-;k: 웰 1ik. 껴,1 綠펙덩 애,4 Vo l. 21, No. 2, 1985 放射性同位元素를利用한뿜陽管出血의該斷 * 延世大學校醫科大學放射線科學敎室 李倍雨 兪亨植 李鍾太 朴昌 ) 閔 原州醫科大學放射線科學敎室 成홉俊 徐樞錫 - Abstract - Radionuclide Localization of GI Bleeding K.W. Lee, M.D., H.5. Yoo, M.D., ).T. Lee, M.D., c.y. Park, M.D. Department of Radio!ogy & Nuc/ear medicine, Yonsei Universitχ College of Medicine, Seou!, Korea K.). 5ung, M.D., ).5. 5uh, M.D. Department of Radio!ogy, Wo 끼 u Medica! College The diagnosis of acute or chronic GI bleeding and the localization of bleeding site is important clinically GI bleeding localization has been done with contrast angiography. However, due to i얀 invasivness & limitation, radionuclide angiography is being widely applicated recently We have studied in 12 cases of surgically & clinically confirmed GI.bleeding lesion with Tc99m PHYTATE & Tc99m BLOOD POOLI NG AGENTS Now we report the significance of radionuclid e angiography for detection of GI bleeding in conjugation w ith clinical history & contrast angiography I. 絡 ~~ jjjjjj 陽出血의成功的인治續는陽出血의確認과出血部位 의局所化에있다. 原發性出血部位가上部몹陽管인지 下部몹陽管인지짧別하는데病歷身體檢훌, 血賴血球 比量計 CHC T), 便에 價血檢좁, ~ 후뽑陽管튜부및直陽 * 本論文은 1985 年度延世大學校醫科大學敎授맑究費 의補助로이루어졌음. 이논문은 1984 년 11 월 1 3 일에접수하여 1 985 년 4 월 3 일에채돼되었음. 鏡檢흉가도움을줄수있으나실제出血部位플確認하기는용이치않다. 通常的인뽑陽에대한放射線學的檢훌法으로는 20 ~ 25% 정도에서는出血部位가발견되지않으며 1, 2) 보다흡害的인過程인뽑內視鏡또는造影뼈j 血管造影術이쭈 Ij 用될지라도出血部位의局所化는出血이間歐的이거나出血量이分당 O. 5ml 以下인경우는不加能하다 3 ) 그러냐最近非훔害的이며安全하고短時間의過程으로쉽게할수있는장점을가지는放射性同位元素血管造影術의말달에따라延世大學校醫大附屬세브란스病院放射線科에서最近 4 年間臨皮的으로檢훌당시陽出血이疑心되는뽕 者 12 名에서 99m Tc-Phyt a te와 99 m Tc - 246
-Blood Pooling Agents 를가지고放射性同位元素血管造 影術을施行한結果를文敵考察과함께報告하고자한다. 11. 對象및方法 1 979 年 7 月부터 1 983 年 8 月까지延世大學校醫大附 屬세브란스病院및原 j! 基督病院에來院하여陽出血 이疑心되는愚 者에서放射性同位元素血管造影術을施 行한후手術이나推助檢효로確談된 象으로하였다. 12 名의愚者을對 愚者의나이는 10 個月에서 71 歲까지이고男子가 8 名, 女子가 4 名이었으며陽出血이疑心되는狀훈및血 樂血球比量計 CHCt) 의減少가있는愚者이었다. 검사장비는 CGR ACTI 3410T -GAMMA CAMERA 와 1 MAC 7300 COMPUTER 및 MAXI CAMERA n 플쭈 IJ 用하였으며愚者는 {fp 멍 A.í 立로굽힌후施行하였다. 放射性同位元素注入量은成 A에서 "m Tc - P h y tate는 10 mci, "mtc-blood Pooling Agents 는 15mCi, 어린 이는各各 2 ~ 5 mci 를靜服注射하였다.,'mTc-Phytate 走흉는 2 秋間隔으로 30 젠間影像을얻고그후 5 分間隔으로運延影像을얻었다. "mtc- Blood Pooling Agents 는 lì 射後 30 : 향間의血流像題影後에 10 分間隔으로한시간동안連續觸影하였고必要에따라時間別影像및 24 時間後의影像도얻었다. III. 結 A. 