슬라이드 1

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1 위장관게실증 성균관대학교의과대학내과이준행

2 위장관게실증 상부위장관게실증 식도게실 ( 상부, 중부, 하부 ) 위게실 십이지장게실 하부위장관게실증 소장게실 대장게실

3 상부위장관게실증 성균관대학교의과대학내과이준행

4 Zenker diverticulum A Zenker diverticulum is a false diverticulum consisting of mucosa and submucosa that arises from the posterior portion of the inferior pharyngeal constrictor muscle.

5 Anatomy of ZD The neck of the diverticulum originates between the fibers of the inferior constrictor muscle and the cricopharyngeus muscle in an area of relative weakness, Killian s dehiscence. Chang. Laryngoscope 2004;114:

6 Zenker s diverticulum True lumen

7 UES 직하방 mass 로생각함 가는내시경으로통과가능

8 Blind end pouch 옆 true lumen 발견

9 내시경삽입이어려웠던환자에서식도구멍이보임 천공의심 憩室로결론

10 증상 Transient dysphagia; early in the course Pulmonary aspiration Neck mass Food regurgitation Esophageal obstruction Recurrent aspiration pneumonia Endoscopy 2001;33:

11 치료

12 Surgical diverticulectomy

13 Rigid endoscopic myotomy Dohlman diverticuloscope

14 Flexible endoscopic myotomy

15 Diverticular septal dissection (Video)

16 Esophageal diverticulum mimicking thyroid mass

17 Esophageal diverticulum mimicking thyroid mass Screening endoscopy: A large out-pouching lesion with food material was seen below the upper esophgeal sphincter.

18 Killian-Jamieson diverticulum (F/59) - Pseudo-thyroid lesion originating in the esophagus

19 GI & Hepatology New, Korean Edition 2010 Aug:1(3)

20 Zenker vs Killian-Jamieson Zenker's diverticulum originates on the posterior wall of the pharyngoesophageal segment in a midline area of weakness just above the cricopharyngeus (i.e., Killian's dehiscence), whereas Killian-Jamieson diverticula originate on the anterolateral wall of the proximal cervical esophagus in a gap just below the cricopharyngeus and lateral to the longitudinal tendon of the esophagus (i.e., the Killian-Jamieson space).

21 Zenker vs Killian-Jamieson - 김영선교수님의의견 KJ 는간혹갑상선좌 (> 우 ) 엽에서결절처럼보일수있습 니다. Zenker 는결절로보이지않아야합니다. 그런데식도조영술에서분명히 Zenker 인데도불구하고 옆으로치우쳐튀어나온경우를보곤합니다. 사람마다 식도의주행이나근육의배치등이다양하기때문에절 대적인것은없는것같습니다. 따라서 Zenker 도드물게 는갑상선결절로보일수있습니다.

22 중부식도게실

23

24 Midesophageal diverticulum with anthracotic pigmentation

25 Midesophageal diverticulum with anthracotic pigmentation 2 years later

26 Differential diagnosis of esophageal melanocytosis/melanosis Esophageal melanoma Pseudomelanosis Anthracosis, exogenous dye ingestion, hemosiderosis, lipofuscin deposition easily excluded after histologic and histochemical examination. Black esophagus Dark-pigmented esophagus with ulcerations which corresponds to severe acute inflammation with mucosal necrosis seen on histologic examination. The etiological factor involved seems to be ischemic injury caused by arteriolosclerosis, arterial thrombosis, or aortic dissection. Blue rubber bleb nevus syndrome Arch Pathol Lab Med 2006;130:

27 Anthrocosis in diverticulum Pathology International 2002;52:

28 Anthrocosis in diverticulum Pathology International 2002;52:

29 Anthrocosis in diverticulum Pathology International 2002;52:

30 M/80 chronic dysphagia 7YA. Dysphagia (+). Heartburn/chest pain(-/-) 3YA. Esophageal diverticulum was diagnosed but no treatment.

31 EGD at SMC

32 Esophagography

33

34 Endoscopic septal dissection

35

36 Diverticular septal dissection (Video)

37 Final image after the procedure

38 Epiphrenic esophageal diverticulum Out-pouching of the distal esophageal lumen Typically originating from 4-8cm above the cardia Prevalence: 0.015% based on radiologic data < 10% of all esophageal diverticula

39 Epiphrenic diverticulum (2006)

40 Bleeding clipping (2016)

41 Rebleeding Surgery (2017)

42 위게실

43 위게실의발생위치 위게실의 75% 이상은위의상부후벽에서발생하며, 이위치는식도-위접합부의약 2 3 cm 하방에, 위소만에서는약 3 cm 떨어진지점에해당되며해부학적으로위분문부의종근층섬유가분리되어있고윤근층만이점막을덮고있어서게실발생에취약한부위로알려져있다. 이부위에서발견되는위게실은선천성이고, 진성게실 (true diverticulum) 로서위벽의모든층으로구성되며약 10% 에서는게실내에이소성췌장조직이나위선조직을함유하는것으로알려져있다.

