clonorchiasis and its complications: cholangiogram revisited · 2017. 4. 6. · clonorchiasis. the...
TRANSCRIPT
-
대 한 방 사 선 의 학 회 지 1992 ; 28 (2) : 229~235 Journal of Korean Radiological Society , March , 1992
Clonorchiasis and its Complications:
Cholangiogram Revisited
Jae Hoon Lim, M.D. , Young Tae Ko, M.D. , Dong Ho Lee, M.D. , Kwan Sup Lee, M.D. , Soo Jhi Suh, M.D.* , Seong Koo Woo, M.D.*
Department o[ Radiology, Kyung Hee University Hospital
- Abstract-
Clonorchiasis is known to be closely related with the development of recurrent pyogenic cholangitis and car-
cinoma of the bile ducts. ln order to ascertain the cholangiographic signs for recurrent pyogenic cholangitis or car-
cinoma of the bile ducts arising in patients with clonorchiasis , we reviewed cholangiograms in 42 patients with proven
clonorchiasis. The population consisted of 29 patients with clonorchiasis alone , six patients with clonorchiasis and
recurrent pyogenic cholangitis , and seven patients with clonorchiasis and carcinoma of the bile ducts.
Cholangiographic abnormalities in 29 patients with clonorchiasis alone were intrahepatic m비tiple. ovaI. or elliptic
filling d efects measuring 2-10 mm in size. representing adult l1ukes (n; 24). The pe디pheral bile ducts were obstructed
(n; 18). and the margins were ragged (n; 20) and hazy (n; 12). The intrahepatic bile ducts were dilated diffusely
(n; 27) . and the dilated peripheral small tributaries gave the impression of “ too many ducts appearance" (n; 22).
On the other hand. the extrahepatic bile ducts were less involved; filling defects were less cornmon (n; 7) 와ld dilatation
was mild (n; 17). In six patients with clonorchiasis and recurrent pyogenic cholangitis ‘ there were filling defects
of stones. and the extrahepatic ducts and larger intrahepatic ducts were predominantly dilated. In seven patients
with clonorchiasis and cholangiocarcinoma. all the biliary tree proximal to the tumor was markedly and diffusely
dilated. In the latter two groups. filling defects of f1 ukes and associated findings were less prominen t. but there was
disproportionately severe dilatation of too many intra hepatic ducts
In patients with recurrent pyogenic cholangitis or cholangiocarcinoma ‘ clonorchiasis should be considered as
a underlying cause when cholangiogram shows “ disproportionately" severe dilatation oftoo many intrahepatic ducts.
lndex Words: Bile ducts. radiography ‘ 765. 122
Bile ducts. calcul i. 765. 81
Bile ducts. neoplasms , 765 . 321
Cholangitis , 765 . 202
INTRODUCTION
Clonorchiasis , infestation of liver f1 uke , Clonorchis
sinensis , is one of the most common parasitic disease
in Korea , caused by ingestion of raw l1esh of
freshwater fish (1 -6) . The infestation is usually silent
but. heavy infestation produces obstructive jaundice ,
*양明大뺑交 醫과大쩔 放射線科學敎室
resulting in late sequela of intrahe patic bile duct
dilatation and fibrosis (1-3 , 7) . In these patients , in-
cidence of recurrent pyogenic cholangitis (1. 7-10)
and cholangiocarcinoma (1 , 11-13) is considerably
high.
There have been several reports concerning
cholangiographic features of clonorchiasis in Korean
(4-6) and English literature (3 , 14, 15) . Howe ve r , to
*Department of RadioJogy. Keimy ung University MedicaJ Co lJege
이 논문은 1991년 8월 1 2일 접수하여 1991년 10월 11일에 채택되었음 Received August 12. Accepted October 11. 199 1.
229
-
Journal of Korean Radiological Society 1992 ; 28 (2) : 229~235
the best of our knowledge , there has been no descrip-
tion concerning the cholangiographic findings in pa-
tients who had clonorchiasis and recurrent pyogenic
cholangitis or cholangiocarcinoma. Here we describe
the cholangiographic findings in 42 patie nts with
clonorchiasis , including what is the first description
in six cases associated with recurrent pyogenic
c holangitis and seven cases associated with
cholangiocarcinoma.
