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1 대한내과학회지 : 제 75 권제 2 호 2008 알코올성간경화증에동반된상행결장의정맥류출혈 1 예 제주대학교의과대학내과학교실 1, 외과학교실 2, 영상의학과학교실 3, 응급의학과교실 4 김흥업 1 허규희 2 김승형 3 김봉수 3 강영준 4 이재천 1 김광식 2 A case of variceal bleeding of the ascending colon associated with alcoholic liver cirrhosis Heung Up Kim, M.D. 1, Kyu Hee Her, M.D. 2, Seung Hyoung Kim, M.D. 3, Bong Soo Kim, M.D. 3, Young Joon Kang, M.D. 4, Jaechun Lee, M.D. and Kwang Sik Kim, M.D. 2 Departments of Internal Medicine 1, Surgery 2, Radiology 3 and Emergency Medicine 4, College of Medicine, Cheju National University, Jeju, Korea We report a very rare case of colonic varix with massive bleeding. A 43-year-old male patient was transferred to our hospital for hematochezia. The patient had a history of chronic liver disease associated with alcohol use. The initial blood pressure was 93/73 mmhg, and the hemoglobin level was 8.4 g/dl. Severe hepatomegaly and periportal fatty infiltration were seen on abdominal computed tomography. Markedly ectatic veins protruded from the luminal side of the proximal ascending colon and drained to the dilated ileocecal and retroperitoneal veins. Emergent colonoscopy failed because of continuous hematochezia and hypovolemic shock, despite massive transfusion. Markedly dilated colonic varices were noticed around the ileocecal and ascending colon on superior mesenteric arteriography. An emergent right hemicolectomy was performed. The presumed bleeding focus was a protruding varix with a red clot on the top of a denuded vein on the anteromedial wall of the proximal ascending colon. (Korean J Med 75: , 2008) Key Words: Colonic varices; Gastrointestinal hemorrhage; Liver cirrhosis; Alcoholic 서 론 증 례 간경변증환자에서문맥고혈압에의한식도및위정맥류출혈은매우흔한질환이다. 그러나대장정맥류출혈은드문질환으로국내에서는특발성대장정맥류및문맥고혈압에의한좌측대장의정맥류출혈이보고되었을뿐이고아직상행결장의정맥류출혈은보고가없다 1, 2). 저자들은하부위장관의대량출혈로내원한알코올성간경변증이의심되는환자에서상행결장정맥류출혈을진단하고수술적으로치료하였기에보고하는바이다. 환자 : 43세남자주소 : 10분전시작된혈변과현기증으로응급실로후송됐다. 병력 : 평소하루소주 2~3 병씩매일먹는환자로 4년전동병원에서알코올성간염진단받고치료한경력있었다. 이후로는병원치료는받지않았다. 내원일새벽까지술을마셨고, 내원당시어눌한말투에술이완전히깨지않은상태였다. 내원일아침화장실에서대변을보려하다가선 Received: Accepted: Correspondence to: Kyu Hee Her, M.D., Department of Surgery, College of Medicine, Cheju National University, 154 Samdo 2-dong, jeju , Korea her-kh@hanmail.net

- The Korean Journal of Medicine: Vol. 75, No. 2, 2008 - A C B Figure 1. Abdominal CT, portal venous phase. (A) Severe hepatomegaly and diffuse periportal fatty infiltration are noted.

