大韓放射線醫學슐誌 Vo1. XJ)(, No. 3. 1983 賢周圍 B 農傷의 放射線學的所見 中央大學校醫科大學放射線科學敎室 金鍵相 沈炯鎭 李寬世 - Abstral't - Radiological Diagnosis of Perinephric Abscess Kun Sang Kim, M.D., Hyung Jin Shim, M.D. and Kwan Seh Lee, M.D. Department of Radiology, Co!lege of Medicine, Chung-Ang University With convenfional radiological approaches, diagnosis of perinephric abscess is difficult in many occaslons. CT and ultrasound enable accurate detection of lesions and precise determination of their extent. We review our cases and discuss the usefulness of these new modalities for the diagnosis and follow up of the lesions. V A tendemess ) 를發見하였다 ~ 피純題部휩훌影에서多 I. 論 絡 햄周 @ 엄 8 農傷은臨 ff 的으로나放射線學的으로나 * 휴꿇한 所見을나타내는일이흔치않은관계로早期該斷이비 교적 어렵고따라서 f 台續時期를놓치는경우가빈번하 다1) 最近에이르려超音波檢좁및양 깎 [ 化斷 l협겼옮影 (CT} 의 활발한臨 ff 的 應用의덕분으로비교적짜1뼈에談斷이 가능하여졌을뿐아니라病짧의波及程度를쉽게알수 있게되어治續에큰도움을줄수있게되었다잊著좀 들은自驗例를중심으로뽑周圍聽陽의放射線學的所見 을討講하고자한다 量의陽管內 '!:!. 氣陰影으로特記할所見을찾을수없었 고經靜 1l*!JJê 路造影에서는左얘 ~ 웹의下端이外뼈 ~ 으로 빌 려있는所見을觀察할수있었다. 超音波짧影에서左에 l업이뻐大되어있었고잔잔한 i^1 rfg에코를보이는둥근쩔間난3 有病變 l 左測뽑下端에 { 효置하여 뽑內眼傷을확인할수있었으며아울러뽑中 心홉ß에에코의變形이觀察되었다 (Fig.3a) 左測뽑 주변에는뽑願에코의 t 曾 1J u 와함께 11:!l!~ 웹 下端얘없 ~ 의 뽑周圍 '!:!. 間에 ~lle 性쨌體의종홉積이 觀察되었다. f훈 ~J II 9 歲 男兒로서 2 週 H 程度에걸친 不明熱을主訴로 하여 來院당시左예!I1J 骨홉維角 I용痛 ( CVA tenderness) :ffe 例 l n. 홈例例示 가있었다. 單純짧흠 B 振影에서 U 없推썽양 JilJ, 11:!l!~ /Jj 씻堆外隊 의消失및까 ë ßI~ 띔陰影의 t 혐失이觀察되었고經靜 lijíu7r 路造影에서左右에뽑杯및 1 업굶의早期造影이觀쫓되었 10 歲女兒로서 I 週日에결친不明熱을主訴로하여으나左 ßI ~ 의펌杯쩍굶의不完숲한充滿괴 t 部原管의來院당시理學的檢좁에서심한左때曲骨홉堆角많뼈 ì (C- 딸 if! 所見등이觀察되었다갱중堆와 1i: ßlJj 뽑과의거리가 t 曾 이논운은 83 년 6 월 4 일에채택되었음. - 580-1Ju 되어左빼뽑이外 fjuj 方으로빌려있음을일수있었다 (Fig. 2 a )
A. 훌훌짧., 혔짧 - 쩔짧파 k 빼 - 잉 & 쫓 γ, B Fig. 1. Plain 떠 m of the emphysematous pyelonephritis. a) Accumulation of abnormal gas density is demonstrated in the perirenal space and mott1ed radiolucent gas density is also noted in the renal parenchyme b) Accumulation of radiolucent rim like gas density in the right side perirenal space is noted by gas forming infection. Fig. 2. Conven tional contrast studies a) I.V.P. (supine, standing) reveal faint visualization of the left pelvis and calyces with compression of upper ureter and scoliosis with loss of left side psoas muscle shadow are also noted. Vertebra to left kidney distance is increased