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1 대한내과학회지 : 제 85 권제 6 호 특집 (Special Review) - 대장게실의제대로알기 대장게실염의진단및치료 원광대학교의과대학내과학교실, 소화기질환연구소 서검석 최석채 Diagnosis and Treatment of Colon Diverticulitis Geom Seog Seo and Suck Chei Choi Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, Iksan, Korea Colonic diverticular disease is the common conditions in industrialized and westernized countries, but it is relatively rare in areas such as Asia. Colonic diverticula are asymptomatic in most cases, only 10-25% develop diverticulitis and 1% finally gets surgery. The location of colonic diverticulitis are significantly different in Western countries and Asia. Left-sided diverticulitis is common in Western countries, while in Asians, right-sided diverticulitis is more prevalent. A CT scans is commonly used to diagnose diverticulitis and its complication such as abscess, obstruction, fistula and perforation. It also has been used in percutaneous drainage of diverticular abscess and predicting the success of medical therapy. After resolution of clinical attack of diverticulitis, colonoscopy can be performed to exclude colon cancer. The current therapeutic approaches for colonic diverticulitis are relieving symptoms and preventing complications. Uncomplicated diverticulitis is successfully treated with antibiotics, bowel rest and pain control, while complicated diverticulitis require surgical consultation. Treatment strategy of recurrent diverticulitis depends on age and comorbid diseases as well as the frequency and severity of subsequent attacks. (Korean J Med 2013;85: ) Keywords: Colon; Diverticulitis; Computed tomography; Diagnosis; Treatment 서론대장게실 (colon diverticulum) 은대장벽의일부가비정상적으로탈출된소낭이고게실증 (diverticulosis) 은염증이나출혈의합병증이없는상태이며합병증이나통증이동반되면게실질환 (diverticular disease) 이라한다. 서구의경우대장게실증의 25% 에서게실질환으로진행한다고하였고이중 3/4은게실염, 1/4은게실출혈이었다 [1]. 서구의경우대부분 은좌측대장게실염이고 [2] 동양인의경우 55-75% 가우측대장게실염인데, 우측대장게실염은남자에서더흔하고좌측대장게실염에비해더젊은연령에서발병한다 [3-5]. 대장게실염의임상양상은다양한데, 경도의복통및열부터 15-20% 는농양, 누공, 폐색, 천공으로진행할수있고천공으로진단된게실염환자의 12-36% 는사망할수있기때문에 [6] 정확하고빠른진단이매우중요하다할수있다 [7]. 