ι대한방사선의학회지 1994 ; 31(5) : 925-932 소장검사의판독지침 : 점막변화를중심으로 1 임재훈 회맹부위에이르는동안시간별로촬영하고소장의여러 서론소장은신체의가장가운데있고, 길이가약 4m 가량되며, 구불거리고, 움직이며, 바륨의장내통과도사람마다또는검사마다달라예측하기도어렵고, 따라서만족할만한조영이어렵다. 점막주름이정상적으로도제멋대로이고, 조영된소장도서로겹쳐, 작은이상은찾기도어렵고따라서가음성이많다. 초음파검사, CT 와 MR 도그이용이사실상어렵거나불가능하여방사선과의사들의관심이적은일종의사각지대이다. 필자는소장검사에서점막변화를계통적으로분류하고진단에이르는분석방법을제시한다. 형태변화를근거로감별진단대상질병의가지수를줄이고좁은범주내에서임상소견을종합하면훨씬쉽고정확하게진단에이를수있으리라본다. 여기서다루는소장검사는바륨을먹은후 부위를압박하여푸시하는 small bowel follow - through examination " 을중심으로기술하며 small bowel enteroclysis 는포함하지않는다. 전형적인점막변화를표본을비교하며설명한후몇예의증예를들어판독연습을하도록구성하였다. 정상소장검사소장에는점막주름이있고이것이소장의연동운동에따라제멋대로배열되므로정상소장검사에서점막주름은꼬불꼬불한모양 (criss-<: ross pattern) 을취한다 (Fig. 1). 소장의내경은대략 2.5 cm 이고점막주름은그두께가 2 mm 미만이다. 점막변화소장병변에서는필연적으로점막이두꺼워지고, 점막 a b Fig. 1. a. Internal surface of the normal proximal jejunum. Note the mucosal folds with smooth, gentle curve, forming criss-cross pattern. The thi ckness of the fo1ds is less than 2 mm b. Normal jejunum on follow-through sma11 bowel examination showing crisscross pattern of mucosal folds. There is lack of parallelism of mucosal folds 1 삼성서울병원진단방사선과 이논문은 1994 년 8월 11 일접수하여 1994 년 9월 1 3일에채택되었음
대한방사선의학회지 1994 : 31 ( 5) : 925-932 Table 1. Classification of Mucosal change Mucosal change Reg 띠와 P 와 IJJ 과 k 빽 Lilidre~ Re 꽤 sp 빼 cke 띠명 Hm4h 행 & 없뼈 we 떠 Je 리 Jl] 싫 1 Heart failure Coagulopathy Renal failure Vasculítis 쩌H Iy poa lbumínemia Thrombocytopeníc purpura Proteín losíng enteropathy Henoch-Schonleín purpura Mesenteric chokíng Trauma Radíation enteritis 꽤 i 뼈 e 싫 ma Eosínophilic Crohn s dísease Lymphoma gastoenteritís Crohn s disease Tumor Lymphoma Behcet dísease (Nodular lymphoid hyperplasia) Leiomyosarcoma Fig. 2. Regular smooth thickening due to mesenteric chok Ing caused by retroperitoneal and mesenteric Iymph node metastasis Irom pancreatic cancer. The thickness 01 the lolds is approximately the same in width (2-3mm), aligned parallel to one another (instead 01 criss-cross pattern ), and perpendicular to the bowel lumen. Note the normal serrated margin wi th r ound incisor teeth" αμfig. 3. Reg 비 ar spiky thickening due to submucosal hemorrhage in a patient with bl eedin g diathesis. The thickness 01 th e lolds is sli ghtly wider (3-4mm) than regular sm ooth thickening. Thickness 01 the lolds are lairly th e same, aligned parallel, an d perpendicular to the bowel lumen, producing picket lence appearance" Note the serrated margin with sharp spiky canine teeth"
임재훈외 소장검사의판독지침 주름이나란히정열되며 (parallel arrangement), 결절이 생기고 (nodular) 점막이파괴되어궤양이생긴다. 질병에 따라내강이확장되기도하고만성화되면섬유화로인하여내강이좁아지고폐쇄를초래하기도한다. 필자는점막변화를평행비후 ( parall el thickening), 규칙적평활비후 (regular smooth thickening), 규칙적침상비후 (regular spiky thickening), 불규칙적비후 (i rreg ular thickening), 결절화 (nodu lar thickening) 와점막파괴 (mucosal destruction) 등으로분류한다. (Table 1) 규칙적평행비후 (Regular parallel thickening) 비후된점막주름의소장축에수직방향으로서로평행 한배열을취한다. 규칙적평활비후 (Regular smooth thickening) 비후된점막주름의두께가 2-3mm 로일정하고장관축 에수직으로, 서로평행으로배열되어 (Fig.2) 마치앞니가 가지런히배열된, 혹은동전을쌓아놓은모양과흡사하다. 이것은주로점막하부종때문이며간경화증, 단백소설증등의저알부민증, 심부전및신부전증으로인한장관부종과, 소장간막의임프관을압박하는창간막질환등에의한다. 