환자 87명과, Crohn 병이외의질병으로진단받은환자 9명 ( 결핵성장염 3명, 베체트병 2명, 궤양성대장염 1명, 포이츠-예거증후군 1명, 지방종 1명, 위장관간질종양 1명 ), 그리고관상영상이재구성되지않는 6명이조사에서제외되었다. 총 66명의환자가최종연구에포함되었으며, 49명의남자와 17명의여자로구성되었고평균연령은 28.5세 (12~62 세 ) 였다. 이들은모두 CT 소장조영술을시행한 30일이내에대장내시경과생검을시행하였으며, Crohn 병으로진단된환자였다. 12명의환자가말단회장에서내시경생검을시행하여 Crohn 병으로확진되었고 6명의환자는소장이나말단회장의수술을통해 Crohn 병으로확진되었다 ( 회장분절절제술 3명 ; 말단회장, 막창자절제술 2명 ; 회장, 맹장, 대장절제술 1명 ). 48명의환자는말단회장에서내시경생검을시행하여만성육아종성염증소견이있었으며환자의임상증상과영상의학적소견을종합하여판단하여 Crohn 병으로진단되었다. CT 소장조영술환자들은 CT 소장조영술을시행하기전 40분동안 polyethyleneglycol (Colyte-F R, Taejoon, Seoul, Korea) 2 L를 10 분간의간격을두고 5차례에나누어, 검사시행하기전 40분, 30분, 20분, 10분, 0분에각각 400 ml 씩마시게하여소장내강에 polyethyleneglycol 을채워소장의내강과소장벽이대비되도록전처치하였다. CT 소장조영술은 64채널다중검출기 CT (Brilliance 64, Philips Medical System, Cleveland, OH, USA) 혹은 16채널다중검출기 CT (Light speed, GE Healthcare, Milwaukee, WI, USA) 를이용하여시행하였다. 108 대한영상의학회지 2013;68(2): submit.radiology.or.kr

