대한내과학회지 : 제 80 권제 1 호 2011 복막투석의합병증으로발생한복막 - 후복막누출 1 예 CHA 의과학대학교구미차병원 1 내과학교실, 2 영상의학과, 3 경북대학교의학전문대학원내과학교실 최혁준 1 김종열 2 최지영 3 조지형 3 김찬덕 3 박선희 3 김용림 3 Peritoneal-Retroperitoneal-Scrotal Leakage as a Complication of Peritoneal Dialysis Hyuk-Joon Choi 1, Jong Yeol Kim 2, Ji-Young Choi 3, Ji-Hyung Cho 3, Chan-Duck Kim 3, Sun-Hee Park 3, and Yong-Lim Kim 3 Departments of 1 Internal Medicine and 2 Radiology, Gumi CHA University Medical Center, CHA University College of Medicine, Gumi; 3 Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea We report a case of retroperitoneal and scrotal dialysate leakage resulting from peritoneal-retroperitoneal communication in a patient on peritoneal dialysis (PD). The ultrafiltration volume was reduced and the scrotum became enlarged in a patient who had been undergoing PD for 4 years. Retroperitoneal and scrotal leakage of dialysate was confirmed by computed tomography (CT) performed 1 hour after the intraperitoneal infusion of contrast-containing dialysate. The PD was halted and the patient was transferred to hemodialysis (HD). One month after the transfer to HD, the PD was resumed and there were no signs of extraperitoneal leakage. (Korean J Med 2011;80:108-112) Key Words: Retroperitoneal space; Scrotum; Leakage; Peritoneal dialysis; Ultrafiltration failure 서론복막투석액의누출은복막투석환자의 10% 미만에서발생할수있는합병증이며, 복벽및생식기의부종또는호흡곤란등의증상으로나타날수있다 [1]. 복막투석액은도관출구, 흉강, 개방성초상돌기 (patent processus vaginalis), 복부탈장또는복벽등으로누출될수있으며 [2,3], 종격동으로의누출도보고된바있다 [4]. 후복막으로의누출은국외에서보고된예는있으나 [5,6] 국내에서는아직보고된바가없다. 저자들은복막투석환자에서복막- 후복막결손을통해투석액이후복막으로누출된후, 다시우측고환까지이동한예를경험하였기에이를보고하는바이다. Received: 2009. 11. 8 Revised: 2009. 12. 7 Accepted: 2010. 1. 21 Correspondence to Yong-Lim Kim, M.D. Department of Internal Medicine, Kyungpook National University School of Medicine, 50 Samduck-2ga, Jung-gu, Daegu 700-721, Korea Tel: +82-53-420-5553, Fax: +82-53-423-7583, E-mail: ylkim@knu.ac.kr * This study was supported by a grant of the Korea Healthcare Technology R&D Project, Ministry of Health & Welfare Affairs, Republic of Korea (A084001). - 108 -
- Hyuk-Joon Choi, et al. Peritoneal-Retroperitoneal-Scrotal Leakage as a Complication of Peritoneal Dialysis - 증례환자 : 남자, 33세주소 : 3일간의복부팽만감현병력 : IgA 신증에의한말기신부전으로내원 4년전지속성외래복막투석을시작하였으며, 내원 2년전부터지속성교환기복막투석 (continuous cycling peritoneal dialysis, CCPD) 을시행해온환자이다. 환자는몸무게 77.4 kg, 키 179.5 cm, 체표면적 1.965 m 2 이며, 평소한외여과량은 1,000~1,500 ml 로유지되었다. 내원 4일전부터배액량이감소하면서우측복부팽만감 이발생하였고, 내원 1일전부터우측고환이종대되어내원하였으며, 내원시호흡곤란이나하지부종은없었다. 과거력 : 내원 10년전부갑상선암으로좌측부갑상선제거수술및좌측갑상선엽절제수술을시행하였으며, 내원 5년전부갑상선암재발로종양절제수술후방사선치료를시행하였다. 가족력 : 특별한이상은없었다. 이학적소견 : 입원당시활력징후는혈압 130/80 mmhg, 맥박 88회 / 분, 체온 36.2, 호흡수 16회 / 분이었고, 만성병색을보였다. 흉부청진시특이소견은없었으며, 복부는전반적으로팽만되어있었으나촉지되는종괴는없었고, 압통및반발통은없었다. 도관출구부위의염증이나누출소견은 A B C Figure 1. CT scans obtained 1 hour after intraperitoneal infusion of contrast-mixed dialysate. (A) It shows abnormal high density and strand (arrowheads) in the right posterior pararenal space outside of the lateral conal fascia. Scanty abnormal high density (arrow) is also noted in the right anterior pararenal space around the duodenum. (B) Retroperitoneal leakage is marked with an arrow. (C) CT shows leakage into the right anterior extraperitoneal space of abdominal wall, and right paravesical space. (D) Extension of leaked dialysate to the right scrotum going along the spermatic cord was noted. - 109 - D
