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복부초음파에서 놓치기 쉬운 증례 삼성서울병원 정우경
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복부초음파에서놓치기 쉬운 증례
삼성서울병원정 우 경
목차
• 초음파의사각지대
• Easy to miss cases: 간
• Easy to miss cases: 담낭
초음파의사각지대
• 초음파검사는주변구조물의영향을받는다
–폐안의공기
–위나대장안의공기
–늑골
– Greater omentum과같은지방조직
–간경화환자의복수
–담낭안의담즙
초음파 검사를방해하는 요소
Blind spots of liver US
• Hepatic dome (right and left)
• Caudate lobe
• Superficial area of right liver (beneath ribs)
• Far lateral portion of left lateral segment
US features of HCC
• Hypoechoic (with/without mosaic pattern)
• Posterior enhancement (weak)
• Peripheral halo
• Lateral shadowing
Hepatic dome
F/30 endometrial sarcoma
Caudate lobe
Caudate lobe
Beneath rib cage
subcostal vs. intercostal
subcostal intercostal
간 좌,우엽 모두 검사늑골에 가리는 경우는 별로없음 (공기에 가림)대부분 검사 잘함sweeping
간 우엽 검사, 비장 검사늑골에 가림 (평행하게)
검사 잘 안함moving
Intercostal scan
Distorted anatomy (intercostal)
Far lateral portion of LLS
F/64 HBV
M/50 HBV
Infiltrating HCC
Infiltrative HCC
• Indistinct margin
– Only liver cirrhosis?
• Overall change: echogenicity change (low)
• Portal vein thrombosis (esp. expansile)
– Using Doppler
– CT!!!
담낭초음파
• ‘쉽지만어렵다.’
– Hepatic hilum에서복벽닿은부분까지
–가짜병변을구별
• 다른영상검사보다고해상도
• 담낭암: 예후가나쁘다
–한번놓치면돌이킬수없는경우가…
담낭의정상소견
• Gallbladder
– GB fossa of the liver (between S4 and S5)
– Fundus, Body, Neck, Infundibulum (Hartmann’s pouch)
– Normal wall thick• 2-3 mm
• Pencil-thin echogenic line (mucosa)Echolucent line (fibromuscular layer& subserosa)
가짜병변혹은병변가림
• 초음파의허상 (artifact)
– X선이나광선과는다른초음파의물리적특성에의해발생
• 담낭초음파
– Reverberation
– Side-lobe
– Beam thickness
Reverberation artifact
• 초음파빔이특정구역에갇혀반사(reflection)가반복되면서발생
– Ex) 복벽의여러층
Beam thickness / side lobe
• 초음파빔은두께가있다
• Side lobe: 전자기파의특성
Solution : harmonic imaging
conventional harmonic
Stone vs. Gas
Stone Gas
위치 Dependent Non-dependent
반사면 Less bright More bright
후방 음영 Clear Dirty
위치변화 Less More (bowel)
F/76
후방음영
Porcelain GB Emphysematous Cholecystitis
Impacted GB stone
Wall W: anterior wall of GB
thin dark line of bile
E: surface of stone
S: shadowing
Echo
Shadow
: contracted GB with stones (찌부러진 담낭내의 담석)
WES sign(Wall-Echo-Shadow, double arc)
Courtesy of Dr. JW Kim
선근종증
• Hyperplastic wall thickening
– Epithelial proliferation
– Muscular hypertrophy
– Invagination of epithel.: Intramural diverticula (R-A sinus)
– Diffuse/Segmental (body)/Focal (fundus)
• GBCA (6.4%)
Diffuse adenomyomatosis
• US: bile sludge, cholesterol crystal, stone in RAS (reverberation or comet-tail artifact)
• MR: pearl necklace sign (specificity=92%)
Courtesy of Dr. SH Kim
Focal adenomyomatosis
• GB fundus
• DDx from GB cancer
Courtesy of Dr. SH Kim
M/67
M/59
After 5 months
74/M Focal Adenomyomatosis?
2000 2003
2008 2009
GB cancer (T2N0)
Summary
• 초음파는한계가있는검사법이다.
–한계를이해하고검사해야좋은검사를할수있다.
• 간을비롯한모든장기는끝에서끝까지보아야한다.
–보지못했으면못봤다고명시해야한다.
• 정상소견을잘알고, 진단이불명확하면다른검사를추가해야한다.
–무분별한검사는지양해야한다.
감사합니다
