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1 Case Report 급성충수돌기염천공으로오인된노인에서의위막성대장염 1 예 동의의료원내과 윤영진 노지훈 한원석 박철우 박성환 박정익 남원욱 A Case of Pseudomembranous Colitis in Old Age which was Misdiagnosed as Acute Appendicitis with Perforation Young-Jin Yoon, MD, Ji-Hun Roh, MD, Won-Seok Han, MD, Cheol-Woo Park, MD, Sung-Hwan Park, MD, Jung-Ik Park, MD, Won-Wook Nam, MD Department of Internal Medicine, Dong-eui Medical Center, Busan, Korea Pseudomembranous colitis is mostly related to antibiotics and it presents symptoms of diarrhea, abdominal pain, fever, hypoalbuminemia and hypovolemia. Diarrhea is the most common manifestation, but in geriatric patients, symptoms of pseudomembranous colitis can be different from those of usual cases and the course of disease can be more aggressive. For these reasons, it can be misdiagnosed. So physicians must take pseudomembranous colitis into consideration in older patients with acute abdominal pain, who have been treated with antibiotics. We reported a case of an older patient with pseudomembranous colitis which was misdiagnosed as acute appendicitis with perforation. Key Words: Pseudomembranous colitis, Acute appendicitis, Old age 서 론 위막성대장염은항생제사용의증가와함께임상에서흔히접하는질환으로수양성설사, 복통, 발열, 백혈구증가, 저알부민혈증등의임상증상을동반한다 1,2). 대부분의위막성대장염은기존사용하던항생제를중단하거나, 경구 Metronidazole이나 Vancomycin 을사용하면호전되지만, 진단이늦어지는경우적당한치료에도불구하고패혈증이생기기도한다 3). 따라서위막성대장염의조기진단이매우중요하지만, 노인환자 Received: November 3, 2011 Revised: January 12, 2012 Accepted: January 12, 2012 Address for correspondence: Ji-Hun Roh, MD Department of Internal Medicine, Dong-eui Medical Center, 62 Yangjeong-ro, Busanjin-gu, Busan , Korea Tel: , Fax: wisroh@naver.com 의경우그증상이모호하고병의악화가급격하여다른질환과의감별이어려울수있어초기에잘못된치료를범할가능성이있다. 저자들은급성하복통및혈변을동반한고령의환자에서신체검사외복부컴퓨터단층촬영에서도충수돌기염천공으로오인된급성악화사례를경험하여문헌고찰과함께보고한다. 증례 78세남자환자가급성하복통을호소하여내과에협진의뢰되었다. 급성복부통증과혈변이외에설사및다른증상은없었다. 환자는 7일전대퇴경부골절로정형외과에서수술이후 3세대 cepha 계열약물 (cefminox sodium) 투여중이었다. 과거병력에서는고혈압이외에특이사항없었다. 협진의뢰당시혈압 110/70 mmhg, 맥박 94회 /min, 호흡 20회 /min, 34 J Korean Geriatr Soc 16(1) March 2012

윤영진외 : 감별이어려운노인에서의위막성대장염 체온 37.0 였다. 진찰소견에서전신상태는급성병색을보였고, 복부진찰에서우하복부의압통및반발통이있었으며, 장음은감소되어있었다. 말초혈액검사에서백혈구 30,350/ mm 3 ( 호중구 85%), 혈색소 12.1 g/dl, 혈소판 241,000 /mm 3 였다.

전해질검사에서는 Na 132 mmol/l, K 4.0 mmol/l 였으며대변잠혈검사에서양성반응을보였다. 문진및신체검사등을토대로한 Alvarado score 에서 9점으로체크되어급성충수염이강력히의심되어복부컴퓨터단층촬영을시행하였다.

이에급성충수돌기염천공으로생각되어적극적항생제치료및수술을고려하였고, 수술에앞서혈변을감별진단하기위하여구불결장경검사를시행하였다. 구불결장경검사에서는담황색의위막성반점이관찰되어 (Fig. 3) 조직검사및 clostridium difficile 독소 A 검사를시행하였고, 위막성대장염으로진단내렸다. 치료의 Fig. 1.