44 위게실은늘그위치입니다.

45 음식물이고여있기도합니다.

46 십이지장게실은 AoV 근처에많습니다.

47 그러나꼭그런것은아닙니다.

48 큰십이지장게실. CT 에서매우잘보임

49 십이지장게실출혈

50 십이지장게실출혈재발

51 십이지장게실이물

52 하부위장관게실증 성균관대학교의과대학내과이준행

53 증례 34/M 내원전날발생한 Hematochezia CBC: 4800(54%) - 7.1/ K PT/aPTT: 1.21INR/33.1sec EGD: WNL Colonoscopy: WNL 자료 : 강북삼성병원내과박정호

54 Bleeding scan Tc-99m lebeled RBC 를정맥주사후 20 분간복부의 dynamic 영상과 1 시간, 3 시간, 6 시간, 26 시간까지복부의 static 영상을얻었음. 6 시간까지영상에서 abnormal activity 는관찰되지않음. 24 시간영상에서 ileo-colic area 에 mild radioactivity 가관찰되며, 추가로얻은 26 시간영상에서 ascending colon 으로이동하는양상임. Conclusion: Active GI bleeding in the ileo-colic area, suggested. 자료 : 강북삼성병원내과박정호

55 Small bowel enteroscopy 자료 : 강북삼성병원내과박정호

56 Surgical diverticulectomy 자료 : 강북삼성병원내과박정호

57 Meckel s diverticulum - recurrent lower GI bleeding True lumen Meckel s D No abnormality in Meckel scan

58 대장게실은조금복잡해졌습니다. - Proposed taxonomy Am J Gastroenterol 2012; 107:

59 무증상대장게실

60 급성게실염

61 내시경으로게실염을보기도합니다.

62 급성게실염 - 急性憩室炎, acute diverticulitis 심한염증 미세천공으로인한염증의파급 CT 에의한진단은추정진단이며최종진단을위해서는임상경과및추후검사결과를종합적으로고려함 게실염이외염증성장질환, 대장암등다양한질환이비슷한모양을보일수있기때문임 80% 는금식과항생제치료로호전 몇주후대장내시경이나대장조영사진으로재확인 통상일주일입원 20% 는수술이필요함 재발이많음 자주재발하면수술 자료작성 : 삼성서울병원소화기내과이준행

63 재발하더라도다시동일한치료 서양에서내과적으로치료한게실염의재발률 : 5년동안 20% 수준 첫게실염이후, 수술이필요한합병증을동반한재발성게실염 5% 미만

64 복막수염 (appendagitis)

65 Sigmoid colon cancer - mimicking acute diverticulitis

66 게실출혈

67

68 게실질환 게실출혈 Most common cause of massive hematochezia (30-50% of cases) 15% of patients with diverticulosis will bleed 75% of diverticular bleeding stops without intervention Risk of rebleeding 14-38% After second episode of bleeding, risk of rebleeding 21-50% 삼성서울병원내과김태준교수님제공

69 게실출혈 내시경적지혈술 게실입구가넓어서게실바닥의혈관을바로 target 하여 clipping 한경우 삼성서울병원내과김태준교수님제공

70 게실출혈 내시경적지혈술 게실입구가좁아서입구만틀어막은경우

71 게실출혈 내시경적지혈술 게실에 epinephrine injection 또는흡인하여게실을반전시켜치료한경우 삼성서울병원내과김태준교수님제공

72 Symptomatic uncomplicated diverticular disease (SUDD) Persistent abdominal symptoms attributed to diverticula Absence of macroscopically overt colitis or diverticulitis Wall thickening in the absence of inflammatory changes on CT Colicky Constant or intermittent Relived by passing flatus Having a bowel movement Symptoms may resemble irritable bowel syndrome (IBS)

73 Segmental colitis associated with diverticula (SCAD) Inflammation in the inter-diverticular mucosa without involvement of the diverticular orifices. Prevalence ranges from 0.26 to 1.5 percent who had underwent colonoscopy with symptoms. Pathogenesis is unclear Chronic diarrhea Cramping abdominal pain primarily in the LLQ Intermittent hematochezia, in some cases

74 Random cases 성균관대학교의과대학내과이준행

75 갈치먹다가이물감 인근에서내시경도중 fistula 의심소견보여의뢰

76 위장관게실증 상부위장관게실증 식도게실 ( 상부, 중부, 하부 ) 위게실 십이지장게실 하부위장관게실증 소장게실 대장게실