대다수의대장게실염환자들은응급실을방문하는데, 동 Correspondence to Geom Seog Seo, M.D., Ph.D. Department of Internal Medicine, Digestive Disease Research Institute, Wonkwang University College of Medicine, 895 Muwang-ro Iksan , Korea Tel: , Fax: , medsgs@wonkwang.ac.kr Copyright c 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 - The Korean Journal of Medicine: Vol. 85, No. 6, Table 1. Treatment algorithm for acute diverticulitis [10] Acute uncomplicated diverticulitis Acute complicated diverticulitis Clinical features Management Clinical features Management LLQ/RLQ pain 1) Oral antibiotics 2) Admission for iv antibiotics in older patients with comorbidity/sign of sepsis Diverticulitis with associated abscess 1) Admission, iv antibiotics if abscess < 5 cm 2) If no response, or abscess > 5 cm, percutaneous abscess drainage Purulent peritonitis Laparoscopic lavage or laparotomy, colon resection with/without proximal diversion Fecal peritonitis Hartmann s procedure 서양을막론하고복부전산화단층촬영 (abdominal computed tomography, CT) 을통하여진단을내리게되며입원또는외래치료를받게된다. 최근유럽에서시행된전향적대조군연구에의하면응급실에내원한환자중퇴원시켜치료를시도한외래치료군과입원치료군사이에치료실패율및삶의질은비슷하였으나입원치료군에서의료비지출이 3 배로증가하였기에합병증이동반되지않은좌측대장게실염이라면외래치료를해도안전하고비용효과적일수있다하였다 [8]. 대장게실염진단방법선택및치료결과를알기위한미국의연구를보면 2003년부터 2008년까지게실염진단코드를이용하여시행되었는데게실염환자중응급실을방문한환자는응급실을방문하지않고외래에서치료받았던환자에비해서응급복부 CT를더많이시행받았고 (85% vs. 14%), 백혈구증가증 (69% vs. 35%), 24시간내조기입원 (30% vs. 3.5%) 및대장절제술 (1.2% vs. 0.4%) 비율이더높았다 [9]. 치료는표 1에제시된바와같이항생제를이용한내과적치료와수술적치료가있으며 (Table 1) [10] 정확한진단및게실관련합병증유무가치료를결정하는중요한요소가된다. 본고에서는대장게실염에의한출혈및천공을제외한대장게실염환자에대한진단및치료에대해서알아보고자하였다. 본론진단증상좌측대장게실염의경우, 좌하복부에국한된통증이특징이고통증과함께가스로인한복부팽만이동반되고통증은식사에의해악화되며가스배출이나배변에의해완화된다. 우측대장게실염중에서맹장게실염은급성충수염과 의감별에어려움이있을수있는데우측대장게실염은급성충수염에비해상대적으로긴시간의우하복부통증이있고통증의이동 (migration), 오심, 구토, 전신염증도더드물다 [11-13]. 중증대장게실염의경우남성에서더흔하고하복부에만국한되지않는통증, 변비, 열, 백혈구증가증등이더많이동반되어있다 [14]. 영상의학검사 1978년보고한 Hinchey분류는임상및수술적소견을근거로한반면 1980년대부터는 CT 검사를통하여표 2와같이다양한분류법들을제시하였다 (Table 2) [15-17]. 현재임상에서급성대장게실질환의진단에있어가장널리이용되는검사법은 CT이고임부및가임기여성등일부에서는초음파검사가방사선노출에대한두려움이있는경우에는복부자기공명영상 (magnetic resonance imaging, MRI) 이시행되고있다. 하복부통증이있을때복부 CT검사의장점은대장게실염의확진, 중증및질환의범위평가, 합병증이동반된게실염의치료계획수립및게실염과유사한증상을초래할수있는다른질환의감별에있다 [17-20]. 대장게실염진단에있어서초음파검사의민감도는 77-98%, 특이도는 80-99% 로우수한성적을보고하고있고 [21,22] 비침습적이며쉽게이용가능하지만시술자의존성이크고다른의사에의해서는판독이어렵다는제한점이있다 [23]. CT 조영제는구강, 직장관장, 정맥으로투여할수있는데특별한조영제금기증만없다면정맥으로투여하게된다. 조영제를이용한복부 CT 검사는대장게실염의진단에있어서높은민감도및 100% 에가까운특이도를보이기때문에과거사용하던대장조영술을대체하게되었다 [20,24]. 특징적인소견으로대장벽의비후 (96%) 및결장주위지방침윤 (pericolic fat stranding, 95%) 등이있고 [25] CT에따른중증도분류에서보면구불창자벽의두께가 5 mm 미만, 결장주위지방침윤

