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1 대한내과학회지 : 제 77 권부록 1 호 2009 증례 보존적치료로호전된대망경색 1 예 경북대학교의학전문대학원내과학교실 윤석진 박영대 정윤진 이세영 김은수 박수영 전성우 case of omental infarction successfully managed with conservative treatment Seok Jin Yoon, M.D., Young Dae Park, M.D., Yoon Jin Chung, M.D., Se Young Lee, M.D., Eun Soo Kim, M.D., Soo Young Park, M.D. and Seong Woo Jeon, M.D., Ph.D. Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Infarction of the greater omentum is an uncommon cause of acute abdominal pain, usually diagnosed during surgery for suspected appendicitis. However, during the last decade, preoperatively diagnosed omental infarctions successfully managed with conservative treatments have been increasingly identified with expanded utilization and technical advancements of sonography and computed tomography (CT). We report a case of omental infarction in a middle aged woman. Diagnosis was confirmed by abdominal CT, and she was successfully managed with conservative treatments including analgesics and prophylactic antibiotics. Follow-up CT performed 14 days after discharge revealed a decrease of infarct area without any intra-abdominal complications. This report emphasizes that nonoperative management of omental infarction may be safe and effective in most cases. (Korean J Med 77:S36-S40, 2009) Key Words: cute abdomen; Omentum; Infarction 서론대망경색은발생빈도가낮고, 임상양상이급성복증의형태로나타나는다양한질환들과유사하여급성복증의초기진단에서간과되기쉬우며, 진단적개복술을통하여진단되는경우가흔하다 1). 그러나최근급성복증에대한초기진단도구로써초음파검사및컴퓨터단층촬영이보편화되면서대망경색의수술전진단이가능하게되었고, 그에따라수술이아닌보존적치료로호전되는예가보고되고있 다. 저자들은보존적치료로호전된대망경색 1예를경험하였기에문헌고찰과함께보고하고자한다. 증례 51세여자환자가 5일전부터시작된좌측배꼽주위통증을주소로외래방문하였다. 3일전타병원에서시행한복부초음파및상부위장관내시경검사에서특이소견이없었으며통증은증상발현당시에좌측복부전반에걸쳐있 Received: ccepted: Correspondence to Seong Woo Jeon, M.D., Department of Internal Medicine, Kyungpook National University Hospital, 50 Samduk 2-ga, Chung-gu, Daegu , Korea swjeon@knu.ac.kr - S 36 -

- Seok Jin Yoon, et al. case of omental infarction successfully managed with conservative treatment - Figure 1.

Figure 2. Follow-up () axial and () coronal contrast-enhanced CT scan performed 14 days after discharge demonstrated the decrease of the infarct area (arrow). Figure 3.

4년전자궁근종으로수술받은병력이있었고, 현재고혈압으로개인의원에서투약중이었으나그외특이사항은없었다. 내원당시활력징후는혈압 130/85 mmhg, 맥박 92회 / 분, 호흡수 16회 / 분, 체온 36.6 였다. 신체검진에서좌측배꼽주위에경한압통과반발통이있었으나, 그외특이소견은없었다. 말초혈액검사에서백혈구 7,950/mm 3, 혈색소 13.