2 - The Korean Journal of Medicine: Vol. 75, No. 2, A C B Figure 1. Abdominal CT, portal venous phase. (A) Severe hepatomegaly and diffuse periportal fatty infiltration are noted. (B,C) Marked submucosal venous engorgement (arrows) is noted in the proximal ascending colon just above the ileocecal valve, with edematous ascending colonic wall thickening. Marked engorgement of the ileocecal vein and retroperitoneal veins are present, without definitively abnormal arterial dilatation. 혈과검붉은피떡이섞여있는다량의혈변을보았으며현기증과식은땀이동반되어응급실로내원했다. 호흡곤란이나흉통, 복통등의증상은없었다. 과거력 : 내원 13일전만취상태에서넘어져얼굴과두피그리고팔등에타박상을입은병력이있었다. 가족력 : 특이병력없었다. 신체검사 : 혈압 93/73 mmhg, 맥박수 114회 / 분, 호흡수 24 회 / 분, 체온섭씨 36.3도였다. 폐음은깨끗했고, 심잡음은들리지않았다. 복부는다소팽만된상태로장음은약간항진되었고, 복부의압통이나반발통은없었다. 응급실도착후 1회구토하였고, 노란색의위액만나왔으며다시코위영양관을삽입하여세척후배액했으나역시혈흔은관찰되지않았다. 직장수지검사에서촉지되는종괴는없었다. 검사실소견 : 말초혈액검사에서백혈구 6,400/mm 3 ( 중성구분획 62.9%), 혈색소 8.4 g/dl, 혈소판 90,000/mm 3 였다. 일 반화학검사에서공복혈당 188 mg/dl, Na/K/Cl 137/3.6/97 mmol/l, BUN/Cr 8.9/1.5 mg/dl, AST/ALT 245/53 U/L, 총빌리루빈 1.8 mg/dl, alkaline phosphatase 238 IU/L, amylase 23 U/L, 총단백 6.0 g/dl, 알부민 2.5 g/dl, prothrombin time 19.2 초 (INR 1.75) 였다. 동맥혈가스분석에서 ph/pco2/ao2/hco3- /O2 saturation 7.247/26.6/89.6/12.9/94.7이었다. 혈청검사에서 HbsAg/Ab(-/+), anti-hcv Ab(-) 였다. 하부위장관출혈을감별하기위해복부전산화단층촬영을시행하였다. 복부전산화단층촬영 : 간비대와심한문맥주위지방침윤소견이관찰되었고, 상행결장근위대장벽의부종과함께회맹판직상부의근위대장에서두드러진점막하정맥의확장소견이관찰되었다 ( 그림 1). 이와동반하여회맹정맥과후복강정맥의확장소견이관찰되었으나동정맥기형을의심할만한동맥의확장은관찰되지않았다. 혈관조영술 : 동맥의이상이나동맥기출혈, 가성동맥류

- Heung Up Kim, et al: Variceal bleeding of ascending colon associated with alcoholic liver cirrhosis - A B Figure 2. Superior mesenteric artery (SMA) angiogram.

(B) Delayed venogram demonstrates colonic varices on the proximal ascending colon with markedly engorged ileocecal and retroperitoneal veins.

3 - Heung Up Kim, et al: Variceal bleeding of ascending colon associated with alcoholic liver cirrhosis - A B Figure 2. Superior mesenteric artery (SMA) angiogram. (A) There is no evidence of arteriovenous malformation, pseudoaneurysm, or arterial bleeding in the SMA territory on arteriogram. (B) Delayed venogram demonstrates colonic varices on the proximal ascending colon with markedly engorged ileocecal and retroperitoneal veins. 등의소견은관찰할수없었고, 정맥기에상행결장의정맥류와두드러지게확장된회맹정맥과후복강정맥이관찰되었다 ( 그림 2). 치료및경과 : 이에근위대장에서발생한정맥류출혈을의심하고대장내시경을시행하기로하고대장정결을위해 polyethylene glycol을구강으로투여하였다. 그러나대장전처치중계속적인생리식염수주입및수혈에도불구하고수축기혈압이 90 mmhg 로낮게측정되고선홍색혈변이멈추지않았으며간성혼수로추정되는의식저하가있어대장내시경을시행하지못하였다. 10시간동안 8단위의적혈구수혈에도출혈의징후가계속되고혈압이불안정하여수술을시행하였다. 수술소견은간이비대되었고, 매우딱딱하게촉진되었으며육안상대결절성간경변증에합당하였다. 맹장과상행결장을후복벽으로부터박리하였을때확장된정맥이맹장에서근위상행결장을거쳐후복강으로배액되는것이확인되어우결장반절제술을시행하였다. 절제된검체에서상행결장의전내측 (anteromedial side) 내강에서피떡이부착되고돌출된정맥류가관찰되었다 ( 그림 3). 조직병리검사에서확장된점막하정맥과점막하부종및출혈소견이관찰되었다 ( 그림 4). 수술직후혈압은안정화되었으나황달, 복수등간부전증상이수주지속되어치료하였고, 호전되어퇴원하였다. 고찰하부위장관출혈의주요원인은동정맥기형, 대장게실, 신생물, 내치핵이고기타드문질환으로고립성직장궤양증후군, 대장정맥류, 장간막정맥부전증, 소장게실, 멕켈게실, 대정맥-장누공, 혈관염, 소장궤양, 자궁내막증, 방사선장염, 장중첩증, 문맥대장병증 (portal colopathy), 전환성대장염 (diversion colitis) 등이있다 3). 대장정맥류는하부소화관출혈의드문원인으로대부분간경변증이나문맥폐쇄등에의해문맥압이증가되어발생하고그외에도일부울혈성심부전이나급성췌장염의합병증으로발생하거나혈전증, 외부압박, 종양, 수술후복강내유착등의장간막정맥순환이저항을받는경우에도발생할수있다 4, 5). 소수에서는원인이밝혀지지않은특발성대장정맥류가있고선천적혈관이상에의한변화로생각된다 6). 문맥고혈압이있을때대개는식도와위에정맥류가발생하는경우가대부분이지만그외에도드물게십이지장, 회장, 맹장, 상행및하행결장, 구불결장, 직장, 그리고회장루, 대장루, 총수담과, 담낭등전위장관및복강부속기에걸쳐발생할수있으며대장에서는주로직장과맹장에발생한다. 이러한이소성정맥류에서의출혈은간경변증환

- 대한내과학회지 : 제 75 권제 2 호통권제 576 호 2008 - A B C Figure 3. Right hemicolectomy specimen. (A) The resected specimen is 33 cm in length.