3 안성은외 촬영조건은 64채널다중검출기 CT의경우 120 kvp, 250 mas, 절편두께 5 mm였으며, 16채널다중검출기 CT의경우 120 kvp, 215 mas, 절편두께 5 mm였다 (Table 1). 소장의연동운동을감소시키기위하여 scopolamine butylbromide (Buscopan, Boehringer Ingerheim Korea, Seoul, Korea) 1 amp (1 ml, 20 mg/1 ml) 를정맥주사하였으며, 환자몸무게 kg당 2~3 ml의요오드제제정맥조영제 (Pamiray R, Dong Kook Pharm., Seoul, Korea) 를 2.5 ml/sec 속도로정맥주입하였고, 15~20 ml 생리식염수를 2 ml/sec 의속도로강력주사기 (power injector) 를사용하여전주와정맥으로주사하였다. 조영제주입후 75초, 3분후에영상을얻었다. 영상분석 CT 영상은임상적질병활성도, 수술혹은내시경적소견에대한정보없이두명의영상의학과의사에의해후향적으로분석되었고, 이견이있는경우합의에의해판정하였다. 정맥기영상을분석하였으며, Picture Archiving and Communication System (Infinitt, Seoul, Korea) 상에저장되어있던절편두께 5 mm의횡단영상과절편두께 3 mm의관상영상을분석하였다. 두영상의분석은 1개월의간격을두었다. 소장의적절한팽대정도를평가하였으며, 소장의팽대정도가 90% 이상잘되어있을때 4점, 70~90% 팽대되어있을때 3점, 40~69% 정도팽대되어있을때 2점, 40% 미만으로팽대되어있을때 1점으로정의하였다 (4). CT 소견은급성기소견, 만성기소견, 합병증의동반여부를분석하였고, 급성기소견으로는점막의과다조영증강, 장벽비후 ( 장벽두께 > 3 mm), 소장벽의층별화와장간막혈관분포증가, 장간막지방침착이있는지조사하였고, 만성기소견으로는점막하층의지방침윤, 가성수포, 주변지방섬유증식, 섬유 성협착이있는지조사하였다 (5-8). 합병증의동반여부소견으로는누공, 동, 염증성농양, 봉소직염이있는지조사하였다. 누공은소장에서다른구조물로조영증강소견이연장되어있을때로정의하였으며, 동은누공과비슷한소견을보이나조영증강소견이다른구조물까지연장되지않았을때로정의하였다. 염증성농양은국한된장관외액이조영증강이잘되는벽으로둘러싸여있을때로정의하였으며, 봉소직염은액체혹은연부조직의감쇠를보이는장관외종괴로정의하였다. 또한대장, 항문주위침범여부에대해서도조사하였다. CT 소장조영술의횡단영상과관상영상에서각각조사한 Crohn 병소견의유무가일치하지않을경우, 이들증례는추후경구소장바륨조영술이나내시경소견과비교하여어떤영상의소견이실제환자의소견에더합당한지에대해평가하였다. 통계적분석통계학적검사는 Statistical Package for the Social Sciences (SPSS) 소프트웨어를이용하여시행하였다 (SPSS 12.0, SPSS, Chicago, IL, USA). 횡단영상과관상영상에서각각분석한 CT 소견의빈도차이가통계학적으로유의한지알아보기위하여카이제곱검정을시행하였으며, p-value < 0.05인경우통계학적으로유의하다고정의하였다. 결과 CT 소장조영술의소장의적절한팽대정도를분석한결과는다음과같았다 (Table 2). 소장팽대정도가 90% 이상되어 4점을받은경우가 6예 (9.1%), 70~90%(3 점 ) 가 30예 (45.5%), 40~69%(2 점 ) 가 28예 (42.4%), 40% 미만 (1점) 이 2예 Table 1. Scan Parameters for CT Enterography Parameter 64-Detector CT Scanner 16-Detector CT Scanner Scan delay 75 sec, 3 min 75 sec, 3 min Beam collimation Gantry rotation time (sec) Table feed per gantry rotation (mm) Field of view To fit To fit Tube current (ma) Tube voltage (KV) Image reconstruction Image plane Axial and coronal Axial and coronal Section thickness (mm) 5 5 Reconstruction interval (mm) 3 3 Note.-16-detector CT scanner = Light speed, GE Healthcare, Milwaukee, WI, USA, 64-detector CT scanner = Brilliance 64, Philips Medical System, Cleveland, OH, USA submit.radiology.or.kr 대한영상의학회지 2013;68(2):

Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 Table 2.

1%) 30 (45.5%) 28 (42.4%) 2 (3.0%) A B Fig. 2. A 19-year-old man with Crohn disease at the ileum.

image (B). A B C D Fig. 3. A 24-year-old man with active Crohn disease at the ascending colon and ileum. A, B.

The thickened wall has a stratified appearance.

Endoscopy image shows erythematous mucosal change at the ileocecal valve. D.

terminal ileum. (3.0%) 에서있었으며, 97% 의대부분의환자에서 2점이상의소장의적절한팽대를유도할수있었다. Crohn 병의급성기소견을횡단영상과관상영상에서나누어분석한결과는다음과같았다 (Table 3). 점막의과다조영증강은횡단영상에서 52예 (78.