MATERIALS AND METHODS
Cholangiographic examinations of 42 patients
with clonorchiasis were reviewed . This was not a con-
secutive series since many patients with clonor-
chiasis did not undergo cholangiography , especially
in mild infestation. Twenty-seven cases were from the
file of Kyung Hee University Hospital during a
lO-year-period. About the same number of patients
with clonorchiasis underwent cholangiography , but
cholangiograms were lost or inadequate for review ,
or hospital records were insufficien t. 50 these cases
were not included in our study. During the same
period , approximately 600 patients were diagnosed
as having clonorchiasis on the basis of stool examina-
tion for ova of C. sinensis. The remaining 15 cases
were from Dong 5an Hospital during a recent 3-year-
period. The latte r hospital is located in the middle of
more endemic area. Twenty four cholangiograms
were endoscopic retrograde cholangiograms, ten were
percutaneous transhepatic cholangiograms and the
remaining eight were T-tube cholangiograms. En-
doscopic retrograde cholangiography and per-
cutaneous transhepatic cholangiographic studies
were performed because of obstructive jaundice or
persistent elevation of serum alkaline phosphatase
level. T-tube chola ngiography was performed after
surgery of bile duct stone , cancer , or severe infesta-
tion of C. sinensis.
The population consists of three groups: (1) 29 pa-
tients with clonorchiasis alone: (2) six patients with
clonorchiasis and recurrent pyogenic cholangitis: (3)
seven patients with clonorchiasis a nd cholangiocar-
cinoma of the bile ducts: one in the right intrahepatic
duct , five at the bifurcation a nd the other one at the
common hepatic duct. The diagnosis was made on
the basis of positive stool examination for ova in 22
patients (1, 16) , positive ova in stool and/or evacua-
tion of adult flukes from the bile ducts during biliary
surgery or catheter drainage in 20 patients . In two
patients , wedge biopsy of the liver revealed
adenomatous hyperplasia of the bile ducts as we \l as
periductal fibrosis , and in one patent adult f1ukes
were found in the bile ducts (Fig. 1). Thirty eight pa-
tients were men and four patients were women. The
average age was 50 years (age range , 29-72 years).
Cholangiograms were analyzed for the presence
of filling defects of flukes in the bile ducts , the degree
and pattern of dilatation of the bile ducts , and the con-
tour of biliary tree.
Fig. 1. Photomicrograph ofliver biopsy specimen show-ing an adult fluke of C. sinensis (open arrows) within the dilated small intrahepatic bile duc t. The wall of the bile duct shows fibrous thickening (between short arrows), adenomatous hyperplasia of periductal glands (curved arrow) and in f1ammatory cell infiltration (H&E , X40).
RESULTS
The cholangiographic findings are summarized in
Table 1. In one patients , the cholangiogram was nor-
mal. Abnormalities varied from minimal changes
such as a few filling defects within normal bile ducts
to extensive filling defects within markedly dilated
intra- and extrahepatic bile ducts .
Group 1. Clonorchiasis alone
F il1ing defects due to flukes and related findings
Ofthe 29 cases with clonorchiasis alone , multiple
- 230-
-
Cholangiographic Findings
Table 1. Chola ngiographic Findings in 42 Cases of Clonorchiasis
Jae Hoon Lim , et al : Clonorchiasis and its Complications
Clonorchiasis Alone Clonorchiasis with Clonorchiasis with
Recurrent Pyogenic Cholangiocarcinoma (n = 7)
(n = 29) Cholangitis (n = 6)
Findings due to nuke per s e
Ova l or elliptic filling defects
In trah epatic bile ducts
Extrahepatic bile ducts
Ga llbladder
Peripheral duct obstruction
Ragged margin of bile ducts
%
7
?