各 / 뚫者의 年敵別分布및 臨짧성狀 1fË은 Table 1 과같다. B 同位元素 Jtn 管造影術 및造影홈j 血管造影術의所見 果 Table 1. Symptoms & Signs of 12 cases No Age/Sex History Most lower Level (Hb/HCT) Op finding and clinical Dx Radiopharmaceutical 36/F 2 18/F 3 23/M 4 71/F 5 38/M 6 26/F 6 51 /M 8 10m/M 9 7l/M 10 10m/M 11 31/M 12 33/M RUQ pain 9.6/ 27.6 rectal 5.5/17.8 bleeding Trauma 9.8%29.8 Trauma 9.1/ 21.1 Anal 8.8/26 bleeding Melena 3.8/12.8 Melena 5.1/ 19.7 bleeding 11.6/ 33.6 diarrhea bleeding 14.8/43 diarrhea Guaiac 6.8/20.8 test(+) palm 6.7/20.3 rectal 11.3/32.9 bleeding. omental ectopic pregnancy 99mTc-phytate with bleeding. abnormal vessel in ileocecal valve bleeding ulcers in the terminal ileum d ue to thypoid fever renallaceration with R t pheriephric hematoma Rt pelvic bone fracture bleeding ulcer in the cecum with intraluminal hematoma metastatic GI bleeding of Chorio, Ca marginal ulcer bleeding in the jejunum incarcerated hernia L2 compression fracture pneumonia & gastroenteritis A M L u1cerative colitis 99mTc-phytate (in vivo) - 247-
99 m Tc -HS A 듭靜 JWil 져t 後正常的同位元素分布는題部動服과陽骨펀bJW에放射能이보이나陽內및陽周違에는放射能의집적이보이지않으며勝뼈에排 if!!: 된放 射能이보인다 (Fig. 1 A,B). 99 m Tc_ Phytate 플않用하여子宮外빠娘에依한쳤믿읍 觸周違의出 [1iJ. 로 ~~ 斷펀愚者에서는右下題部에陽出血 생織 챙썰 A Tc"!.' HSA Fig. 1. A & B. Normal radionuc1ide angiogram. By using, static images reveal significant activity in major vessels, liver, kidneys, & bladder. B... 20 sec 24 S Fig. 2. Case 1 A: Serial anterior abdominal images using 99mTc-phytate demonstrate an abnormal focus of activity (arrows) in the right lower qudrant. - 248-
B C Fig. 2. B & C; Contrast angiogram reveal hypervascular lesion with extravasation (arrow) in ileocecal valve area, corresponding to scintigraphically demonstrated lesion. 에依한異常의放射能훌積이動的影像에서보인다 (Fig. 動物實驗하여前者는分당 O.lml 以下의出血에도出血 2 A). 部位가確認되며食道, 뽑, 十二指陽의背後放射能이높그後造影햄j 血管造影術像右下題部에젊血에의한造아上部뽑陽管出血의檢훌에는의의가적다고하였으影齊 j의增加가보인다 (Fig.2 B, C). 며下部陽管出血檢흉時에좋다고하였다 8 ) 또한 플使用하여홉陽에慣覆出血로談그外 99m Tc - Al l:umin을 Miskowiak 等이 S 字狀結陽 斷된愚者의動的影像에서右下題部에同位元素의異常放射能훌積이보이며 (Fig. 3 A) 運延影像에서異常의放射能훌積部位가陽管內에서上部로離動된것이보인다 (Fig. 3 B). 에想室로부터出血을檢훌하기위해서使用되었으며 9 ) 1977 年 Pavel 등이 99 m Tc - Pertechnetate 에未血球를부착시키는데試驗管內方法으로 97% 까지부착되나 10) 그過程이복잡하여좀더쉬운方法으로부착시키는生 N. 