2 윤영진외 : 감별이어려운노인에서의위막성대장염 체온 37.0 였다. 진찰소견에서전신상태는급성병색을보였고, 복부진찰에서우하복부의압통및반발통이있었으며, 장음은감소되어있었다. 말초혈액검사에서백혈구 30,350/ mm 3 ( 호중구 85%), 혈색소 12.1 g/dl, 혈소판 241,000 /mm 3 였다. 생화학검사에서는 aspartate aminotransferase 20 U/L, alanine aminotransferase 13 U/L, 총빌리루빈 0.6 g/dl, blood urea nitrogen 33.0 mg/dl, 크레아티닌 2.0 mg/dl였다. C-reactive protein은 8.23 mg/dl로증가되어있었다. 전해질검사에서는 Na 132 mmol/l, K 4.0 mmol/l 였으며대변잠혈검사에서양성반응을보였다. 문진및신체검사등을토대로한 Alvarado score 에서 9점으로체크되어급성충수염이강력히의심되어복부컴퓨터단층촬영을시행하였다. 복부컴퓨터단층촬영에 서회맹부아래의경계가명확하지않은확장된관주위로체액이저류되어충수돌기염천공소견보였으나, 복강내의공기음영은관찰되지않았고, 구불결장의전반적인장벽부종소견도관찰되었다 (Fig. 1). 이외복강내여러부위의체액저류및양측흉강의흉수저류를보였다 (Fig. 2). 이에급성충수돌기염천공으로생각되어적극적항생제치료및수술을고려하였고, 수술에앞서혈변을감별진단하기위하여구불결장경검사를시행하였다. 구불결장경검사에서는담황색의위막성반점이관찰되어 (Fig. 3) 조직검사및 clostridium difficile 독소 A 검사를시행하였고, 위막성대장염으로진단내렸다. 치료의 Fig. 1. Abdomen computed tomography shows ill-defined and dilated tubular structure under cecum with fluid collection. It could be seen like acute appendicitis with perforation. Fig. 2. Abdomen computed tomography shows paracolic fluid collections. Fig. 3. Sigmoidoscopic finding shows multiple elevated brownish yellowpseudo membranes with diffuse edematous mucosa. It is a typical endoscopic finding of pseudomembranous colitis. J Korean Geriatr Soc 16(1) March

Young-Jin Yoon, et al: Difficult Evaluation of Pseudomembranous Colitis in Old Age Fig. 4. A mushroom-like mass of mucus and neutrophils attached to the surface of the mucosal glands is present.

3 Young-Jin Yoon, et al: Difficult Evaluation of Pseudomembranous Colitis in Old Age Fig. 4. A mushroom-like mass of mucus and neutrophils attached to the surface of the mucosal glands is present. (H&E, 200) 방향에있어서충수돌기염천공과위막성대장염은상반되는질환이고, 구불결장경검사에서위막성대장염이강력히의심되었으므로충수돌기염의정확한감별을위하여복부초음파검사를시행하였다. 그러나복부초음파검사에서는충수돌기주변으로명백한염증성변화나충수주위의침윤소견및장벽의두꺼워짐이관찰되지않았고, 충수돌기의직경이 6 mm 이하로관찰되었다. 저자들은이에충수돌기염의가능성을배제하고, 투여중이던 cefminox sodium의투여를곧바로중지후경구 metonidazole 로치료를시작하였다. 추후조직검사에서전형적인위막성대장염으로확진되었다 (Fig. 4). Metronidazole 치료 7일째환자의복통은소실되었고, 이학적소견및검사실소견상호전을보여퇴원하였다. 고 찰 위막성대장염은항생제에의한장염의일종으로 1893년에처음소개된이후 1970년대혐기성세균인 clostridium difficile 과의관련성이밝혀졌다 4,5). 임상적으로수양성설사 ( %) 가가장흔한증상이고, 복통 (33-63%) 과발열 (29-44%) 또한나타날수있지만, 연구마다그빈도의차이가있으며, 혈변이나흑색변은드물게동반된다 6,7). 설사를심하게하는경우전해질불균형, 저알부민혈증, 전신부종등의증상을보일수도있다. 드물게위막성대장염에서독성거대결장, 괴사성대장염과대장천공등의합병증이동반될수있다 8,9). 반면 급성충수돌기염은외과에서가장흔히경험하는급성복증의하나로우하복부동통, 식욕부진, 오심, 구토, 발열이흔한증상으로보고되나설사나혈변은드문것으로알려져있다 10,11). 위막성대장염의진단은다른대장염증상과유사하므로임상적의심이가장중요한데대변에서 clostridium difficile 독소 A의검출, 세균배양검사를통한원인균의증명, 대장내시경검사를통한위막확인, 조직검사를통한현미경적관찰등으로진단이가능하다. 현재가장많이쓰이는방법중하나인 clostridium difficile 독소 A를검출하는방법은그양성률이각연구마다 36.8% 에서 95% 로다양하게보고된다. 따라서항생제사용병력과그임상양상이위막성대장염을의심하게될경우진단이빠르고육안적소견이특징적인구불결장경검사가반드시요구된다 12-14). 구불결장경검사에서위막성대장염은경계가명확하고, 약간융기된황백색의플라크 (plaque), 즉위막이산재하는특징적인양상을보인다. 이러한플라크의크기는초기에는 1-3 mm 에불과하나진행되면합쳐져서장관의전주를뒤엎을수도있다. 플라크의주변점막은정상으로보일수도있고, 부종, 발적및취약성을보일수도있다 15). 복부컴퓨터단층촬영은위막성대장염의진단에반드시필요하지는않지만, 심한위막성대장염의경우뚜렷한점막하의부종이관찰되고, 조영제가대장의 haustra 에갇혀전형적인 accordion sign 이관찰될수도있다 16). 급성충수돌기염의경우임상적지표에의한진단법으로 Alvarado score, Ticher, Lindber, Christian, Ohmann, modified Alvarado score 등의도구가사용된다 17-21). Alvarado score 는 1986년 Alvarado 가급성충수돌기염진단의보조적인도구로제시한것으로이동통증 1점, 식욕부진 1점, 오심또는구토 1점, 우하복부압통 2점, 반발통 1점, 발열 1점, 백혈구증가 2점, 호중구증가 1점을부여하여총 10점으로점수화된검사로, 민감도 73-87%, 특이도 60-87% 로보고되고있다 17,18). 급성충수돌기염의가장중요한진단도구인복부초음파검사나컴퓨터단층촬영에서는충수돌기주위의염증성변화나장벽의두꺼워짐, 7 mm 이상으로늘어난충수돌기의직경을확인할수있다. 일부연구에서는초음파검사 ( 정확도 71-97%, 민감도 %, 특이도 47-94%) 보다컴퓨터단층촬영 ( 민감도 98%, 특이도 83%) 이더우수하다는보고가있으며, 하복부로의이동통증이초음파검사보다더정확한기준이될수있다는보고도있다 10,11,22). 36 J Korean Geriatr Soc 16(1) March 2012