- 대한내과학회지 : 제 80 권제 1 호통권제 605 호 2011 - 없었으며사지에함요부종은없었으며우측고환이종대되어있었다. 검사실소견 : 말초혈액검사에서혈색소 8.3 g/dl, 백혈구 3,710/μL, 혈소판 318,000/μL, 적혈구침강속도 15 mm/hr였으며, 일반화학검사상혈청총단백량 6.2 g/dl, 혈청알부민 3.8 g/dl, AST 15 IU/L, ALT 18 IU/L, 혈청요소질소 65.9 mg/dl, 혈청크레아티닌 16.67 mg/dl, C-반응성단백 0.1 mg/dl였다. 흉부 X-선검사상폐부종의소견은없었으며, 단순복부촬영상도관끝은골반내에정상적으로위치하고있었다. 배액한복막투석액은맑았으며, 세포수는 0/mm 3 이었으며, 내원후시행한 4.25% 포도당용액을이용한복막평형검사에서 4시간째, 순수한외여과량은 520 ml였으며 D/Pcreatinine은 0.82로고투과성복막기능을보였다. 경과및치료 : 환자는내원시우측복부팽만감을호소하였으며우측고환이종대되어있어서복막투석액의복벽및고환으로의누출을의심할수있었으며, 이를확인하기위하여복부전산화단층촬영을시행하였다. 조영제를사용하지않은복부전산화단층촬영상우측후복막강에수분으로의심되는음영이관찰되었으며, 이를확인하기위하여투석액 2 L에조영제 100 ml를섞어복강내에주입하고 1시간이경과한후복부전산화단층촬영을다시시행하였다 [7]. 촬영을통하여조영제를포함한복막투석액이 right posterior pararenal space, right anterior pararenal space, 우측복벽의 extraperitoneal space, right paravesical space로누출되어있음을확인하였으며, 우측정삭주위조직을통해우측음낭까지투석액이누출되어있음을확인하였다 ( 그림 1, 2). 이에복막- 후복막누출로진단하고환자는복막투석을중지하였으며, 혈액투석용경정맥도관삽관후혈액투석으로전환하였다. 혈액투석시행 1개월후복막투석 (CCPD) 을다시시행하였을때, 정상적인배액량이유지되고, 복벽및고환종대등의누출소견이보이지않아복막투석을지속할수있었다. 고찰복막투석의합병증중탈장및투석액누출은복막투석액에의한복강내압력의증가로발생할수있다. 투석액누출은복벽또는생식기의부종또는호흡곤란등의증상으로나타나며, 복막투석환자의 10% 미만에서발생한다 [1]. 투석액누출은복막투석도관삽관 30일이내에발생하는조기복강관류액누출과 30일이후에발생하는후기복강관류액누출로나뉘어지며, 이들은다른임상양상으로나타난다 [8]. 도관삽관 30일이내에일어나는조기복강관류액누출은일반적으로도관설치와연관되어발생하며도관출구부위또는수술봉합부위로의체외누출이대표적이다. 30일이후에 A B Figure 2. Coronal reformatted image shows fluid collections in the peritoneal space and in the retroperitoneal space, right paravesical space (A). Leaked fluid is extended to the right scrotum via the spermatic cord (B). - 110 -
- 최혁준외 6 인. 복막투석의합병증으로발생한복막 - 후복막누출 1 예 - 나타나는후기복강관류액누출은대부분복강내압력증가에의한복막의물리적손상으로발생하며탈장또는흉강, 복벽, 외부생식기등으로체내누출로나타난다 [2]. 투석액의피하누출은조기및후기누출모두에서나타날수있다 [3]. 복강으로부터의복벽, 흉강등으로누출되면한외여과량이감소하며, 간질공간으로의누출은복벽부종과연관될수있으며생식기의부종도동반될수있다. 진단은조영제가첨가된투석액의복강내주입을포함한전산화단층촬영을이용하여진단되며, 방사성핵종복막촬영술을이용하여진단할수도있다 [7,9-11]. 소량의누출인경우복막투석액량을감소시키거나혈액투석으로의변경을통해일시적인복막투석중단 ( 통상 2~3 주 ) 또는간헐적복막투석을통한복막을쉬게함으로써저절로치유될수도있으며, 재발할경우혈액투석을더연장하거나 (4~6주 ) 수술적재건이필요할수도있다 [3,5,7,12,13]. Leblanc 등 [2] 에의하면조기복강관류액누출은일시적인혈액투석으로의전환또는수술적재건에의해치료하였으며, 후기복강관류액누출은일시적인혈액투석 (29%), 수술 (27%), 자동복막투석으로의전환 (16%), 혈액투석으로의전환 (25%) 에의해치료하였으며, 재발률은각각 65%, 25%, 14%, 0% 였다. 개방성초상돌기 (patent processus vaginalis) 를통한누출의경우에는수술적치료가요구되지만, 복벽을통한누출은수술적치료가요구되는경우는드물다 [1]. 이증례는복막투석중갑작스럽게발생한배액감소로내원한환자에서전산화단층촬영을통하여조영제를포함한복막투석액이후복막강으로누출되고, 우측고환까지복막투석액이이동됨을확인함으로써복막- 후복막누출로진단된경우이며, 고환으로의누출의원인이될수있는개방성초상돌기또는서혜부탈장등의소견은관찰되지않았으며, 후복막강에서연결된복막외공간을통하여고환까지투석액의누출이연장되어있음을확인할수있었다. 복막투석액누출의유발요인으로는복부수술, 탈장, 과도한운동, 투석액량의증가, 비만, 복막염, 스테로이드의사용등이있을수있으나 [2,3], 이증례에서는뚜렷한유발요인을찾을수없었다. 