2 - Seok Jin Yoon, et al. case of omental infarction successfully managed with conservative treatment - Figure 1. Initial () axial and () coronal contrast-enhanced CT scan demonstrated a cake-like fatty mass and associated whirling appearance of vascular structure just beneath the anterior abdominal wall (arrow). Figure 2. Follow-up () axial and () coronal contrast-enhanced CT scan performed 14 days after discharge demonstrated the decrease of the infarct area (arrow). Figure 3. Follow-up () axial and () coronal contrast-enhanced CT scan performed 6 months after discharge demonstrated the disappearance of the infarct area (arrow). 었으나내원당시에는좌측배꼽주위로국한되는양상을보였다. 4년전자궁근종으로수술받은병력이있었고, 현재고혈압으로개인의원에서투약중이었으나그외특이사항은없었다. 내원당시활력징후는혈압 130/85 mmhg, 맥박 92회 / 분, 호흡수 16회 / 분, 체온 36.6 였다. 신체검진에서좌측배꼽주위에경한압통과반발통이있었으나, 그외특이소견은없었다. 말초혈액검사에서백혈구 7,950/mm 3, 혈색소 13.8 g/dl, 혈소판 280,000/mm 3 이었고, 호중구분획은 62.1% 였다. 생화학적검사에서 ST/LT 10/7 IU/L, total protein/albumin 7.5/4.6 g/dl, total bilirubin/direct bilirubin 0.35/ <0.01 mg/dl, LP/GGT 53/15 IU/L, amylase/lipase 20/161 IU/L, UN/creatinine 12/0.6 mg/dl이었으며전해질검사는 정상소견을보였다. 단순복부촬영에서경한장폐색이관찰되었으나, 복부초음파검사에서는증가된대장내공기음영으로인해추가적인정보를얻을수없었다. 복부컴퓨터단층촬영에서정중선으로부터좌측으로약간편위된부위에비교적경계가뚜렷한지방밀도의종괴와혈관구조물의소용돌이 (whirling appearance) 가관찰되었으며그외복부장기에이상소견은없었다 ( 그림 1). 대망경색으로진단하고경험적항생제및진통제투여등의보존적치료를시행하였다. 환자는이후통증이경감되었고, 활력징후및검사실소견또한지속적으로정상범위를유지하여, 입원 7일째퇴원하였다. 퇴원 2주후시행한복부컴퓨터단층촬영에서경색부위로생각되는종괴의크기는감소하였고, 복강내합 - S 37 -