考흉찢放射性同位元素血管造影術은 1962 年 Ariel 이 Chro' mium-51-1abeled RBC 를利用하여食道에서얼어나는出血과食道보다遠位部의出血과籃別하기위하여便用한것이처음으로알려져있다4) 13 그後 1974 年 D'Addabooa 等이 1 1_ labeled All:umin 을動物實驗하였으냐臨많的應用으로는적당치않았다 5) 1975 年 A 間에서上部볍陽管出血을보기위하여 In -113m Transferrin 으로實驗하였으며 6, 7) 1977 年 Alavi 等이 99 m Tc-Sulfur colloid 와 99 m Tc -DTPA 를개에서 - 249- 體內方法을開發하여 95% 까지부착에成功하였다 11) 1978 年 99mTc - Sulfur C이 loid 를가지고 Barry 등은造影簡 j 血管造影術로는陽出血이안보이는愚者에서홉陽靜服짧와홉陽으로出血되는것을報告한바있다 12) Alavi 등은 99 m Tc - Sulfur Coiloid 이용의진단적의의에대한實驗的핍究로早期影像이陽出血의응? 斷및出血部位의確認에도움을준다는것을증영하였으며또한이方法으로뽑職, 陽間鷹및骨盤部外傷뿔 者에서陽性所見을報告하였다 13) 著者들도 99 m Tc- Sulfur Colloid 와작용기전이같은 99mTc - Phytate 를使用하여陽出血이疑心되는愚者 2 f7u를맑究한結果子宮外없振에 2 次的으로發生된행둡觸주위에異常血管에의한出血
Fig. 3. Case 5 A. Serial anterior abdominal images using demonstrate an abnormal focus of activity (arrow) in the right lower qudrant. R 및장티부스에의한末端펄陽部位에置覆出血로確談된 2{ 列모두陽性所見을관찰하였다. Heyman 등은 99 m Tc_O. 를가지고 Meckel's 씨想室 때문에생기는陽出血의檢흉를報告하였다 14 ) 1979 年 Winzelberg 등이 10 名의陽出血이疑心되는愚者에서 9 밴 Tc- RBC C in v ivo) 를使用하여活性의또 는間 ~ 的陽出血의檢훌에 敏感한方法이라고報告하 였으며 15) 著者들도生體內方法으로호陽의가장자리 出血로確앙된 뽑 6 윷場手術愚者 H 징 j 에서陽性所見을觀 察하였다. 99 m Tc_ labeled RBC 의正常分布를맑究하여早期影像 J::&'f 究例中 60% 가大血管, 밤, 牌職, 賢顧 11 서放射能홈積을보이고 50% 가몹에서放射能을보이며 24 時間運延影像에서大血管,!ff, 牌廳뽑職의放射能은變하지않고早期影像의뽑의放射能이大陽의放射能 으로變하여 50% 가보였다고報告하였으며또한輸血 量과陽性走흉時間의 & 다究에서輸血을많이要求했던愚者에서陽性走훌時間이빨랐던것으로報告했다 16) Fig.3. B. Activity later moved up toward liver in 著者들도正常分布는 Winzelberg 等은 99 m Tc_RBC 走 ascending colon 흉로下部陽管陽出血의檢흉에서敏感度는 91% 特異度는 95% 로報告하였다 16) - 250-
1981 年 Som 等이 99 m Tc heat treated RBC 를개와著者들의結果로도陽出血및그外藏器의出 oíl 을즙 Á F. 닐애! 서檢훌하여 8 0 % 以上이뺑職에隔離되고 99 m Tc 斷하는데放射性同位元素血管造影術은非慢害的이며安 - Sulfu r Colloid ( Tl/ 2 = 2 分 ) 보다느린血波除去率 (T 全하고쉰게利用할수있는長點을가지며또한陽出 m 1/ 2 = 10 分 ) 로써右上順部를잘볼수있다고報告하였의장斷및造影簡 j 血管造影術의施行與否와檢표部位結 으나短點으로未血球에加熱處理方法에어려운이있다定에重要한역할을하는選別檢훌임을알수있었다. 고報告하였다 17,18, 19, 20) Miskowiak 等이 99mTc-Sulfur Colloid 와 99mTc-Blood Pooling agents 의比較돼究에서前者는 9 千, 牌魔에 V. 結 同位元素쫓積때문에上部뽑陽管의出血檢흉가어렵다고著者들은 1 2 例의放射性同位元素를利用한 lúl 管造影 하였으며 Blood Pooling Agents 는背後放射能은높지만 Eι,. õl!!l 術影 f 象을分折하여판바放射性同位元素플 flj 用한血管 몹陽管의出 lúl 을局所化하는데에는도웅이된다고한造影術은比較的간단한過程이며非룹害的인檢홉로써 다 21) Flukinger 가 99 m Tc _ Sulfur Colloid 로大 9 易想室로부 터出血檢훌의 f 列를報告한바있으며 22' Alav i 等은急性 陽出血愚者에서造影簡 l 血管造影術과 99 m Tc _ Sulfur Co lloid 에의한放射能同位元素 Jfu 管造影術의比較 % 究에 活性의또는間값的陽出 rúlo] 疑心되는愚者에서應急 手 術의與否를結定하는첫選別檢좁로써아주有用하다고 생각한다. REFERENCES 서後者가더鏡敏한檢훌라報告하였다 2 3 ) Mukusick 等은 99 m Tc-RBC 血管造影術과造影陣 j 血 管造影術의比較 & 다究에서前者가더 銀敏한檢훌라報告 하였다 24) Bunker 等은臨皮的으로陽出血이 疑心되어 99 m T c _ labeled RBC 플使用한走훌上手術로陽出血이 6훌 ~.