Histologic features (H & E stain, 10). Dilated submucosal veins (arrows) are seen, with submucosal hemorrhage and edema.

4 - 대한내과학회지 : 제 75 권제 2 호통권제 576 호 A B C Figure 3. Right hemicolectomy specimen. (A) The resected specimen is 33 cm in length. (B,C) Submucosal hemorrhage and a protruding luminal varix with red clot (arrows) are noted in the proximal ascending colon, suggesting previous active bleeding from this lesion. Figure 4. Histologic features (H & E stain, 10). Dilated submucosal veins (arrows) are seen, with submucosal hemorrhage and edema. 자의 1~4% 에서발생하며, 식도나위정맥류에비해빈도는적지만대장정맥류도간경변증환자에서출혈을유발하는원인으로서대부분의대장정맥류환자는간경변증을동반하고있다 7). 한편간경변증환자에서하부위장관출혈을일으키는원인중대장정맥류는 1~8% 정도를차지한다 8, 9). 진단은임상적으로간경변증을진단하고대장내시경, 복부전산화단층촬영, 혈관조영술등으로정맥류의유무를확인하는것이다. 대장내시경으로대장정맥류의위치및출혈유무를확인하고필요시내시경적치료를시행하는것이수술을피할수있는가장확실한방법이나급성하부위장관출혈시혈액에의해시야가확보되지않을수있고전신상태가좋지않은경우합병증의위험성이있으며대장전처치과정중의부작용이있을수있다는단점이있다. 급성하부위장관출혈시대장내시경을성공적으로시행하여확진을할수있는경우는 69% (48~90%) 로알려져있다 10)

5 - 김흥업외 6 인 : 간경화증에동반된상행결장의정맥류출혈 - 복부전산화단층촬영은비침습적검사법으로간경변증과연관된정맥류진단에도움을주며, 최근 3차원다중검출기전산화단층촬영 (three-dimensional multi-detector low computed tomography) 이개발됨에따라영상의우수성이높아지고동맥기에서동맥성출혈소를찾을뿐아니라문맥고혈압이있는경우문맥정맥기 (portal venogram) 에서우회로를발견하고정맥성출혈질환에대한치료의계획을세울수있는장점이있다 11, 12). 혈관조영술은분당 0.5~1 ml/ 분의소량의출혈도찾아낼수있는검사법이다. 그러나혈관조영술도 9.3% 에서는합병증을초래할수있으며 13) 정맥류출혈은동맥성출혈이아닌이유로동맥기에직접조영된영상을얻을수없다. 또한정맥기영상을얻었다하더라도출혈유무를확인할수없는경우가많은데그이유는정맥류내에조영제가고르게분포지않아출혈병소로조영제가유출되지않을수있기때문이다 14). 대장정맥류출혈에대한치료는출혈의정도에따라결정해야하며대량출혈이나만성적인빈혈을유발할경우수술적치료를먼저고려해야한다 15). 간경변증의경우환자의전신상태가좋지않은경우가많아출혈에의한빈혈이심하지않거나미만성으로전대장에걸쳐정맥류가존재하는경우보존적치료를먼저생각해볼수있다. 그러나대장의일부분절에만정맥류가있는경우나급성재발성출혈이있는경우는수술적치료를고려할수있다 7). 최근에는여러가지비수술적치료법들이시도되고있는데 TIPS (transhepatic intravenous portosystemic shunt), BRTO (balloon occluded retrograde transvenous obliteration), EVL (endoscopic varix ligation), histoacryl injection 등이대표적이다 16-19). 진단및치료법은질병의중증도와진료항목에대한가용성과숙련도를고려하여각병원의여건에따라선택할수있다 20). 간경변증환자의위장관출혈은식도및위정맥류출혈이대부분이나이번증례처럼드물게대장이나다른위장관의이소성정맥류출혈도있다는것을간과해서는안될것이며대량의정맥류출혈시다른보존적치료와함께수술적치료도적극고려해야할것이다. 요약간경변증이나문맥고혈압에의한정맥류출혈은주로식도와위에발생하나일부에서는소장과대장등에서도발생할수있다. 대장의정맥류출혈은주로직장과맹장에발생하며국내에서는좌측대장에발생된소수의예만보고되 었고, 아직상행결장의정맥류출혈은보고된바없다. 알코올성간경변증으로의심되는 43세남자환자가대량의혈변으로내원하였고, 복부전산화단층촬영및혈관조영술로상행결장의정맥류를확인하고우결장반절제술을시행하였고, 수술후지혈되었으며수술검체에서정맥류에의한출혈이확인되었다. 저자는 43세남자환자에서발생한알코올성간경화증에의한상행결장의정맥류출혈을문헌고찰과함께보고하는바이다. 중심단어 : 대장정맥류 ; 하부위장관출혈 ; 알코올성간경변증 REFERENCES 1) Han JH, Jeon WJ, Chae HB, Park SM, Youn SJ, Kim SH, Bae IH, Lee SJ. A case of idiopathic colonic varices: a rare cause of hematochezia misconceived as tumor. World J Gastroenterol 12: , ) Song CY, Lee YC, Cho HR, Kim DK, Kim S, Choi WJ, Park HR. Massive gastrointestinal hemorrhage from the colonic varices: report of 1 case. J Korean Surg Soc 44: , ) Miller LS, Barbarevech C, Friedman LS. Less frequent causes of lower gastrointestinal bleeding. Gastroenterol Clin North Am 23:21-52, ) van Gossum M, Reuss K, Moussaoui M, Bourgeois V. Idiopathic colonic varices: an unusual cause of massive lower gastrointestinal hemorrhage. Acta Gastroenterol Belg 63: , ) Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine FH, Abbott WM. Gastrointestinal hemorrhage from adhesion-related mesenteric varices. Ann Surg 183:24-29, ) López-Cepero Andrada JM, López Silva M, Ferré Alamo A, Salado Fuentes M, Benítez Roldán A. Familial colonic varices: report of two cases. Gastroenterol Hepatol 23: , ) Iredale JP, Ridings P, McGinn FP, Arthur MJ. Familial and idiopathic colonic varices: an unusual cause of lower gastrointestinal haemorrhage. Gut 33: , ) Hosking SW, Snart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet 1: , ) Ganguly S, Sarin SK, Bhatia V, Lahoti D. The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension. Hepatology 21: ,