18
20
Bile duct change
ξι 따
d
gQ ’l
P」
S
S
G
’ m
비 rJ
따 m U
R
”
이 ”n
바
iω ·m d
씨 n
땅 없
(
r t i
s l
e
e … f
대‘ s m
” ” b
O
하 G
씨
b
b
r
S
표 C
「
F
띠 빠
”
때i 찌 ιω
애 ψ
뼈 빼 뼈 밟 없 때 뼈
뻐 m nM
때 때 m m
D
I
f
F
H
T
마
낀 η 5 U
껑 이)
5 5
1 • 3
6
5
7
5 7
1 •
‘ Number of cases among the 20 cases in which the gallbladder was visualized
oval or elliptic fill ing defects (Fig. 2). ranging from 2
mm to 10 mm , were visualized predominantIy within
intrahepatic bile ducts in 24 cases (83%) , ex-
trahepatic bile ducts in seven cases (24%) and the
gallbladder in two cases . In severe infestation , the bile
ducts were packed with the defects (Fig. 2) but in mild
Fig , 2_ A 35-year-old man with a history of raw fish in-gestion complained of ja undice. A stool examination for ova was positive a nd eggs per day was 1,600 ,000. En-doscOpic retrogade chola ngiogram discloses severe dilatation of intrahepatic bile ducts and innumerable ‘ oval or e lliptic lìlling defects of adult nukes (white arrows) in the peripheral bi le ducts , resulting in obstruction. Bile ducts are hazy , especially in the left h epatic lobe , and margin is ragged. Note relatively s ligh tIy dila ted (13 mm) extrahe patic ducts (black arrow)
infestation , there were several defects scattered
within the dilated bile ducts (Fig. 3). In 18 cases
(62%) , the peripheral bile ducts , namely tertiary ,
Fig. 3. A 51 .year-old man with a history of jaundice. Stool test for ova was positive and egg per day was 800 ,000. Cholangiogram of the left hepatic lobe discloses few , oval filling defects offlukes (arrows) within the tips of diffusely dilated peripheral smaller bile ducts. Note fusiform dilatation of the far periphera l ducts , the periphery being wider than the central ducts and bile ducts are e longated and tortuous . Peripheral ends of some of the ducts are blunt due to obstruction by nukes or aggregates of nukes (open a rrows). At a glance . the intra hepatic bile ducts a re “ too many". There is a minima l stenosis (curved black arrow). The extrahepatic bile ducts are slightly dilated. Arrowhead points the pan-creatic duct
- 231-
-
Journal of Korean Radiological Society 1992 ; 28 (2) : 229~235
quaternary. or more peripheral tributaries. were
obstructed and filling of contrast medium was in-
terrupted (Fig. 2. 3). The tips of these ducts were
blun t. The contour of the bile ducts were irregular
and ragged in 20 cases (69%) due to filling defects.
Bile duct changes
The small intrahepatic bile ducts. tertiary. quater-
nary. or more peripheral ducts. were dilated diffuse-
ly and uniformly (Fig. 2 . 3) in 27 cases (93%). In 22
cases (76%) ‘ the biliary tree was dilated and well
opacified up to the periphery of the liver (Fig. 3). giv-
ing the impression that there were “ too many in-
trahepatic bile ducts' ’. Some cases showed fusiform
dilatation of the peripheral duct. the diameter of the
peripheral ducts being larger than that of the more
central ducts (Fig. 3). The ducts were elongated and
tortuous in these cases. Minimal stenosis of the in-
trahepatic bile ducts (Fig. 3) was present in five pa-
tients (17 %). The margin of the bile ducts is hazy (Fig.
2) in 12 patients (41 %). The extrahepatic ducts were
not dilated (less than 10 mm) in 12 cases (41 %). and
were slightly dilated (less than 15 mm) in 17 cases
(59%).
Findings of the gallbladder
The gallbladder was visualized in 19 cases. There
were two cases showing oval or elliptic filling defects.
The gallbladder was distended moderately or
markedly in 9 cases (44%)
Group 2: Clonorchiasis with recurrent pyogenic
cholangitis.