3 - 대한내과학회지 : 제 77 권부록 1 호 병증은보이지않았다 ( 그림 2). 이후로도환자는특별한복부증상을호소하지않았으며퇴원 6개월후시행한복부컴퓨터단층촬영에서경색부위의소실을보였다 ( 그림 3). 고찰대망경색은발생빈도가낮고수술전진단이쉽지않아서급성복증에대한개복술을통해우연히진단되는경우가많다 1). 대망경색은충수돌기염에대한개복술에서약 0.1% 를차지하는것으로알려져있다 2). 1896년 ush 등이처음으로대망경색을보고하였으며, 1993년까지전세계적으로 350예에가까운증례만이보고되었다 3,4). 대망경색에관한국내보고또한 1964년류등의보고이후주로충수돌기염에대한개복술을통해우연히발견된증례를중심으로드물게보고된바있다 5,6). 그러나최근에국내외적으로대망경색의진단예는꾸준히증가추세에있는데, 이는질환에대한인식의향상과초음파및컴퓨터단층촬영의보급에기인한다 7). 명확히알려진바는없으나, 대망경색은정맥내혈전에기인하는것으로생각된다 7). 정맥내혈전의원인으로는이상혈관발달이흔하며, 이외에도비만, 식후내장혈관의울혈및허혈, 활동이나기침등에의한정맥꼬임, 응고이상, 외상등이가능하다 8,9). 대망꼬임은경색의원인일수도, 결과일수도있으며두가지상황의임상적및방사선학적소견, 예후그리고치료가다르지않아서과거대망꼬임유무에따른대망경색의분류는그임상적의의가미미하다고하겠다 7,9). 대망경색의임상양상은흔히비전형적으로나타나지만, 급성혹은아급성의우측복통을호소하는경우가많다 10). 일반적으로열이없거나미열이동반되며오심, 구토, 식욕부진, 설사등의소화기증상은흔치않다 10,11). 검사실소견에서경한백혈구증가증, ESR 및 CRP의상승이동반될수있으나진단에특이적인소견은없다 1). 신체검진에서는경색부위에집중된압통이나타난다. 그런데과거국내에서보고된대망경색의몇몇증례를보면이러한증상과징후는대망경색의정확한진단을내리는데큰도움을주지못한경우가많았고, 대부분충수돌기염을의심하여시행한개복술에서발견되었다 6). 그러나 2003년김등 12,13) 이복부초음파및컴퓨터단층촬영소견에근거하여대망경색을진단한예를보고한후수술전에진단되는대망경색의예가드물게보고되고있다. 본증례에서도아급성의복통과통증 부위의압통외에는대망경색을의심할만한증상이나징후는관찰되지않았으며, 결과적으로진단은복부컴퓨터단층촬영을통하여이루어졌다. 대망경색의전형적인복부초음파검사소견은압통부위의복벽에접한, 고형의압박되지않는고음영종괴이다 2,7). 복부컴퓨터단층촬영에서는염증성복막에의해둘러싸인경계가분명한지방밀도의염증성종괴를발견할수있다 2,7). 종괴는비균질성의케이크모양으로섬유성밴드나확장된혈전성정맥 (thrombosed vein) 을나타내는고음영의줄무늬를포함하며이러한구조가소용돌이의형태로보일수있다 14). 대망외복부장기에는이상소견이없지만때로인접한장벽의비후를관찰할수있다 15). 방사선학적으로감별을요하는질환은복막수염 (epiploic appendagitis), 악성종양의대망전이, 지방육종등이있는데상대적으로감별이어려운복막수염의경우대망경색보다지방종괴의크기가작고해부학적위치에의해주로하복부의대장을따라발생하는경향을보인다 16). 본증례에서는증가된대장내공기음영으로인해초음파검사를통한진단적접근은어려웠다. 그러나복부컴퓨터단층촬영에서복부장기의이상소견없이비교적경계가뚜렷한지방밀도의종괴와혈관구조물의소용돌이를관찰함으로써대망경색을진단할수있었다. 대망경색의치료는아직까지논쟁의여지가있다. 과거대망경색의치료는수술이주를이루었는데, 이는수술전진단이어려웠다는점외에도수술을통해경색된대망을제거해줌으로써농양이나유착의발생을피할수있고특히복강경수술을시행할경우빠른회복과퇴원이가능하다는점을근거로하였다 10,11). 그러나최근에는대망경색이수술적치료없이도시간경과에따라자연치유될수있는양성질환이라는주장이제기되고있다. 이에따르면, 대망경색에대해보존적치료를시행할경우증상은경구진통제에반응하여 1~2주에걸쳐호전되며흔히투여되는예방적항생제요법또한필수적이지는않다 17). 김등 12,13) 이보고한국내대망경색의예에서도보존적치료는항생제요법없이진통제및수액투여를통해이루어졌으며두예모두보존적치료로호전을경험하였다. 성공적인보존적치료후의자연경과에대해 Puylaert 등과 Singh 등은복부초음파검사혹은컴퓨터단층촬영을통한추적관찰에서복강내합병증없이지방종괴의크기가점차감소함을보고하였다 18,19). 본예의경우진단후예방적항생제를투여하였으나임상적인호전을확인한입원 2일째부터는항생제를중단하였으 - S 38 -