규칙적침상비후 (Regular spiky thickening) Fig. 4. Irregular fold thicken ing in a patient with Iymphoma. The thickness of the folds varies in width. Folds are distorted r bent at preculiar angles to the bowel lumen. The contour is irregular 비후된점막두께가 2-4mm 로일정하고배열이장관축에수직으로정열되나평활비후와는달리점막주름이바깜으로뾰족하게되어 (Fig. 3) 마치송곳니가배열된것같은, 흑은나무울타리모양 (picket fence appearance) 으 a Fig. 5. a. Nodular internal surface in a jejunal loop in tuberculous enteritis due t innumerable inflammatory p 이 yps. Note thickening of jejunal folds at the margin (arrows) b. Noduarities and irregular thickening of jejunal folds in tuberculous enteritis g
대한방사선의학회지 1994; 31 ( 5) : 925-932 로보인다. 대개점막하출혈에의한다고생각되며이런모양을초래하는질환으로는창간막혈관허혈증, 혈관염, 특발성혈소판감소성자반증, H enoch-schonlein purpura, 혈액응고장애, 장관외상과방사선장염등장관출혈을초래하는질환이있다. 불규칙비후 (Irregular thickening) 비후된점막의두께가일정치않고방향이서로평행이아니고장관축방향에수직으로배열되지않고제멋대로이며급격히구부러지거나 (b ent) 없어진다 (Fig. 4). 이러한 점막비후는점막하조직에염증세포나암세포의침윤에의하며호산구성장염 (eosinophili c gast r oenteri t i s ), Crohn 병이나럼프종에서나타난다. 결절성비후 (Nod 비 ar thickening) 점막비후의모양이불규칙하고점막주름이평행으로정열되지않고제멋대로이며특히결절의형태를취하는경우로 (Fig. 5 ) 주로장결핵, Crohn 병, Behect 병, Yersinia 장염등의염증성질환과럼프종등의종양에서이러한모양이나타난다. 6 7 Fig. 6. Gross appearance of mucosal destruction in jejunal Iymphoma. Note total lack of jejunal folds (arrowheads) within the internal surface of the tumor. The margin of the tumor is sharp (curved arrows) Fig.7 Total destruction of mucosal lolds in jejunal leiomyosarcoma. Note irregular margin without criss-cross normal jejunal lolds. Also noted are irregular thic- kened 101 ds (arrows) a b c Fig. 8. Diagramatic representation 01 various types of mucosal change a. Regular smooth thickening b. Regular spiky thickening c. Irregular thickening d. Nodular thickening. 81ack area represents 1 inear ulcer e. Mucosal destruction (black area) ass ociated with irregular and nodular thick enlng d e - 928 -
임재훈외 소장검사의판독지침 점막파괴 (Destroyed mucosa) 정막이염증세포나암세포로침윤되어두꺼워지고파괴되어궤양이생기기도하여정상점막주름이소실되어바륨조영상모양이불규칙하고제멋대로취하게된다 (Fig.6). 점막비후, 결절, 종괴등과함께불규칙한모양의궤양을형 상인지구별이안되는경우도있으며병이심하거나약함에따라서같은질환이서로다른형태로보이기도한다. 따라서소장의질환을점막변화와함께임상소견이나검사소견, 또는다른방사선검사결과를참고하여진단하면보다정확한진단에이를수있다. 성하며궤양이장벽밖으로도형성되어대단히큰궈 l 양 / 공동을형성한다 (Fig. 7). 이러한병변을초래하는경우는영증성질환중에서는특히 Crohn 병이나 Behcet 병이있고, 대부분종양질환, 즉선암, 럼프종과평활근종 / 평활근육종등이있다. 소장의점막변화를이와같이 5가지로분류할수있고, 전형적인경우의모식도를 Fig. 8에제시한다. 이러한점막비후의양상은확실히구별되기도하지만때로는어느양감사의말 : 자료수집에협조하여주신경희대학병원진단방사선과의국원일동에게감사를드린다. *~ C그 고 C 그 Lr 1. Goldberg H 1. Sheft DJ. Abnormalities in small intesteine contour and caliber. A working classification. Radiol Clin North Am 1976 14 ; 46-475 2. Lishtenstein JE. Aspects of radiologic-pathologic correlation In : Herlinger H, Maglinte DDT eds. Clinical radiology of the small intestine Philadelphia : Saunders, 1989: 54-571 3. Herlinger H, Maglinte DDT, Rubensin SE. Small bowel imaging - an overview of indications and a practical approach to the interpretation of abnormalities. In : Herlinger H, Maglinte DDT eds. Clinical radiology of the small intestine.. Philadelphia Saunders, 1989: 573-592 헌 Journal of the Korean Radiological Society, 1994; 31 (5) : 925-932 Abnormalities of Mucosal Folds of the Small Intestine: a Guide in Interpretation of Small Bowel Series' Jae Hoon Li m, M :D. l Department o( Diagnostic Imaging Samsung Medical Center Normal small intestinal