Cholangiograms in six patients with clonorchiasis
associated with recurrent pyogenic cholangitis show-
ed basically similar findings but modified con-
siderably. There were filling defects of f1ukes. ragged
and hazy margin of the bile ducts. dilatation of the
intrahepatic bile ducts. and “ too many ducts ap-
pearance ‘' . bu t those findings of fI uke per se are less
frequent and less prominent (Fig. 4) . Besides. there
were defects of stone or stones ‘ in contrast to the
Fig. 4. Endoscopic retrograde cholangiogram of a 66-year-old man had a long history of ingestion of raw fish. Stool test disclosed ova of C. sÏnensis. “ Too many intrahepatic bile ducts" are slightly dilated whereas the extrahepatic ducts are markedly dilated. There is an oval filling defect of a stone (arrow). The intrahepatic bile ducts are opacified up to the periphery of the liver but there is no demonstrable filling defect. At surgery. stones in the intrahepatic duct. extrahepatic bile duct and gallbladder were removed
cases with clonorchiasis alone. Cholangiograms in
this group showed predominantly dilated ex-
trahepatic ducts in four cases.
Groups 3: Clonorchiasis with cholangiocarcinoma.
Cholangiograms in all seven patients with clonor-
chiasis and cholangiocarcinoma showed severe
dilatation of the intrahepatic bile ducts proximal to
the tumor. much more severely than in patients with
clonorchiasis alone or clonorchiasis and bile duct
stone (Fig. 5). Bile duct cancer was visualized as a
focal or diffuse narrowing or complete obstruction
Other findings were basically simUar to but less pro-
- 232-
-
Fig.5. A 57-year-old man presented with pruritus and progressive jaundice. Sonogram and CT disclosed diffuse severe dilatation ofthe intrahepatic bile ducts and a mass at the con f1 uence of the right and left hepatic ducts. Drainage catheter was inserted and flukes were evacuated through the catheter. Cholangiogram shows severe diffuse dilatation of the intrahepatic bile ducts. Very smal\ tributaries of “ too many' ’ bile ducts are dilated up to the far peripheral portion ofthe Iiver. dilated much more severely than might be expected in clonor-chiasis alone. Note complete obstruction by cancer (ar-row) at the confluence of the right and left hepatic ducts.
Jae Hoon Li m. et al : Clonorchiasis and its Complications
ding (Figs. 2. 3). The involved bile ducts were ragg-
ed owing to f1 ukes and aggregates of f1 ukes abutting
the wall of the bile ducts as well as cholangitis (Fig.
2). There were only few cases of minimal bile duct
stenosis (Fig. 3).
The change of the bile ducts consisted of diffuse
dilatation of smaller intrahepatic bile ducts (Figs. 2.
3 . 4) and no or minimal dilatation of extrahepatic bile
ducts (3 -6. 14 ‘ 15). The right and left hepatic ducts
and extrahepatic ducts were usually normal. or mild-
ly dilated in some patients with severe infestation.
There was no dist외 biliary obstruction except in cases
with concomittant cholangiocarcinoma. As the en-
tire intrahepatic bile duct are diffusely dilated .
cholangiogram revealed .‘ too many ducts ap-
pearance" at a glance when the biliary tree is ade-
quately visualized (Fig. 2. 3 ‘ 4.5). This is not caused
by actual increase in number of bile ducts. but by
visualization of the dilated smaller tributaries such
as tertiary. quaternary and more peripheral
tributaries. Some of the peripheral tributaries show
ed fusiform dilatation (Fig. 3). The severity ofthe bile
duct dilatation was not necessarily proportional to the
minent than those patients with clonorchiasis alone. number of f1 ukes. Sometimes bile duct margin is hazy
(Fig. 2) due probably to increased mucous secretion
DISCUSSION in the bile duct. p∞r mixing and insufficient amount of contrast media not enough for the dilated
Adult worms of C. sinensis reside in the human peripheral ducts (1 4).