4 윤영진외 : 감별이어려운노인에서의위막성대장염 본증례에서환자는위막성대장염의위험인자로밝혀진고령, 면역저하, 장기간입원, 위장관수술, 간질환등에서고령의나이이외에는다른위험인자는없었다 23). 또한위막성대장염의가장흔한증상인설사를하지않았으며, 혈변의양도많지않았다. 오히려급성충수돌기염의전형적인임상양상인우하복부통증, 압통, 반발통, 복부강직이나타났고급성충수돌기염진단의보조적도구인 Alvarado score에서 10점만점중 9점이었으며, 복부컴퓨터단층촬영에서도 accordion sign은관찰되지않았으며, 급성충수돌기염천공소견을보였다. 그러나항생제를사용한병력및혈변, 노인이라는특수성을감안하여적극적항생제치료및수술전에구불결장경검사및조직검사로위막성대장염을진단하였다. 구불결장경검사로위막성대장염으로진단을내린이후급성충수돌기염을재감별하기위하여복부초음파검사를다시시행하였으나명백한염증성변화나충수주위의침윤소견및장벽의두꺼워짐을볼수없었고, 직경또한 6mm 이하로관찰되었다. 급성충수돌기염천공으로생각하였던복부컴퓨터단층촬영의소견, 즉회맹부아래쪽의경계가명확하지않은관상구조물과체액저류는아마도위막성대장염으로인한복수가국소저류된것을오인한것으로생각된다. 또한 clostridium difficile 독소 A 검사도음성이었지만, 내시경소견및조직검사에서전형적인위막성대장염의소견을보였으므로위음성으로생각된다. 항생제투여기간과위막성대장염의병발시기와의관계는통상항생제를사용중이거나중단한지 5-10일후, 드물게항생제치료가끝나고 10주후까지도발병할수있다 24). 위막성대장염의치료방법은기존의항생제투여를중지하고보존적치료만으로도약 30% 의환자에서대략 10일이내에증상이호전되지만 12), 심한장염이있는환자에서는경구용 metronidazole 또는 vancomycin 을투여하는것이추천된다 23). 노인에서의급작스러운복부통증은그임상증상의비특이성과다른연령층환자보다낮은협조성을고려해보았을때진단이어려운편이다. 특히위막성대장염의경우감별진단이요구되는급성충수돌기염이나, 다른장질환과는치료의방향이다르기때문에반드시초기에진단하는것이매우중요하다. 따라서항생제를사용하고있던노인환자에서갑작스러운복통이발생할경우그임상증상이나검사실소견, 심지어영상의학적소견이다른질환을의심하게할지라 도반드시위막성대장염의가능성을염두에두어야하겠다. REFERENCES 1. Wilcox MH. Gastrointestinal disorders and the critically ill. Clostridium difficile infection and pseudomembranous colitis. Best Pract Res Clin Gastroenterol 2003;17: Zuckerman E, Kanel G, Ha C, Kahn J, Gottesman BS, Korula J. Low albumin gradient ascites complicating severe pseudomembranous colitis. Gastroenterology 1997;112: Fekety R, McFarland LV, Surawicz CM, Greenberg RN, Elmer GW, Mulligan ME. Recurrent Clostridium difficile diarrhea: characteristics of and risk factors for patients enrolled in a prospective, randomized, double-blinded trial. Clin Infect Dis 1997;24: Bong JD, Boo GB, Sim DS, Park HO, Lee TW, Koh KS, et al. A casce of rifampicin induced pseudomembranous colitis in elderly patient. J Korean Geriatr Soc 2005;9: Surawicz CM, McFarland LV. Pseudomembranous colitis: causes and cures. Digestion 1999;60: Gebhard RL, Gerding DN, Olson MM, Peterson LR, McClain CJ, Ansel HJ, et al. Clinical and endoscopic findings in patients early in the course of clostridium difficile-associated pseudomembranous colitis. Am J Med 1985;78: Chung MH, Hyun MS, Lee HJ, Chung MK, Shim MC, Lee TS. A clinical study of pseudomembranous enterocolitis. Korean J Intern Med 1988;34: Cleary RK. Clostridium difficile-associated diarrhea and colitis: clinical manifestations, diagnosis, and treatment. Dis Colon Rectum 1998;41: Koh DH, Lee HL, Kim JM, Moon W, Lee OY, Yoon BC, et al. A case of toxic megacolon associated with fulminant pseudomembranous colitis. Korean J Gastrointest Endosc 2008;36: Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15: Balthazar EJ, Birnbaum BA, Yee J, Megibow AJ, Roshkow J, Gray C. Acute appendicitis: CT and US correlation in 100 patients. Radiology 1994;190: Kim JH, Park JH. A case of rifampicin associated pseudomembranous colitis. Korean J Gastroenterol 2004;43: Monaghan T, Boswell T, Mahida YR. Recent advances J Korean Geriatr Soc 16(1) March