causing lateral displacement of left kidney. bl) I.V.P. reveals cresentic deformity of pelvis and calyces causing large, sharply outlined mass. (Renal ce1i carcinoma with perireilal abscess). b2} Enema colon study of the same patient (bl) shows loss of proximal half psoas muscle shadow and lateral displacement or proximal descending colon. B 超품波檢홉에서 1i íll U 賢의 6밍大와內部에코가없고後方陰影 t홈彈의所見을보이는뽑內盤場과쩔벼心힘8 에코의뾰 ill. 및移動의所見을觀察할수있었고뽑體에코의增加와뽑周圍옐間에충만된쨌뽑의 i용影을볼수있었다 (Fig. 3 bj,b z ). - 58 1 - íæølj rn. 56 歲女子로서짧l 原性좁睡로入院하였고觸륨ß x - 線擔影上右..tH흉部어l 非正常的언 '!i'. 氣陰影이觀察되었으며댈純題部握影에서뽑魔및웹周圍에홉짧된 '!i'. 氣陰影을
A B B" Fig.3. C c D Ultrasonography a) Longitudinal scan reveals en1argement of left kidney and round weak echogenic area is shown in the lower pole of left kidney with distortion of central echo complex. bl, b2) Longitudinal and transverse left kidney ultrasound reveal en1argement of kidney and echo free area with posterior enhancement in the renal parenchyme. Compression and displacement of central echo complex is also shown. Thickened and increased echogenicity of renal capsule with accumulation of perirenal fluid are demonstrated cl, c2) Transverse and longitudinal scan reveal renal and perirenal gas producing reverberation artifact. Perirenal effusion is manifested as echo free area in the lower part of perirenal space d) Supine transverse u1trasound reveals large amount of retroperitoneal fluid accumulation with ascitic fluid (Renal cell carcinoma with perirenal abscess). Renal capsule also appears thicknened. 觀察할수있었다 (Fig. 1 a ). CT 홉影에서石에j 督縣및 뽑周圍空間에多量의空氣가發見되어소위 氣睡狀뽑잦 (emphysematous nephritis) 및뽑職周圍잦을確認할 수있었다 (Fig. 4 b). 1Æ ~j IV 42 歲男子로서수년간햄原病을앓고있었고갑작스 런高熱과助骨참推角짧痛 (CVA t enderness) 를主訴 로 X 院하였다 r 힘純 & 훌部握影 1: H 없堆쩔曲파右에띔嚴및 뽑周圍 ~ 圖에空氣가觀察도 l 었고 (Fig.l, 6) 이들소견 은超흡波 ( Fig. 3 cr,cz) 빚 CT 檢훌 (Fig.4a ) 로서 確認되었다 - 1Æ~jV. 49 歲 男子로서血民, H흉 $lllf; 澈 및高熱을主訴로入 院하였다 單純題部및大 陽造影에서 j 總外緣의 t 융이消失된 所見괴下行結陽近 f 立部의外예빼 -ÜL를볼수있었다 (Fig. 2 b z ). 經靜빙 ~* 路造影에서 l엽內陣塊의所見을볼수있었고 ( Fig. 2 b r ) 超音波檢홈에서뽑영용睡 p'l에發生한賢,ffij g 包의所見과題水및後題願뾰內에옳짧된多量의 i!u영陰影을볼수있었고뽑題이두꺼워진所見을觀察할수있었디 (Fig.3d). 病理組織檢훌로뽑細 8 包홉이確認되었고뽑周 @ 협 6 農傷이.~ 뚱認되었다 - 582 -