intrahepatic bile ducts and produce m echanical The intrahepatic bile duct dilatation re f1ects basic
obstruction of the bile ducts. cholangitis and periduc- disease process. AduIt f1 ukes reside in the m edium
tal fibrosis (1, 2. 7). It is well known that characteristic and small intrahepatic bile ducts (Fig. 1) and produce
oval or elIiptic filling defects on cholangiogram repre- cholangitis (1, 2. 7) . Dilatation of the smal\er bile
sent liver f1ukes (3-6. 14. 15) . They vary from 2-3 mm ducts is most likely caused by obstruction by f1 ukes.
to 5-10 mm in size. Adult f1 ukes are flat. willow as demonstrated on cholangiograms (3-6. 14. 15). The
leaf1ike. measuring 8-15 mm long. 1.5-4.0 mm wide f1uke or aggregates of f1 ukes could easily occlude the
and about 1 mm thick. As f1 ukes reside in the small small peripheral ducts (Fig. 1). but larger ducts such
intrahepatic bile ducts. these defects were as rightand left hepatic ductsand extrahepatic ducts
predominently within the intrahepatic ducts (Figs. are wide enough to be patent. even if f1 ukes are lodg-
2.3). occasionally scattered in the extrahepatic ducts ed within them (9. 13). Mucosal hyperplasia. mucus
and the gallbladder (3) . These defects are distinguish- in the ducts caused by cholangitis. periductal in f1am-
ed from stone by their elliptical or oval shape. mation. fibrosis and stricture may play additional
smallness and uniformity in size (14). Sometimes roles in the occlusion of ducts and resuItant proximal
f1 uke or aggregates of f1ukes blocked and interrupted small intrahepatic duct dilatation (l. 3. 7)
contrast filling of the small peripheral intrahepatic Cholangiograms in patients complicated with
bile ducts (1 5). giving the impression of abrupt en- recurrent pyogenic cholangitis or cholangiocar-
- 233-
-
Journal of Korean Radiological Society 1992 ; 28 (2) : 229~235
cinoma showed basically similar appearances to
clonorchiasis alone , but were considerably modified
(Fig. 4). In six cases with clonorchiasis and recurrent
pyoge nic cholangitis , the extrahepatic ducts were
predominantly dilated. a typical cholangiographic fin-
ding in recurrent pyogenic cholangitis without clonor-
chiasis (16-19). In patients with clonorchiasis alone ,
the extrahepatic ducts were normal or mildly dilated
(3-6 , 14 , 15). The findings caU3ed by f1 ukes such as
filling d efects, peripher외 obstruction , and raggedness
of bile ducts were apparent but much less prominen t.
This may be due to extinction of f1 ukes in recurrent
pyogenic cholangitis. The f1ukes are killed by
bacterial infection (1 . 7).
In eight cases of clonorchiasis c omplicated with
cholangiocarcinoma , t h e proximal biliary tree to the
tumor , especially t h e peripheral ducts was marked-
Iy dilated (Fig. 5 ), much more s e verly than might b e
expected in cases of c1onorchiasis alone . Choi et al
(20), in a CT review of c1onorchiasis , described that
CT of the patients with clonorchiasis associated with
the extrahepatic biliary maligna n cies had markedly
dilated intrahepatic bile ducts , while the patients with
c lonorchiasis a lone had diffuse ‘ minimal or mild
dilatation. This may be attributed to the fact that
biliary malignancy is a high pressure obstruction
whereas c1onorchiasis is an incomplete , low pressure
obstruction.
In conclusion , when c holangiogram shows “ too
m a ny intrahepatic bile ducts sign ' ’ and “ dispropor-
tionately" dilate d peripheral intrahepatic bile ducts
in patients with recurrent pyogenic cholangitis or bile
duct carcinoma. clonorchiasis s hould be borne in
mind as a cause of the disease.