6 - The Korean Journal of Medicine: Vol. 75, No. 2, ) Abraham-Igwe C, Patel R. Idiopathic colonic varices: a case report. Endoscopy 34:680, ) Choi JW, Lee CH, Kim KA, Park CM, Kim JY. Ectopic varices in colonic stoma: MDCT findings. Korean J Radiol 7: , ) Kang HK, Jeong YY, Choi JH, Choi S, Chung TW, Seo JJ, Kim JK, Yoon W, Park JG. Three-dimensional multi-detector row CT portal venography in the evaluation of portosystemic collateral vessels in liver cirrhosis. Radiographics 22: , ) Egglin TK, O'Moore PV, Feinstein AR, Waltman AC. Complications of peripheral arteriography: a new system to identify patients at increased risk. J Vasc Surg 22: , ) Lieberman DA, Krippaehne WW, Melnyk CS. Colonic varices due to intestinal cavernous hemangiomas. Dig Dis Sci 28: , ) Lopes LM, Ramada JM, Certo MG, Pereira PR, Soares JM, Ribeiro M, Areias J, Pinho C. Massive lower gastrointestinal bleeding from idiopathic ileocolonic varix: report of a case. Dis Colon Rectum 49: , ) Allgaier HP, Ochs A, Haag K, Hauenstein KH, Tittor W, Rössle M, Blum HE. Recurrent bleeding from colonic varices in portal hypertension: the successful prevention of recurrence by the implantation of a transjugular intrahepatic stent-shunt (TIPS). Dtsch Med Wochenschr 120: , ) Anan A, Irie M, Watanabe H, Sohda T, Iwata K, Suzuki N, Yoshikane M, Nakane H, Hashiba T, Yokoyama M, Higashihara H, Okazaki M, Sakisaka S. Colonic varices treated by balloon-occluded retrograde transvenous obliteration in a cirrhotic patient with encephalopathy: a case report. Gastrointest Endosc 63: , ) Misra SP, Dwivedi M. Ligation of a bleeding colonic varix using an upper gastrointestinal endoscope. Endoscopy 38:657, ) Chen WC, Hou MC, Lin HC, Chang FY, Lee SD. An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature. Am J Gastroenterol 95: , ) Lingenfelser T, Ell C. Lower intestinal bleeding. Clin Gastroenterol 15: ,

Jksvs019(8-15).hwp

Jksvs019(8-15).hwp Grade I Grade II Grade III 12 대한혈관외과학회지 : 제 20 권 제 1 호 2004 Control Group A Group B Fig. 4. Microscopic findings of vein wall in control, group A and group B on the day of 7 after venous occlusion. The