4 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 Table 2. Each Numbers of Bowel Distention Score Score 4 (Optimal): > 90% Score 3 (Good): 70 90% Score 2 (Moderate): 40 69% Score 1 (Mild): < 40% 6 (9.1%) 30 (45.5%) 28 (42.4%) 2 (3.0%) A B Fig. 2. A 19-year-old man with Crohn disease at the ileum. CT enterogram shows concentric wall thickening and mucosal hyperenhancement (arrows) at the ileum on axial image (A), which were missed on coronal image (B). A B C D Fig. 3. A 24-year-old man with active Crohn disease at the ascending colon and ileum. A, B. CT enterogram shows concentric wall thickening and mucosal hyperenhancement (arrows) at the ileum on axial image. The thickened wall has a stratified appearance. CT enterography also shows increased attenuation of the mesenteric fat on axial image, which was not shown on coronal image. C. Endoscopy image shows erythematous mucosal change at the ileocecal valve. D. Image from barium study demonstrates transient luminal narrowing, mucosal fold widening and thickening on the proximal ascending colon and the terminal ileum. (3.0%) 에서있었으며, 97% 의대부분의환자에서 2점이상의소장의적절한팽대를유도할수있었다. Crohn 병의급성기소견을횡단영상과관상영상에서나누어분석한결과는다음과같았다 (Table 3). 점막의과다조영증강은횡단영상에서 52예 (78.8%), 관상영상에서 49예 (74.2%) 에서관찰되어횡단영상에서 3예 (4.5%) 더관찰되었으나두군간에유의한통계학적차이를보이지않았다. 장벽비후도횡단영상에서 53예 (80.3%), 관상영상에서 50예 (75.6%) 에서관찰되어횡단영상에서 3예 (4.5%) 더관찰되었으나두군간에유의한통계학적차이를보이지않았다 (Fig. 2). 장간막지방 침착은횡단영상에서 28예 (42.4%), 관상영상에서 25예 (37.9%) 에서관찰되었고, 횡단영상에서 3예 (4.5%) 더관찰되었으나두군간에유의한통계학적차이를보이지않았다 (Fig. 3). 소장벽의층별화와장간막혈관분포증가는횡단영상과관상영상에서모두 16예 (24.2%) 에서관찰되었으며두군간에차이를보이지않았다. Crohn 병의만성기소견을횡단영상과관상영상에서나누어분석한결과는다음과같았다 (Table 3). 가성수포는횡단영상에서는관찰되지않고, 관상영상에서만 4예 (6.1%) 에서관찰되었으며, 이는통계학적으로유의한차이가있었다 (p = ) 110 대한영상의학회지 2013;68(2): submit.radiology.or.kr

5 안성은외 Table 3. Each Numbers of Active Findings of Crohn Disease at Axial and Coronal Images Mural Hyper-Enhancement Wall Thickening (> 3 mm) Mural Stratification with a Prominent Vasa Recta (Comb Sign) Mesenteric Fat Stranding Axl 52 (78.8%) 53 (80.3%) 16 (24.2%) 28 (42.4%) Cor 49 (74.2%) 50 (75.6%) 16 (24.2%) 25 (37.9%) Note.-Axl = axial, Cor = coronal Table 4. Each Numbers of Chronic Findings of Crohn Disease at Axial and Coronal Images Submucosal Fat Deposition Pseudosacculation Surrounding Fibrofatty Proliferation Fibrotic Strictures Axl 8 (12.1%) 0 4 (6.1%) 4 (6.1%) Cor 8 (12.1%) 4 (6.1%) 4 (6.1%) 12 (18.2%) Note.-Axl = axial, Cor = coronal Table 5. Statistical Analysis and Significantly More Detected on Coronal Image Axial Coronal p-value Pseudosacculation 0 4 (6.1%) Fibrotic strictures 4 (6.1%) 12 (18.2%) Data in parentheses are percentages, p-value less than or equal to 0.05 was considered to indicate a statistically significant difference. Table 6. Each Numbers of Complication Findings of Crohn Disease at Axial and Coronal Images Fistulas Sinus Tracts Abscesses Phlegmons Axl 7 (10.6%) 0 4 (6.1%) 0 Cor 8 (12.1%) 0 4 (6.1%) 1 (1.5%) Note.-Axl = axial, Cor = coronal Fig. 4. A 31-year-old man with long-standing Crohn disease at the ileum. CT enterogram shows typical straightening of the mesenteric boder (arrows), a finding that indicates linear ulceration or ulcer scar and pseudosacculation of the antimesenteric border (arrowhead) at the ileum on coronal image. (Table 4, Fig. 4). 섬유성협착은횡단영상에서 4 예 (6.1%), 관 상영상에서 12 예 (18.2%) 에서관찰되었고, 관상영상에서 8 예 (12.1%) 더관찰되었으며이는통계학적으로유의한차이가있 었다 (p = )(Figs. 5, 6, Table 5). 반면, 점막하층의지 방침윤은횡단영상과관상영상에서모두 8 예 (12.1%) 에서관 찰되어두군간의차이가없었으며주변지방섬유증식도횡단 영상과관상영상에서모두 4 예 (6.1%) 에서관찰되어두군간 의차이가없었다. Crohn 병의합병증동반여부소견을횡단영상과관상영상에 서나누어분석한결과는다음과같았다 (Table 6). 누공은횡단 영상에서 7 예 (10.6%), 관상영상에서 8 예 (12.1%) 에서관찰되 었고, 관상영상에서 1 예 (1.5%) 더관찰되었으나두군간의유 Table 7. Each Numbers of Large Bowel and Perianal Involvement Findings of Crohn Disease at Axial and Coronal Images Large Bowel Perianal Lesion Axl 39 (59.1%) 32 (48.5%) Cor 39 (59.1%) 32 (48.5%) Note.-Axl = axial, Cor = coronal 의한통계학적차이는없었다 (Fig. 7). 염증성농양은횡단영상 과관상영상에서모두 4 예 (6.1%) 에서관찰되었으며두군간 의차이가없었다. 봉소직염은횡단영상에서는관찰되지않았 으나관상영상에서는 1 예 (1.5%) 에서관찰되었고, 동이관찰된 증례는없었다. 대장, 항문주위침범여부도조사하였으며, 대장침범을동반 한경우는횡단영상과관상영상에서모두 39 예 (59.1%) 에서관 찰되었으며두군간의차이가없었고, 항문주위침범을동반 한경우는횡단영상과관상영상에서모두 32 예 (48.5%) 에서 관찰되었으며차이가없었다 (Table 7). 또한사전에분석하기로한 CT 소견은아니었으나, 횡단영상 에서는십이지장침범여부를간과하였으나, 관상영상에서발견 submit.radiology.or.kr 대한영상의학회지 2013;68(2):

Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 A B C Fig. 5.

CT enterogram shows fibrotic stricture (arrows) at the pelvic ileal loop on coronal image, which was missed on axial image.

A 27-year-old woman with fibrotic stricture in Crohn disease. A-C.

coronal images, which was missed on axial image. D. Endoscopy image shows numerous pseudopolyp and cecal deformity.

고찰 최근다중절편 CT는해상도가향상되고, 빠른속도로얇은영상을얻을수있어, 등방성 (isotropic) 의관상면과, 시상면의재구성영상을재현할수있게되었다.

CT 소장조영술은다량의경구조영제를투여하여소장내강을확장시킴으로써, CT보다소장의내강과소장벽에대한더좋은영상을얻을수있다.

6 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 A B C Fig. 5. A 27-year-old man with fibrotic stricture in Crohn disease. A, B. CT enterogram shows fibrotic stricture (arrows) at the pelvic ileal loop on coronal image, which was missed on axial image. C. Image from barium study also shows typical fibrotic stricture (arrows) at the pelvic ileal loop. A B C D Fig. 6. A 27-year-old woman with fibrotic stricture in Crohn disease. A-C. CT enterogram shows fibrotic stricture (arrows) at the ileocecal (IC) valve with dilatation of terminal ileum on serial coronal images, which was missed on axial image. D. Endoscopy image shows numerous pseudopolyp and cecal deformity. Scope couldn t be passed of stenotic portion of IC valve. 된증례가 2예 (3.0%) 있었고, 이들증례는추후내시경소견에서십이지장의침범여부가확인되었다. 고찰 최근다중절편 CT는해상도가향상되고, 빠른속도로얇은영상을얻을수있어, 등방성 (isotropic) 의관상면과, 시상면의재구성영상을재현할수있게되었다. 최근연구에따르면이러한관상면의재구성영상을횡단영상과함께평가할경우, 위장관평가에도움이된다고하였고, Horton 과 Fishman (9) 에의하면특히소장과장간막혈관의평가에도움이된다고하였다. CT 소장조영술은다량의경구조영제를투여하여소장내강을확장시킴으로써, CT보다소장의내강과소장벽에대한더좋은영상을얻을수있다. 따라서 CT 소장조영술은이전에전통적인영상의학적검사방법으로여겨져왔던경구소장바륨조영술에비해, 서로중복되어있는골반내의소장을평가할수있고, 소장의장벽이나, 소장주변의장간막, 고형장기, 주변의섬유성협착이나농양등의합병증도함께평가할수있다는장 점이있다 (10). 또한 CT 소장조영술은고위관장법 (enteroclysis) 에비해비침습적이고, 실행하기쉽다는장점이있으며 (11), 섬유성협착이의심되는상황에서캡슐내시경이소장폐색을유발할수있기때문에금기로알려져있는반면, CT 소장조영술은실행이가능하다 (12). MR 소장조영술도최근에사용이증가되고있으나시간이오래걸리고, 가격이비싸영상의질을좋게하는데 CT 소장조영술보다더많은고려를해야하며, 특히숨을참기힘든환자의경우에는 MR 보다 CT가더좋은영상의질을얻을수있다 (13, 14) 년에발표된 ACR 에따르면 CT 소장조영술은 Crohn 병을진단받은환자에서급성악화나합병증이의심되는상황에서평가하는데현재까지알려진영상의학검사중가장좋은검사로알려져있고, Crohn 병치료의성공여부는질병의활성도나침범정도에달려있다. 그러나현재까지보고된문헌중 Crohn 병환자에서 CT 소장조영술의횡단영상과관상영상에대한비교연구는없었다. 본연구에서횡단영상에비해유의하게관상영상에서잘관찰된소견은가성수포 (p = ) 와섬유성협착 (p = ) 이 112 대한영상의학회지 2013;68(2): submit.radiology.or.kr