A B Fig.4. Computed tomography of emphysematous pyelonephritis a) Multiple abnormal gases are demonstrated in the renal and perirenal space of right kidney. b) Large amount of gas accumulation is noted in the right perirenal space and renal parenchyme, which is characteristic finding of emphysematous pyelonephritis. ill. 考 超품波와 CT 가臨똥的으로利用되기뼈에는後題題 臨의 ~ 愚을등2 斷하는데있어서상당한制約이있었으나 A 體斷面相을쉽게얻을수있는이들談斷法들의 활발 한應用으후後 8찢願뾰흉惠의談斷은울론이부분에發 生한흉뽕 의 波及程度를評 6옆하는데큰도움을받을수 있게되었다 2) 뽑周圍 8 農傷은흔치 않은흉惠으로흔히 臨 lf 的 lle 勢 냐放射線學的所見이非特異的이다 J) 이 용愚은血 行性으로發生하는수도있고手術後遺효으로도發 ~ 할 수있으며廳原病을앓고있거니 3) 뽑細뼈修등기타뽑 흉愚을앓고있는경우에合혐효으로서發生하는일이 按 充浦, 뺑 f 立짧ifl. 등의所見을 i을tju로觀察할수있다. 檢 좁중呼期時銀影과吸期時擬影을하여 업의 üz 置를비 교하면웹의移動範랩가현저히줍어들어 있는所見을 觀察할수있다 이러한웹固定現狀은愚子플몽AÜZ와立 位에서搬影하여비교하여도觀察할수있다. Gallium - 67 - Citrate 을利用한 j 司 üz 元素走흉에서 非正常的인同 f 立元素의集積으로有意한所見을얻을수 있으나 j) 著者들은 自驗例가숲無하여 詳細 i한記述은 省略하는바이다. 超音波檢훌와 CT 檢훌는이 g늦愚의 등? 斷과 波及의程 度을얹定하는데중요할뿐아니라該斷이確定뭔後 f 台 驚에대한 反應 을追顧하는데도有用하며 穿刺등의續 法에길깎이로서대 l까히큰역할을한마 2, 5, 6) 이 두 많은것으로일려져있다 4) 單純題힘3 振影에서는所見이非特흥용的인관겨l 로진행된 lle 例에서만特徵的인所見을볼수있다. H 했推의짧曲, 體節外緣의 f 법失이나뽑驗의輪節이不分明해지는所見 등을觀察할수있다. 소위氣睡狀샘잦에鏡發한협周造影퉁이있다 圍體혔에서는多量의 2E 氣陰影이觀察되고이 所見은後 檢홉에서띔범大, 뽑의 üz 置移퍼 b, 쩔 I^II! 홉傷의所見및 뽑周圍의 ~lle 앤 : It 훗홉엽의 iit 첩을쉽게觀察할수있으여 뽑體의 R 巴훔등을詳細 -o j 觀察할수있어 wi 該에큰도웅 을준다. 기타補助的인檢좁로서는大陽造影및뽑血管 題睡용外陽이나後 g힐體 & 효과陽管과의擾孔形成의경우를제외하면 I업周圍 8앓傷을確장할수있는特異的인所見이될수있다. I! 農없의波及程度에따라同에橫隔題의上昇, 뽑敵 üz 置의移動, 또는同예뾰뼈쨌慘出등의所見도觀察할수있다 1, 5) 經靜 l!ir}}j( 路造影에서는웰純題部嚴影에서觀察되는所見들을좀더확실히볼수있고 l협杯및협 j굶의不完全 REFERENCES l. Witten DM, Myeres GH, DC Emmett 5 C/iníca/ ùrography. 4th ED Vol 2:843-848, W.B. 5aunders, 7977. 2. Gerzof SG, Gale M E Computed tomography and ultrasonography for diagnosis and treatment of - 583-
renal and retroperitoneal abscess. Nor. Amer. 9:785-793, 7982. Urol. Clinic. 3. Sinpkins KC, Barradough NC Renal cortical abscess, perinephritis and perinephric abscess in diabetes. 8j R 46:43436, 79 73. 4. Childs GJ, Pickelman J, Churchill RJ et al : Renal cel! carcinoma complicated by perinephric abscess and colon perforation. Urol. clinic 4:3740, 7982 5. Wickes J D, Thornbury J R Acute renal infections in adult. Radiol. c/inic Nor. Amer. 77:245-2 60, 7979. 6. Schneider M, Becker JA, Staiano 5, et al : Sonographic-radiographic correlation of renal and perirenal infections. AjR 727:7007-707 4, 7976. - 584-