~ 된!1{ 列中 10 例에서陽住所見을手術前에 f짜見할수있었 음을報告하였 S 며 25 ) 著者블도試驗管內方法으로 5 例 를맑究한結果 5 例中外傷에의한웹緣의싫 i% 파털魔 의出血性慣傷및惡性睡없의轉移에依한陽出띠 l 로確 씀된 3 例에서 陽住所見을觀察하였다. Donald 等은 99mTc_ Sulfur Colloid 와 99 m Tc_ Bl oo d p 이 ing Ag e nts 의長短點을比較하였는데前者는長點 이 出血部位를早期에보여춤과出血量이적을때도檢 훌가加能하며 檢훌時間이짧다는것이며後者는上部陽 管 出血檢흉에좋고間歐的인 陽出血의 檢좁에좋다는 것이다 그러나各各의 短點으로는前者는檢훌당시活性的인 出血이있어야되며上部陽管出血檢훌로는적당치 않다 는것이고後者는背後放射能이높다는것과正常的으 로뿜와泌 J]j( 生꺼훌器에는放射能이 存 te한다는것이다 26 ) Berget 等은 99m Tc-Sulfur O:> ll o id 는分당出 lúl 量이 0.05~0.lmI 8 ), 99 m Tc - heat treated RBC 는分당出 1Úl 量이 O_12ml 18) 造影뺑IJ J:fll 管造影術은 O. 5 mi 3 ) 의境遇 確認加能住을說明하면서그結果 99mTc - Sulfur Co ll이 d 플利用한血管造影術은陽出血의 6훌 ßN 도움이된다고 다섯例를報告하였다 2 7 ) 1. Thoe ni RF, Cello JP.: A critical look at the accuracy of endoscopy & double contrast radiography of the upper CI tract in patients with substantial UCI hemorrhange Radiology 135: 305-308, 1980. 2. Cooley RN.: The diagnotic accuracy of UCI radiologic studies. Am J M ed 242, 628-650, Nov 1961 3. Nusba um M, Baum 5.: Radiographic demonstration of unkowen sites of CI bleeding. Surg Forum 14, 374-375, 1963 4. Ariel 1M.: The site of UCI bleeding, detection by radioactive tagged R8C. JAιIA 180, 212-214, Apr, 1962. 5. 0 addabbo A, Fersini M.: Detection of intraabdominal bleeding by radioisotope scanning after experimental extravasation. J Nuc/ 8io Med 18, 170-174, Oct-Dec 1974 6. 5hapiro 5H, Castronovo FP, Callahan RJ, et a l.: Utilization of indium-113m for the detection of occult CI bleeding. J Nuc/ Med 16, 569, 1975 (abst) 7. Ferrant A, Oehasque N, Lene rs N, Meunier E.: Scintigraphy with In-111 labeled cells in intermittent CI bleeding. J Nuc/ M ed 21. 844-5. 1980 8. Alavi A, Oann RW, Ba um 5, et a l.: Scintigraphic detection of acute CI bleeding. Radiology 124: 753-756, Sep 1977. 9. Miskowiak j, Nielsen 5L, Munck 0, et al. : Abdominal scintiphotography with Tc-99m labeled albumin in acute CI bleeding. An experimental study and a case report. Lancet 2, 852-854, 22, Oct 1979 10. 5mith TO, Richards P.: A simple kit for the preparation of Tc-99m labeled R8C. J Nuc/ M ed 17, 126-132, Feb 1976-251-