안성은외 A B C D E F Fig. 7. A 23-year-old woman with ileo-colonic fistula in Crohn disease. A-E.

Fistula extends from the distal ileum (arrowheads) to the adjacent distal sigmoid colon (open arrows). F.

Sigmoid colon (open arrow) and rectum are seen. 었으며, 이는통계학적으로유의한차이가있었고모두 Crohn 병의만성기에나타나는소견이었다.

따라서가성수포는주로종축에평행하게형성되고, 관상영상에서는한단면에서가성수포전체를평가할수있기때문에관상영상에서좀더잘관찰되었던결과를얻었다고생각된다.

섬유성협착이관상영상에서통계학적으로유의하게더잘관찰된이유는관상영상이횡단영상에비해소장의전체주행을더쉽게평가할수있기때문이라고생각된다. 횡단영상에비해관상영상에서 Crohn 병의합병증소견에해당하는누공이나봉소직염이잘관찰되는경향을보였다.

그러나, 누공과봉소직염은횡단영상과관상영상에서관찰되는빈도가유의한차이를보이지는않았는데, 이는본연구에포함된 Crohn 병환자군중누공이나봉소직염합병증을보인증례자체가적기때문이며,

7 안성은외 A B C D E F Fig. 7. A 23-year-old woman with ileo-colonic fistula in Crohn disease. A-E. CT enterography shows ileo-colonic fistula on serial coronal images, which was missed on axial image. Fistula extends from the distal ileum (arrowheads) to the adjacent distal sigmoid colon (open arrows). F. Image from barium study obtained after 4 hours, demonstrates ileocolonic fistula on sagittal image (arrow). Sigmoid colon (open arrow) and rectum are seen. 었으며, 이는통계학적으로유의한차이가있었고모두 Crohn 병의만성기에나타나는소견이었다. 가성수포는 Crohn 병이중기로진행되면서, 아프타성궤양이길게합쳐져만들어지는종축의선형궤양이장간막쪽에생기고주변장간막과장벽의비후및경화를일으킴으로써, 상대적으로장간막반대쪽의벽은길이가남아형성하게된다. 따라서가성수포는주로종축에평행하게형성되고, 관상영상에서는한단면에서가성수포전체를평가할수있기때문에관상영상에서좀더잘관찰되었던결과를얻었다고생각된다. 또한, 소장의섬유성협착이있는지여부를평가하기위해서는소장의내경감소가있는지여부를확인해야하며, 전체소장의주행을평가하는것이중요하다. 섬유성협착이관상영상에서통계학적으로유의하게더잘관찰된이유는관상영상이횡단영상에비해소장의전체주행을더쉽게평가할수있기때문이라고생각된다. 횡단영상에비해관상영상에서 Crohn 병의합병증소견에해당하는누공이나봉소직염이잘관찰되는경향을보였다. 이는관상영상에서는대부분의대장이한단면에서관찰되고, 소장의주행경로도쉽게평가되며, 횡단영상에서는봉소직염이정상적인장의내강이나장간막의지방침착등과혼돈될수있기 때문이라고생각된다. 그러나, 누공과봉소직염은횡단영상과관상영상에서관찰되는빈도가유의한차이를보이지는않았는데, 이는본연구에포함된 Crohn 병환자군중누공이나봉소직염합병증을보인증례자체가적기때문이며, 이부분에대해서는향후좀더많은수의환자를대상으로한연구가이루어져야할것으로생각된다. 또한본연구에서관상영상에비해횡단영상에서점막의과다조영증강, 장벽비후, 장간막지방침착이잘관찰되는경향을보였으나이들소견은통계학적으로유의한차이는없었다. 본연구의제한점으로는후향적으로이루어졌으며, CT 소장조영술에서관찰된 Crohn 병의소장병변을확인하기위한방법으로캡슐내시경검사를이용하지않았다. 캡슐내시경은소장의점막을평가하는데 CT 소장조영술보다더민감한것으로알려져있으나, 섬유성협착이의심되는상황에서는캡슐내시경이소장폐색을유발할수있어금기로알려져있기때문이다 (11). 본연구에서는 Crohn 병의소장병변확인을위하여, 대장내시경을통하여원위부회장에대한검사를함께시행하였으나그역시소장병변을모두확인하지는못하여내시경소견과 CT 소장조영술소견의직접적인비교를하지못한제한점이있다. 또한각각의 CT 소장조영술소견과부위별염증의정도및 submit.radiology.or.kr 대한영상의학회지 2013;68(2):