이처럼다른원인으로설명되지않는복막투석액의배액감소가있을경우에후복막누출도원인이될수있다. CT peritoneography를통해진단할수있으며혈액투석으로의일시적전환이이문제를해결할수있는방법이될수있다. 요 복막투석액의누출은복막투석환자의 10% 미만에서발생하는합병증으로, 투석액은도관출구, 흉강, 복부탈장, 복벽으로누출될수있으며, 개방성초상돌기를통한외부생식기로도누출될수있다. 저자들은흔히발생하는누출경로가아닌후복막으로투석액이누출되는드문예를경험하였다. 배액감소로내원한환자에서 CT peritoneography를시행함으로써, 투석액이후복막으로누출된후누출된투석액이우측고환까지이동함을확인하였기에이를보고하는바이다. 중심단어 : 후복막강 ; 고환 ; 누출 ; 복막투석 ; 한외여과부전 약 REFERENCES 1. Mahale AS, Katyal A, Khanna R. Complications of peritoneal dialysis related to increased intra-abdominal pressure. Adv Perit Dial 2003;19:130-135. 2. Leblanc M, Ouimet D, Pichette V. Dialysate leaks in peritoneal dialysis. Semin Dial 2001;14:50-54. 3. Tzamaloukas AH, Gibel LJ, Eisenberg B, et al. Early and late peritoneal dialysate leaks in patients on CAPD. Adv Perit Dial 1990;6:64-71. 4. Kim YL, Cho YJ, Park SH, Jeon K, Bae K, Cho DK. Peritonealmediastinal leakage complication of peritoneal dialysis. Am J Kidney Dis 2003;42:E17-E19. 5. Lam MF, Lo WK, Chu FS, et al. Retroperitoneal leakage as a cause of ultrafiltration failure. Perit Dial Int 2004;24:466-470. 6. Bargman J. The law of diminishing returns: it is not always ultrafiltration failure. Perit Dial Int 2004;24:419-421. 7. Mujais S, Nolph K, Gokal R, et al. Evaluation and management of ultrafiltration problems in peritoneal dialysis. International society for peritoneal dialysis Ad Hoc committee on ultrafiltration management in peritoneal dialysis. Perit Dial Int 2000;20(Suppl 4):S5-S21. 8. Gokal R, Alexander S, Ash S, et al. Peritoneal catheters and exit-site practices toward optimum peritoneal access: 1998 update. (Official report from the international society for peritoneal dialysis) Perit Dial Int 1998;18:11-33. 9. Litherland J, Gibson M, Sambrook P, Lupton E, Beaman M, Ackrill P. Investigation and treatment of poor drains of dialysate fluid associated with anterior abdominal wall leaks in patients on chronic ambulatory peritoneal dialysis. Nephrol Dial Transplant 1992;7:1030-1034. 10. Litherland J, Lupton EW, Ackrill PA, Venning M, Sambrook P. Computed tomographic peritoneography: CT manifestations in the investigation of leaks and abnormal collections in patients on - 111 -
- The Korean Journal of Medicine: Vol. 80, No. 1, 2011 - CAPD. Nephrol Dial Transplant 1994;Ve449-1452. 11. Kopecky RT, Frymoyer PA, Witanowski LS, Thomas FD, Wojtaszek J, Reinitz ER. Prospective peritoneal scintigraphy in patients beginning continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1990;15:228-236. 12. Nomoto Y, Suga T, Nakajima K, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis--a collaborative study of 161 centers. Am J Nephrol 1989;9:363-367. 13. Contreras-Puertas P, Benitez-Sánchez M, Jimánez-Heffernan A, Rebollo-Aguirre A, Cruz-Muñoz S. Hydrothorax in continuous ambulatory peritoneal dialysis: peritoneoscintigraphy in a case of spontaneous closure of pleuroperitoneal communication. Clin Nucl Med 2002;27:208-209. - 112 -