REFERENCES
1. Rim HJ. The current p at hobio logy and
chemotherapy of clonorchiasis. Korean J Parasitol
1986:24 [suppl] ’ 7-20
2. Ya maguchi T . Clinical parasitology. London : Wolfe
Medical. 198 1:50-57
3. Lim JH. Radiologic findings of clonorchiasis. AJR
1990: 155: 1001-1008
4 姜益遠, 徐興錫, 林東蘭, 延.titt홍 a千吸蟲f눔의 放射線科學
的 所見 大韓懶f線醫學會誌 1990 ; 16: 159- 162
5. 이정일, 유지홍, 임규성, 이창홍, 민영일, 임재훈. 간홉충
증 환자의 내시경적 역행성 담도조영술 소견. 대한소화기
내시경학회지 1991 ; 1 : 29 -32
6 임재영, 전석길, 박삼균, 이정규, 현성택, 김약호, 정덕
수. 간홉충증의 내시경적 역행성 담도조영술 소견. 대한방
사선의학회지 1983 ; 19: 132 • 136
7. Ho PC. The pathology of Clonorchis sinensis infesta-
tion of th e liver. J Pathol 1955:70:53-64
8. Cook J. Hou PC. Hou HS. McFadzean AJS. recur-
rent pyogenic cholangitis. Br J Surg 1954:42:
188-203
9. Lim JH , Ko YT , Lee OH . Kim SY. Clonochiasis
sonographic findings in 59 proved cases. AJR
1989: 152:761-764
10. Teoh TB. A study of gallstones and included worms
in recurrent pyogenic cholangitis . J Pathol Bacteriol
1963:86: 123-129
11. Belmaric J. Intrahepatic bile duct carcinoma and
clonorchiasis infection in Hong Kong. Cancer
1973:31 :468-473
12. Flavell OJ. Liver-f1 uke infection as an aetiological
factor in bile duct carcinoma of man. Tra ns Roy Soc
Trop Hyg 1981 :75 ’ 814-824
13. Choi BI. Park JH. Kim YL. et a l. Peripheral
cholangiocarcinoma and clonorchias is: CT findings ‘
Radiology 1988: 169 ’ 149-153
14. Okuda K. Emura T ‘ Morokuma K. Kojima S ,
Yokagawa M. Clonorch iasis studied by per-
cutaneous cholangiography. and a therapeutic trial
of toluene-2. 4-diiso-thiocyanate . Gastroenterology
1973:65:457 -46 1
15. Choi TK , Wong KP. Wong J . Cholangiographic ap-
pearance in clonorchiasis. Br J Radiol 1984:57
681-684
16. Wastie ML. Cunningha m IGE. Roentgenologic fin-
dings in recurrent pyogenic cholangitis. AJR
1973:119:71-77
17. Lam SK. Wong KP. Chan PKW. Ngan H. Ong GB.
Recurrent pyogenic cholangitis: a study by en-
doscopic retrograde cholangiography ‘ Gastroen tero-
logy 1978:74:1196-1203
18 林在勳, 尹榮均, 金짧觸, 閔榮 뺀觸管結石효의 內視鏡
的 遊行{生 廳管造影術. 大韓放射線醫學會誌 1982 ; 18 :
116- 124
19 ‘ 洪慶뻐 林在敵 高永泰, 李東鎬. 再發性化腦廳管쏘의 內
視鏡的 遊行性 8흉管造影術. 大韓放射線醫學會誌 1990 ;