8 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 병리소견과의관련성은검증하지못하였다는제한점이있다. 그러나이전연구에서, CT 소장조영술의 Crohn 병소견은내시경소견과매우일치되며, 특히급성기 Crohn 병환자에서 CT 소장조영술의점막의과다조영증강소견, 장벽비후소견은내시경이나병리소견과통계학적으로유의하게상관관계를보인다고보고된바가있어내시경소견이나병리소견을 CT 소장조영술과직접적인비교를하지못하였다는본연구의제한점을극복할수있다고생각된다 (15, 16). 또한본연구는절편두께 5 mm의횡단영상과절편두께 3 mm의관상영상을분석하였는데황단영상과관상영상의절편두께가다른제한점이있다. 결론적으로 Crohn 병환자에있어서 CT 소장조영술의소견은횡단영상과관상영상에서대부분유의한차이를보이지않았으나, 만성기소견인가성수포와섬유성협착은관상영상에서유의하게높은빈도로관찰되었다. 이러한점을숙지하고, 만성기 Crohn 병환자의 CT 소장조영술분석을할경우, 가성수포와섬유성협착이의심된다면, 관상영상을보다주의깊게살펴, 정확한진단과치료계획수립에도움을줄수있을것으로생각된다. 참고문헌 1. Furukawa A, Saotome T, Yamasaki M, Maeda K, Nitta N, Takahashi M, et al. Cross-sectional imaging in Crohn disease. Radiographics 2004;24: Jaffe TA, Martin LC, Thomas J, Adamson AR, DeLong DM, Paulson EK. Small-bowel obstruction: coronal reformations from isotropic voxels at 16-section multi-detector row CT. Radiology 2006;238: Jaffe TA, Martin LC, Miller CM, Franklin KM, Merkle EM, Thompson WM, et al. Abdominal pain: coronal reformations from isotropic voxels with 16-section CT--reader lesion detection and interpretation time. Radiology 2007;242: Wold PB, Fletcher JG, Johnson CD, Sandborn WJ. Assessment of small bowel Crohn disease: noninvasive peroral CT enterography compared with other imaging methods and endoscopy--feasibility study. Radiology 2003;229: Elsayes KM, Al-Hawary MM, Jagdish J, Ganesh HS, Platt JF. CT enterography: principles, trends, and interpretation of findings. Radiographics 2010;30: Booya F, Fletcher JG, Huprich JE, Barlow JM, Johnson CD, Fidler JL, et al. Active Crohn disease: CT findings and in- terobserver agreement for enteric phase CT enterography. Radiology 2006;241: Goldberg HI, Gore RM, Margulis AR, Moss AA, Baker EL. Computed tomography in the evaluation of Crohn disease. AJR Am J Roentgenol 1983;140: Lee SS, Ha HK, Yang SK, Kim AY, Kim TK, Kim PN, et al. CT of prominent pericolic or perienteric vasculature in patients with Crohn s disease: correlation with clinical disease activity and findings on barium studies. AJR Am J Roentgenol 2002;179: Horton KM, Fishman EK. The current status of multidetector row CT and three-dimensional imaging of the small bowel. Radiol Clin North Am 2003;41: Paulsen SR, Huprich JE, Fletcher JG, Booya F, Young BM, Fidler JL, et al. CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. Radiographics 2006;26: ; discussion Maglinte DD, Sandrasegaran K, Lappas JC, Chiorean M. CT Enteroclysis. Radiology 2007;245: Hara AK, Leighton JA, Heigh RI, Sharma VK, Silva AC, De Petris G, et al. Crohn disease of the small bowel: preliminary comparison among CT enterography, capsule endoscopy, small-bowel follow-through, and ileoscopy. Radiology 2006;238: Tolan DJ, Greenhalgh R, Zealley IA, Halligan S, Taylor SA. MR enterographic manifestations of small bowel Crohn disease. Radiographics 2010;30: Schmidt S, Lepori D, Meuwly JY, Duvoisin B, Meuli R, Michetti P, et al. Prospective comparison of MR enteroclysis with multidetector spiral-ct enteroclysis: interobserver agreement and sensitivity by means of sign-by-sign correlation. Eur Radiol 2003;13: Bodily KD, Fletcher JG, Solem CA, Johnson CD, Fidler JL, Barlow JM, et al. Crohn Disease: mural attenuation and thickness at contrast-enhanced CT Enterography--correlation with endoscopic and histologic findings of inflammation. Radiology 2006;238: Hara AK, Alam S, Heigh RI, Gurudu SR, Hentz JG, Leighton JA. Using CT enterography to monitor Crohn s disease activity: a preliminary study. AJR Am J Roentgenol 2008;190: 대한영상의학회지 2013;68(2): submit.radiology.or.kr