3 - Geom Seog Seo, et al. Diagnosis and treatment of colon diverticulitis - Table 2. Hinchey classification and its modification [15-17] Stage Original Hinchey classification Sher, Kohler modification Wasvary modification Kaiser modification I Pericolic abscess confined by the mesentery of the colon Pericolic abscess Ia; Phlegmon Ib; Pericolic abscess Ia; Confined pericolic inflammation-phlegmon Ib; Confined pericolic abscess II III IV Pelvic abscess resulting from a local perforation of a pericolic abscess Generalized peritonitis resulting from rupture of pericolic/pelvic abscess into the general peritoneal cavity Fecal peritonitis results from the free perforation of a diverticulum IIA; Distant abscess amenable to percutaneous drainage IIB; Complex abscess associated with/without fistula Pelvic abscess Pelvic, distant intrabdominal or retroperitoneal abscess Generalized purulent peritonitis Purulent peritonitis Generalized purulent peritonitis Fecal peritonitis Fecal peritonitis Fecal peritonitis 소견만있으면중등도게실염, 농양, 관강외공기음영 (extraluminal air) 및관강외조영제소견이관찰되면중증게실염이라할수있다 [26]. MRI 검사는대장게실염을진단하기위해서일차적으로시행하는검사는아니지만좌측대장게실염에대한검사민감도는 86-94%, 특이도는 88-92% 로알려져있고 [27,28] 특징적인소견은 CT 검사와동일하다 [29]. 최근보고에의하면복부 MRI의경우 CT에비해서게실염환자에서동반된대장암의진단에있어서더우월함을보고하고있어향후이에대한대규모연구가필요할것으로생각한다 [30]. CT검사를통해대장게실염과다른질환을감별하는데도움을얻을수있는데, 감별이필요한질환으로는대장암, 충수돌기염, 복막수염 (epiploic appendagitis), 허혈성대장염, 염증성장질환등이있다. 대장내시경복부 CT로진단받은좌측대장게실염환자에서치료후대장내시경검사는직장출혈, 체중감소, 지속적인복통을호소하는경우에만제한적으로시행하여야하고 [31] 우측대장게실염의경우근거자료가부족하지만항생제치료를시행하여염증이호전되었음에도불구하고국소적대장벽비후 (local wall thickening) 가지속적으로관찰될때는대장내시경검사를고려해보아야하며시행시기는게실염을치료하고 6주경과한다음이다 [32-34]. 이러한일반적인원칙에벗어나입원 1주일이내에조기대장내시경검사를시행해야하는경우로는복부 CT에서대장벽의두께가 6 mm 이상이거나농양, 폐색, 림프림이관찰될때이다 [35]. 호주에서시행된 연구에서보면좌측대장게실염을가진환자에서추적대장내시경검사를시행하거나또는지속적으로관찰하였을때 2.1% 에서대장암이발견되었는데복부 CT검사에서농양, 국소적천공, 누공이있는경우에는합병증이동반되지않은게실염에비해각각 6.7배, 4배, 18배대장암의빈도가증가한다는보고를하고있어 [36] 최근에대장내시경을시행받지않은좌측게실염환자들은추후에대장내시경검사를받을것을권유하였다. 대장내시경을시행할때진통제및수면유도제를사용해야하는지에관한연구에서여성게실염환자의경우반드시두가지모두를사용하고남자환자의경우여러개의위험인자를가지고있는경우 (40세이하, 과거에복부수술경험이있는경우, 이전에시행한대장내시경에서복부통증이있었던경우, 과거의게실염병력 ) 에는수면유도제를사용할것을권유하였다 [37]. 이처럼조기대장내시경이게실염환자에서대장암의동반여부를확인하는데중요한검사이지만좌측게실염환자를대상으로한여러연구에서비교적낮은맹장삽관율및천공을문제점으로제시하고있다 [38]. 우측대장게실염의경우이론적으로좌측대장게실염에비해더높은맹장삽관율및낮은천공률을보일것으로예측되지만향후전향적다기관연구를통해확인이필요할것으로생각한다. 치료합병증이동반되지않은게실염 (Uncomplicated diverticulitis) 합병증이동반되지않은대장게실염은 75% 로알려져있