5 Young-Jin Yoon, et al: Difficult Evaluation of Pseudomembranous Colitis in Old Age in Clostridium difficile-associated disease. Gut 2008;57: Lee JK, Cho JY, Kim YS, Kim SE, Ryu SH, Lee JH, et al. Compative value of sigmoidoscopy and stool cytotoxin- A assay for diagnosis of pseudomembranous colitis. Intest Res 2005;3: Yang SK, Min YI. Colonoscopic diagnosis. Seoul: Koonja Publising Inc.; Federle MP, Brooke Jeffrey R, Woodward PJ, Borhani A. Diagnostic imaging: abdomen. Salt Lake City: Amirsys; Douglas CD, Macpherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000;321: Crnogorac S, Lovrenski J. Validation of the Alvarado score in the diagnosis of acute appendicitis. Med Pregl 2001;54: Fenyö G, Lindberg G, Blind P, Enochsson L, Oberg A. Diagnostic decision support in suspected acute appendicitis: validation of a simplified scoring system. Eur J Surg 1997;163: Bhattacharjee PK, Chowdhury T, Roy D. Prospective evaluation of modified Alvarado score for diagnosis of acute appendicitis. J Indian Med Assoc 2002;100:310-1, Andersson RE, Hugander A, Ravn H, Offenbartl K, Ghazi SH, Nyström PO, et al. Repeated clinical and laboratory examinations in patients with an equivocal diagnosis of appendicitis. World J Surg 2000;24: Wade DS, Marrow SE, Balsara ZN, Burkhard TK, Goff WB. Accuracy of ultrasound in the diagnosis of acute appendicitis compared with the surgeon's clinical impression. Arch Surg 1993;128: Yun JW, Hwang JH, Ham HS, Lee HC, Roh GH, Kang SJ, et al. A case of rifampicin induced pseudomembranous colitis. Tuberc Respir Dis 2000;49: Tedesco FJ. Pseudomembranous colitis: pathogenesis and therapy. Med Clin North Am 1982;66: J Korean Geriatr Soc 16(1) March 2012

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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,