folds are less than 2mm in thickness and criss-cross in appearance. Many diseases of the small interstine produce an abnormality in mucosal folds, namely thickening and parallel (perpendiulcer to the bowel lumen) arrangement of folds, nodularity, destruction, and ulcer. Diseases causing submucosal edema produce regular smooth thickening whereas diseases producing submucosal hemorrhage produce reg 비 ar spiky thickening. Inflammatory bowel diseases and Iymphoma produce irregular (in width, or distorted or bent at peculiar angles to the bowel lumen) thickening nodularity of the mucosa. Severe inflammatory processes as well as malignant tumors produce mucosal destruction and ulcer. Proposed here is an approach to narrow the category of disease processes based on mucosal fold abnormality. This approach with sufficient clinical history is invaluable in the interpretation of small bowel series Address reprint r equests to : Jae Hoon Lim, M.D. Department of Diagnostic l maging Samsung Medical Center Tel. 82-2-3410-2501 Fax. 82-2-3410-2529, 255-929 -
대한방사선의학회지 1994 ; 31 (5) ; 925-932 I 소장검사의판독연습 : 문제 Fig.9. Fig. 10. Case 1. A 23-year-old woman presented with intermittant lower gastrointerstinal bleeding and fainting. These symptoms started 2 years before and waxed and waned thereafter. She looked pale. Serum hemoglobin level was 2.6g %. A small bowel sereis (Fig. 9, a spot film of the left lower abdomen) was done. Case 2. A 33-year-old man admitted because of diffuse abdominal pain accompanied by diarrhea and melena for 15 days. Physical examination disclosed nosignificant abnormality. Laboratory findings were elevated leucocyte count in peripheral blood, 74, OOO/m 미, with differential count being neutrophil, 64 % and Iymphocyte 36 %. Chest radiograph showed infiltration in the left upper lung field suggesting active p 비 monary tuberculosis. A small bowel follow-through examination (Fig. 1 이 disclosed subtle mucosal abnormal ity 'Case 3. A 41-year-old woman presented with abdominal pain of sudden onset. She had a history of similar attack 6 months before. Physical examination disclosed diffuse abdominal tenderness. A small bowel series was performed (Fig. 11 ) Fig.11. - 930
임재훈외 소장검사의판독지침 Case 4. A 32-year-old woman admitted because of general weakness. Physical examination revealed diffuse mass feeling in the upper abdomen. A small bowel series (Fig. 12)was performed. Fig. 12. Fig. 13. Case 5. A 24-year-old woman presented with diffuse abdominal pain. Physical examination disclosed no specific abnormality. A small bowel series (Fig. 13) was performed - 93 1 -
대한방사선의학회지 1994 ; 31 ( 5) : 925-932 Fig.14. Case 6. A 64-year-old man admitted with discomfort in the upper left part of the abdomen. Physical examination disclosed no gross abnormality. Ultrasound and CT examination disclosed a large mass in the upper left part of abdomen. A small bowel examination (Fig 14) was performed to evaluate the bowel loops. Case 7. A 66-year-old woman complained of tarry stool and severe abdominal pain of sudden onset. A small bowel series (Fig. 15) was pertormed. Fig.15. < 해답은 965, 966 page 를보세요 > 요Q J