26 : 117- 120
20. Choi BI. Kim HJ ‘ Ha n MC. 00 YS , Han MH ‘ Lee SH.
CT findings of clonorchiasis. AJR 1989: 152:281 -284
- 234-
-
< 국문 요약 >
Jae Hoon Lim, et al : Clonorchiasis and its Compl ications
8千吸蟲효과 合f井'ilE: 擔管造影像의 再照明
慶熙大學校 뽑科大學 放射線科學敎室, 양明大學校 醫科大學 放射線科學敎室
林在勳 • 高永泰 • 李東鎬 • 李寬燮 • 徐修之* • 禹뿔組*
1lf吸蟲효이 오래 지속되면 合↑井효으로 再發性化職體管꽃이나 腦管카침이 생길 수 있다. 걱정:者들은 府l댔蟲효과 再發性化腦
體짤꽃이나 觸管햄이 {井發한 경우와 단순히 府吸蟲효만 있는 경우의 腦管造풍끼象을 比較 觀察 하였다. 大便檢훌나 手術時
廳管에서 1lf吸蟲의 .!l ß이나 成蟲을 확인한 42 思者의 總管造풍!*"r을 後向的으로 觀察 하였는데 이 중 29例는 밤1냈蟲효만 있
는 경우였고, 6W~는 府吸蟲효과 再發'1生f 뼈農廳管찢。1. 나머지 7例는 딴吸蟲효과 廳管찮이 {井發된 경우였다. n千吸蟲효만 있
는 29예에서는 成體에 의한 充滿缺根 (n=24) , 末稍略管의 閒塞(n= 1 8) , 不規則 하거나(n=20) 희미한 體管(n= 1 2) , 미만성 R꾸
內 觸管據張 (n=27) , 그리고 “R內 多管 효候" ( n=22 )가 보였다. 再發性 化體體管*이나 廳管찮 뽕、者(n = 1 3) 에서는 觸管 結
石이나 觸管癡에 의한 所見外에, 府吸蟲 成蟲 自體에 의한 變化는 적으나 거의 모두 딴內觸管이 “유난히” 또는 “이상스
레 ” 심하게 據張되고(n= 13) 多管효候(n=12 )가 보였다.
再융휩훈 ↑때훌R홉管갖이나 廳웹훨 뽕、者의 廳管造몽끼象에 府內體管이 “유난히” 심하게 據張 되고 “多管뾰候”가 보이면 두
가지 f짙뽕、의 원인으로서 8꾸I!及蟲효을 꼭 생각해야 한다.
- 235-
-
29th Congress European Society of Pediatric Radiology (ESPR) venue: Hotel Hilton Budapest, Hungary. contact: Dr. Bela Lombay (pres. ), Borsod County Hosp .’
Ped. Rad. , P.O. Box 188, 3501 Miskolc , Hungary . (Tel: 36-46-2121 1; Fax: 36-46-23694) 1992/04/27 -01
8th Int. Symposium Radionuclides in Nephro-Urology venue: Chester, United Kingdom contact: Mr. P.H. 0 ’ Reilly. Dep t. of Urology.
Stepping Hill Hospital, SK2 7JE Cheshire , United Kingdom. (Tel: 061-419 5484; Fax: 06-419 5699) 1992/05/06-08
92nd Meeting American Roentgen Ray Society venue: Marriot World Center Orlando , Florida, USA. contact: American Roentgen Ray , Society ,
1891 Preston White Drive , VA 22091 Reston , USA. (Tel: 703-6488992; Fax: 1992/05/10-15
Radiology & Oncology 92 venue: Int. Convention Centre , Birmingham , United Kingdom. contact: British Institute 0 [, Radiology ,
36 Portland Place , W1N 4AT London , United Kingdom. (Tel : 071-5804085; Fax: 071 -255 3209) 1992/05/18-20
39th Annual Meeting Society for Nuc1ear Medicine venue: L.A. Convention Center Los Angeles , California, USA. contact: Soc . of Nuclear Medicine ,
136 Madison Ave .. 8th fl. , NY 10016 New York , USA. (Tel: ; Fax: 1992/06/09-12
Car ’92. Computer Assisted Radiology venue : Baltimore , Maryland , USA. contact: Prof. Heinz U. Lemke , Univ. Klinikum , Raum 1005 ,
Augustenburger Platz 1, D-1000 Berlin 65 , Germany. (Tel: 49-30 45052044; Fax : 49-30 45052043) 1992/06/14-17
3rd Annual Meeting Eur. Soc. of Gastrointestinal Radiologists (ESGR) venue: Hotel Beach Regency Nice , France. contact: SOCFI - ESGR,
14 rue Mandar , 75002 Paris , France. (Tel: ; Fax: 1-40260444) 1992/06/22-24
- 236-