비뇨기초음파표준영상 및급여기준imedimp4.castcity.net/kacu/20190609/ba12/05.pdf ·...
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비뇨기초음파표준영상및급여기준
대구 21세기 내과
신 이 철
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Contents
• 급여 기준과 분류, 판독 소견서
• Kidney, Ureter• Anatomy• Scanning method• Standard scan• Normal variant• Common disease
• Adrenal gland• Anatomy• Scanning method
• Bladder • Anatomy• Scanning method• Standard scan
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급여기준과 분류
1. 언제 비뇨기계 초음파를 시행 하는가?
진료의사의 의학적 판단에 따라 충수·소장·대장·서혜부·직장·항문,
신장·부신·방광에 질환이 있거나 의심되어 해부학적
구조 이상을 진단하거나 경과관찰하기 위 하여의사가직접시행한 경우건강보험 적용됨.
2. 비뇨기계 초음파의 대상 장기(신장, 부신, 방광) 의 영상을 획득하고영상과 판독지를 작성, 보관 하여야함
3. 시행시기 : 2019년 2월 1일 부터 시행함
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초음파검사 코드 및 산정기준
구분 EDI코드
기본
초음파
단순초음파(Ⅰ) EB401
단순초음파(Ⅱ) EB402
진단 초음파
신장·부신·방광 EB448
신장·부신 EB449
방광 EB450
제한적 초음파
신장·부신·방광 EB448001
신장·부신 EB449001
방광 EB450001
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초음파검사 코드 및 산정기준
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초음파검사 코드 및 산정기준• 진료의사의 의학적 판단에 따라 비뇨기 질환의 진단 혹은
경과관찰시 아래와 같이 인정하고 이를 초과하는 경우본인부담 율80%
• 신장 또는 소장 이식 전·후 상태 평가, 신장 또는 부신 종양의상태 확인, 혈관기형이 있거나 출혈이 의심되어 도플러검사를시행하는 경우 산정 가능하며 소정점수의 10% 가산(산정코드두 번째 자리에 1로 기재)함(예) EB449010 100% 청구
• 30일 이내 비뇨기 초음파 검사를 반복하는 경우 다른 질병이라도 동일 episode 로 간주.
• 동일부위 동일상병이라도 증상변화, 치료 후 재발 등 의학적판단에 따라 별개 에피소드 가능
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초음파검사 코드 및 산정기준
• 본인 희망에 의하여 건강검진으로 시행한 초음파검사에서 질환이 진단된
경우 급여 대상인가?
진료의사가 질환이 있거나 의심하여 초음파검사를 시행한 것이 아니고,
환자의 희망에 의하여 시행한 건강검진이므로 비급여임.
• 경과관찰이 필요한 복합 신낭종은 Bosniak classification ⅡF와 환자의상태(
고령, 단일신장 등)로 인하여 수술을 시행하지 못하고 경과 관찰하는
Bosniak classification Ⅲ, Ⅳ를 의미함.
• 장기별*초음파검사 급여기준에서 정하는 연 단위 경과관찰자 횟수적용 기준-
회계연도 기준으로 매년 1월 1일부터 12월 31일까지로 함.
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비뇨기 초음파 판독소견서
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Scanning Method
position of patient -
supine or decubitus
2-5 MHz convex probe
NPO or not
Patient assistance :
patient take in a deep
breath Kidney is located behind, sometimes posterior approach will be effective
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Scanning Method
cranial medial to caudal lateralcranial dorsal to caudal ventral
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Scanning Method
cranial caudal
liver
Rt. Lt.
spleen
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Fanning Method
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신장 및 부신 표준영상
• 신문(renal hilum)을 포함하는 좌·우신 각각의 관상면 스캔
• 좌·우신 각각의 상부 / 중간부 / 하부 횡스캔※ 부신 종괴가 있는 경우 종괴를 포함한 스캔
• 중간부 횡단면 영상에서 신우의 늘어난정도를 확인한다
• 간과 비장 등 주변 장기와 신실질의 음영을 비교하고 신장및 신장 주위의 이상 소견 여부를 확인해야 한다.