11. Pavel DG, Zimmer Am, Patterson VN.: In vivo labelling of R8C with Tc-99m; a new approach to blood pool visualization. J Nucl Med 18, 305-308, Mar a new approach to blood pool visualization. J Nucl Med 18, 305-308, ι1ar 1977. 12. Barry JW, Engle CV.: Detection of hemorrhage in a patient with cecal varice: using Tc-99m sulfur colloid Radiology 129: 489-90, 1978. 13. Alavi A, Berg B, Dann RW. Tc-99m sulfur colloid scans in the evaluation of abdominal trauma (abst). J Nucl Med 19, 686, 1978. 14. Heyman 5, Sacks B, Khettry J, et al.: Localization of bleeding small intestinal lesions using scanning techniques. Surgery 85, 372-76, 1979. 15 Wingelberg GG, Mukusick KA, Strauss HW, et al.: Evalua tion of GI bleeding by RBC labeled in vivo with Tc-99m J Nucl Med 20, 1080-1086, Oct 1979. 16. Winzelberg GG, Froelich JW, Mckusick KA, et al.: Radionuclide localizaôon of lower GI hemorrhage. Radiology 139: 465-469, 1981. 17. Atkins HL, Goldman AG, Fairchild RG, et al.: Splenic sequestration of Tc-99m labeled heat treated RBCs Radiology 136: 501-503, Aug. 1980. 18. Som P, Oster ZH, Atkins HL, et al.: Detection of GI blood loss with Tc-99m labeled heat treated RBC. Radiology 138: 207-209, 1981. 19. Eckelman W, Richards P, Atkins HL, et al.: Visualization of the human spleen with T c-99m labeled RBC. J Nucl ι1ed 12, 310-3 11, Jun, 197 1 20. Dann R, Alavi A, Baum R, et al A comparison of in vivo labeled RBC with Tc-99m sulfur colloid in detection of acute CI bleeding β bst). J Nucl Med 21, p75, Jun 1980. 21. Miskowiak, J, Nieken SL, Munck 0.: 호intigraplhic diagnosis of CI bleeding with Tc-99m labeled blood pool agents Radiology 141: 499-504, 1981. 22. Flickinger FW. Location of active lower GI bleeding by Tc-99m sulfur colloid scan. J Nucl Med 22, 38-9, 1981. 23. Alavi A, Ring 티. Localization of GI bleeding; superiority of Tc-99m sulfur colloid compared with angiography. AJR 137, 741-748, 1981. 24. Mckusick KA, Frolich JW, Callahan RJ. Tc-99m RBC for detection of GI bleeding. AJR 137, 1113-1118, 1981. 25. Bunker SR, Brown JM, Mca비 ey RJ, et al.: Detection of CI bleeding sites. Use of in vitro Tc-99m labeled RBC JAMA 247, 789-792, 1982 26. Donald GJ, Coleman RE.: New techniques in radionuclide imaging of the alimentary system. Radiol clin North Am 20, 635-651, Dec 1982. 27. Berger RB, Zeman RK, Gotle chalk A. : The Tc-99m sulfur colloid angiogram in suspected GI bleeding. Radiology 147: 555-558, ι1ay 1983-252-