4 - 윤석진외 6 인. 보존적치료로호전된대망경색 1 예 - 며진통제또한경구투여로전환하였다. 퇴원 2주후시행한컴퓨터단층촬영에서는복강내합병증없이경색부위의크기가감소하였으며, 퇴원 6개월후시행한검사에서는경색부위가소실되었다. 이는대망경색에대한보존적치료의효용성과안전성을보여주는경과라고생각한다. 그러나본예와는달리강등 20) 은대망경색에대한보존적치료에도불구하고임상증상이악화되어결국수술적절제를시행한예를보고한바있다. 그러나이들의예에서도대망경색에대한우선적인치료는보존적치료였으며, 진단이확실하지않은상태에서임상증상의악화가있어서확진및치료의목적으로수술을시행하였다. 따라서대망경색에대한일차적인치료로서수술을주장하는경우와는다르다고하겠다. 최근의문헌고찰과본증례에근거할때대망경색은기본적으로양성의경과를보이는질환으로복부초음파검사혹은복부컴퓨터단층촬영을통해수술전진단이가능하며, 수술전에대망경색을진단한경우보존적치료를우선함으로써불필요한수술과그에따른합병증을피해야할것으로생각한다. 요약본증례는원인이불분명한 5일간의좌측배꼽주위통증을주소로내원한여성에대해임상적및방사선학적소견에근거하여대망경색을진단한경우이다. 환자는예방적항생제및진통제투여등보존적치료를받았고, 특별한합병증없이입원 7일째퇴원하였다. 퇴원 2주후시행한추적복부컴퓨터단층촬영에서복강내합병증없이경색부위의크기가감소하였으며퇴원 6개월후시행한복부컴퓨터단층촬영에서는경색부위가소실되었다. 원인이불분명한급성복증환자의진단과정에서대망경색은간과되어서는안될질환이며복부초음파검사혹은복부컴퓨터단층촬영을통해수술전진단이가능하다. 대망경색은기본적으로양성의경과를보이는질환으로서수술전에대망경색을진단한경우보존적치료를우선함으로써불필요한수술과그에따른합병증을피해야할것으로생각한다. 중심단어 : 급성복증 ; 대망 ; 경색 REFERENCES 1) Epstein LI, Lempke RE. Primary idiopathic segmental infarction of the greater omentum: case report and collective review of the literature. nn Surg 167: , ) Lardies JM, bente FC, Napolitano, Sarotto L, Ferraina P. Primary segmental infarction of the greater omentum: a rare cause of RLQ syndrome: laparoscopic resection. Surg Laparosc Endosc Percutan Tech 11:60-62, ) ush P. case of hemorrhage into the greater omentum. Lancet 1: , ) althazar EJ, Lefkowitz R. Left-sided omental infarction with associated omental abscess: CT diagnosis. J Comput ssist Tomogr 17: , ) Ryu HW, Choi HS, Lee SS, Shin YC. Omental torsion in 3 cases. J Korean Surg Soc 6:41-47, ) Yoon JH, Park YK, Sohn K, Jeon YC, Sohn JH, Han DS. case of primary omental torsion presenting as an acute abdominal pain. Korean J Gastroenterol 49:41-44, ) van reda Vriesman C, Puylaert J. Epiploic appendagitis and omental infarction: pitfalls and look-alikes. bdom Imaging 27:20-28, ) Tolenaar PL, ast TJ. Idiopathic segmental infarction of the greater omentum. r J Surg 74:1182, ) Karak PK, Millmond SH, Neumann D, Yamase HT, Ramsby G. Omental infarction: report of three cases and review of the literature. bdom Imaging 23:96-98, ) Sakellaris G, Stathopoulos E, Kafousi M, rbiros J, itsori M, Charissis G. Primary idiopathic segmental infarction of the greater omentum: two cases of acute abdomen in childhood. J Pediatr Surg 39: , ) Varjavandi V, Lessin M, Kooros K, Fusunyan R, McCauley R, Gilchrist. Omental infarction: risk factors in children. J Pediatr Surg 38: , ) Kim JN, Lee SH, Kim JS, Kim JH, ae YO, Park SK, Yoon SJ, Han HY, Lee HY. case of acute abdomen caused by omental infarction treated with conservative care. Chungnam Med J 30: , ) Kim SJ, Joo MD, Choi DH, Jun DH, Lee DP. Primary segmental ometnal infarction: a case report. J Korean Soc Emerg Med 14: , ) badir JS, Cohen J, Wilson SE. ccurate diagnosis of infarction of omentum and appendices epiploicae by computed tomography. m Surg 70: , ) Periera JM, Sirlin C, Pinto PS, Jeffrey R, Stella DL, Casola G. Disproportionate fat stranding: a helpful CT sign in patients with acute abdominal pain. Radiographics 24: , ) Rioux M, Langis P. Primary epiploic appendagitis: clinical US, and CT findings in 14 cases. Radiology 191: , S 39 -

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Jkss hwp 급성복증을보이는감염성요막관기형 Infected Urachal Remnants with Symtoms of the Acute Abdomen: The Differential Diagnosis & Proper Management Jan Dy Lee, M.D., Chee Young Lim, M.D. 1, Hyoung Il Kim, M.D. 1, Chul Woon Chung,