9 안성은외 Crohn 병의진단과질병활성도, 합병증평가에있어서 CT 소장조영술의횡단영상과관상영상의유용성비교 1 안성은 1 박성진 1 문성경 1 임주원 1 이동호 1 고영태 1 김효종 2 목적 : Crohn 병환자에서 CT 소장조영술의횡단영상과관상영상을비교하여, 질환의진단과합병증평가에있어서차이점이있는지알아보고자하였다. 대상과방법 : 소장의 Crohn 병이의심되어 CT 소장조영술을시행한환자 168 명중, Crohn 병으로진단된 66명의환자를대상으로하였다 ( 말단회장에서내시경생검 : 12명, 소장이나말단회장의수술 : 6명, 말단회장의내시경생검소견, 임상증상, 영상의학적소견을종합하여판단 : 48명 ). 2명의영상의학과의사가, CT 소장조영술의횡단영상과관상영상을각각 1개월의간격을두고분석하였다. CT 소견은 Crohn 병의급성기소견, 만성기소견, 합병증동반여부를분석하였고, 이중횡단영상과관상영상에서더잘관찰되는소견을카이제곱검정을이용하여서로비교하였다. 결과 : CT 소장조영술의횡단영상에서는점막의과다조영증강, 장벽비후, 장간막지방침착이잘관찰되는경향을보였고, 관상영상에서는거짓주머니, 섬유성협착, 누공, 봉소직염이잘관찰되었다. 특히, 만성기소견인가성수포와섬유성협착은관상영상에서통계적으로유의하게더잘관찰되었다 (p = , p = ). 결론 : Crohn 병의 CT 소장조영술의소견은횡단영상과관상영상에서대부분유의한차이를보이지않았으나, 만성기소견인가성수포와섬유성협착은관상영상에서유의하게높은빈도로관찰되었다. 경희대학교병원 1 영상의학과, 2 소화기내과 submit.radiology.or.kr 대한영상의학회지 2013;68(2):

(

317 318 319 320 1 3 5 5 5 5 2 321 : 1.,,,,, 06 2. X-ray beam penetration (density) (contrast) 03 3. patch coating, precipitation, flaking 03 4. centering 03 5. Esophagus, cardia, fundus, body, angle, antrum,