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Right Kidney Left Kidney
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Transverse scan at Upper pole
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Transverse scan at Hilum
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Transverse scan at Lower pole
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Anatomy of Kidney, Ureter무게 : 120~150g
크기 : 장경 9~12cm(Lt>Rt) 단경 4~5cm
좌우 2cm이상차이, 9cm보다작으면이상male : female = 10-14 cm : 9-13 cm
> 10 cm: normal< 9 cm: abnormal
Position : T11~L3, 후복막장기Rt가 Lt보다 약간 아래
https://www.youtube.com/watch?v=805VoHIIQCs or http://osms.it/more.
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Anatomy of Kidney, Ureter
https://www.youtube.com/watch?v=805VoHIIQCs or http://osms.it/more.
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Anatomy of Kidney, Ureter
Liver
Colon
IVC Aorta
Celiac axisSMA
Colon Small bowel
Pancreas
SpleenAdrenal
Adrenal
Small bowel
Duodenum
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Anatomy of Kidney, Ureter
Cortex
Medulla(renal pyramid)
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Anatomy of Kidney, Ureter
Renal column
Renal papilla
Renal lobe
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Anatomy of Kidney, Ureter
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Anatomy of Kidney, Ureter
interlobar
segmental
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US Anatomy of Kidney
Renal Medulla (수질)
Renal Cortex (피질)
Renal Column (신주)
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Anatomy of Kidney, Ureter
Central echo complex <Renal parenchyme >
Renal cortex thickness
Renal medulla thickness
Parenchymal thickness (renal capsule~outer margin of renal sinus) polar region 3~3.5cm, interpolar region 2~2.5cmIf minimum thickness <1cm & length <9cm → Irreversible pathologic change
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Renal artery & Vein
• RRA : usually passes posterior to IVC• LRA : usually course posterior to Lt renal vein• Multiple renal artieres in 25%
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Anatomy of Kidney, Ureter
www.ultrasoundpaedia.com
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Transeverse scan of Rt kidney
ureter
Renal sinus
Renal a.Renal v.
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Echogenecity of Kidney
Anatomy of the Kidney Brenner and Rector's The Kidney. Fenton, Robert A.; Praetorius, Jeppe. Published January 1, 2016. Pages 42-82.e8. © 2016.
• kidney < liver/spleen (normal adult)
• kidney = liver/spleen (normal neonate)
• kidney > liver/spleen (parenchymal disease)
Platt JF, et al. AJR 1988
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Resistive Index (RI)- (S-D)/S- interlobar a, arcuate a- upper, inter, lower poles- normal < 0.7- variables:
age, sample location, PR, BP, compression
interlobar a.
Spectral Doppler – Resistive Index(RI)
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Contents
DM obstruction
RAS Rejection
RI increase RI increase
Pulsus tardus RI increase
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What shall we do if we detect renal pathology on USG?
Simple cyst vs complicated cyst
Focal renal mass vs Pseudo mass
Hydronephrosis or Not?
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Simple renal cyst
① Anechoic② Sharply defined, smooth wall③ Post acoustic enhancemet④ No doppler signal, round or oval shape
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Renal cysts, Complex Renal cysts
• Prevalence: 10 %
• 5~10% cysts are not simple cysts
• 5~10% of complex cysts prove to be tumor
• 2 main causes: complicated simple cyst & cystic RCC
• Characteristic-Wall thickening,
Septation & nodularity
calcification
Enhancement
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Complex renal cyst
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Bosniak Classification
Septa enhancement Septa morphology Calcification
II No enhancement A few hairline Fine/short segment
IIF No enhancement Multiple hairline Thick and nodular
III Measurable enhancement Thickened
IV Distinct enhancing soft tissue components independent of septa
I & II : >3cm, periodic fu for 2~3yrsIIF & indeterminate III : 3,6,12mo and annually fu by CTIV & definite III : surgery
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Pseudo-tumors andnormal variations in the kidney
• Prominent column of Bertin
• Dromedary hump
• Fetal lobulation
• Localized compensatory hypertrophy of renal parenchyma
• Junctional parenchymal defect
• Sinus lipomatosis and abnormal echo of sinus fat
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Column of Bertin Hypertrophy• common pseudotumor
• thickened aggregate of cortical tissue
• junction of the upper and middle thirds
• No deformity of adjacent calyces
• CDUS is helpful in DDx from true tumor
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Dromedary hump
• Focal buldge on the lat margin of LK• Adaptation of kidney to the spleen/liver• Normal vascularity/ preserved calyx
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Persistent Fetal lobulation
① Fecal kidney subdivided into lobe(#14,4M), fusion(7M)
② Incomplete fusion of developing renal lobules③ Renal surface indentations btw the pyramids/regular
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Junctional Parenchymal Defect
① 신장 발생시 parenchymal mass의 불완전한fusion으로 발생
② Extension of renal sinus fat③ Upp pole of RK > low pole of LK④ Echogenic triangular or linear shape⑤ DDx : AML, renal parenchymal scar
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Hydronephrosis?
Parapelvic cyst Hydronephrosis due to UPJ stone
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Hydronephrosis
• pelvocaliceal dilatation
• splitting of renal sinus
• increased parenchymal echo in advanced stage
• enlarged kidney
• acute obstruction
• RI > 0.7
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Parapelvic cyst, Extrarenal PelvisParapelvic cyst : Lymphatic ectasia, multiple, septated
Renal sinus
no communication with collecting system
Extrarenal pelvis : Normal variant
Renal pelvis location outside the renal hilumBox shapedNo calyceal dilatation
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HydronephrosisGrade 0 : NormalGrade 1 : mild dilatation of pelvisGrade 2 : mod dilatation of pelvisGrade 3 : dilatation of pelvis and calycesGrade 4 : Gr 3+ renal parenchymal thickness <50% of normal
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Angiomyolipoma• m/c benign tumor, Hamartoma(fat, smooth ms, vessels)
• USG : round/oval well demarcated, hyperechoic>isoechoic
• Size<3cm, discrete round high reflective mass
• 1/3 acoustic shadowing
• Spontaneous hemorrhage >4cm
• Ddx : small bright RCC(% fat-low, irregular echo)
- hypoechoic rim, intralesional cysts, calcification
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Renal Cell Carcinoma• Solid tumor, distort normal architecure
• Variable appearance : solid, cystic, complex
• Hyperechoic(48%), isoechoic(42%),
hypoechoic(10%)
• <3cm : usually hyperechoic, simulate AML
• >3cm : hypoechoic, exophytic with anechoic
necrotic area
• Hypoechoic rim : pseudocapsule
• Color doppler : most prominent around tumor
periphery
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RCC
AML
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Adrenal gland
Rt. Adrenal gland Lt. Adrenal gland
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Adrenal Gland
• Located retroperitoneum• Rt : suprarenal, posterior to IVC, medial to RL : 90%
• Lt : suprareanal, lat to aorta, posterior to pancreas and splenic vessels : 40-50%
• Shape• V, Y or λ (우측:삼각형, 좌측:반월형)• Central hyperechoic line(medulla), surrounded by hypoechoic
layers(cortex)
• Size• Thickness : 0.3~0.6mm• Length : 4~6cm• Width : 2~3cm• 주위에 지방조직이 둘러싸고 있어 정확한 크기측정이 어렵다
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Cyst
Adenoma
Pheochromocytoma
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Anatomy of Bladder
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Preparation for Bladder US
1. Transducer: 3.5~5 MHz convex probe with color doppler
2. 2Hrs prior to the appointment, empty their bladder
3. Over the next hour, they should drink at least 1 Liter of water
4. Do not go to the toilet until test ends
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Bladder wall
Consists of 4 layer- Mucosa, submucosa, muscle layer, serosa
Wall thickness – measured at ant wall of bladder with High frequency probe
<3mm – fully distended state<5mm – not fully distended state
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Scanning of Bladder
• 소변으로 방광이 충만한 상태에서 검사
1. 방광의 위쪽, 중간부위, 경부의 횡단면 스캔
2. 방광 중간부위의 시상면을 스캔
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Transverse scan of Bladder(Upper& Mid)
한국 초음파의학회 실행가이드라인
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Transverse scan(lower) & Sagital scan
한국 초음파의학회 실행가이드라인
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Urine Jet
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Contents
김일봉 원장님 증례
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비뇨기초음파표준영상
대한임상초음파학회 김대현 이사 slide