4 - 대한내과학회지 : 제 85 권제 6 호통권제 640 호 으며 [39,40] 전형적인증상은하복부통증, 고열, 백혈구증가증이고진단은복부 CT를통하여이루어진다. 주된치료는항생제사용, 장휴식 (bowel rest), 복통조절이다. 항생제치료는그람음성및혐기성균을모두포함할수있는조합이필요한데, 외래환자들의경우 ciprofloxacin과 metronidazole 또는 amoxicillin/clavulanate를사용한다. 입원환자들의경우는정주용광범위항생제를투여하는데, ceftriaxone 과 metronidazole, 단일제제로는 beta-lactam/beta-lactamase 억제제 (piperacillin/ tazobactam) 또는 meropenem 을사용하며 [41,42] 사용기간은 7-10일이다. 입원기간동안에복통없이압통 (tenderness) 만있는경우물을마실수있고음식을섭취한후에도증상의악화가없다면퇴원가능하며퇴원후외래에서환자가복통이남아있다고말하는경우에는추가로경구항생제를처방할수있다. 환자를입원시킬것인지는입원당시의환자의임상양상에의해서결정되는데, 고열이없거나현저한진단검사의학또는영상의학적이상소견이없다면입원이필요치않다. 이러한환자들은집에서보존적인치료로잘호전이되는경우가대부분이지만임상양상이악화되는경우입원하도록교육하여야한다. 면역이억제된환자의경우는발현양상이가볍다하더라도애매모호한증후를보일수있고또한일반적인내과치료에잘반응하지않을수있기때문에입원이필요하다 [43]. 합병증이동반되지않은게실염의경우 2-3일경과한후에증상의호전을보이면서서히식이를진행할수있다. 증상의호전을보이지않는경우에는합병증발생여부를알아보기위하여영상촬영을시행하고필요할때는외과에협진을요청해야하는데 [44] 결국 25% 의환자에서는게실염의호전이없어수술을받게된다 [45]. 환자의 1/3에서재발성게실염을경험하게되는데과거에는재발할수록심한경과를보인다는주장이있어서두번째재발시에예방적수술을권장하였지만 [7,44,46,47] 최근에는재발시항상더심한경과를취하는것은아니라는보고가있어 [48-51] 재발의횟수및심한정도뿐만아니라환자의나이, 동반질환을고려하여환자개개인에맞게 (case-by-case) 수술을결정해야한다고주장하였다 [6,52,53]. 50세이하의젊은나이에발생한게실염환자에대한치료전략은아직은분명하지않고미국대장직장외과학회에서는환자개개인에맞게결정해야한다고주장하였다 [44,52]. 문헌고찰을통해살펴보더라도젊은나이의게실염은더이상좋지않은예후를보이는위험인자가아니라는보고부터 [54,55] 더좋지않은경과및재발의위험성이더높다는상반된보고 [56,57] 들이혼재되어있다. 미국보고에의하면 년사이에합병증이동반되지않은게실염의내과적인치료후선택적수술 (elective surgery) 은 38% 증가하였는데, 44세이하의젊은환자에서특히더증가하였고 (73%), 이러한치료방침으로인해수술사망률의감소 (1.6% vs. 1.0%), 입원기간의감소 (5.9일 vs. 5.3일 ) 를보였다 [58]. 선택적수술을시행한경우수술방법의결정에있어복강경을이용한절제를권장하고있는데, 90% 이상에서일차적인문합을시행할수있고무작위대조연구에의하면 15.4% 의이환율감소, 통증감소, 짧은재원기간및향상된삶의질을유지하였고 6개월이경과하였을때주요한이환율을 27% 까지감소시켰다 [59,60]. 합병증이동반된게실염급성좌측대장게실염의 25% 에서농양, 누공, 협착 / 폐색, 천공과같은합병증이발생한다 [61]. 작은농양은항생제단독치료를시행하나 4-5 cm 이상의큰농양에대해서는 CT 유도하농양배액을시행하여호전시키거나수술전에가교적 (bridge) 목적으로시행한다 [62,63]. 대장게실천공에의한누공의형성은수술적치료가필요한데, 가장흔한부위는대장방광 (colovesicular) 과대장질 (colovaginal) 이다 [64]. 반복적인재발에의한섬유화및대장협착이발생한경우대장암과의감별이중요하며수술적치료가필요할수있는데, 1 단계 (single stage) 선택적수술을시행하기위해수술전대장스텐트를삽입할수있다 [65,66]. 게실천공에의한복막염은흔하지않은합병증이지만사망률이높아즉각적인항생제사용및수술만이사망률을감소시킬수있다 [67]. 최근보고에의하면일차적문합술이 Hartmann 수술방법을먼저시행한후수개월후에대장루복원술을시행하는수술법에비해사망률이증가하지않고이환율감소에의해의료비용및재원기간단축을가져온다고하였다 [68-70]. 우측게실염의합병증에대한수술방법으로회맹장절제술 (ileocecectomy), 우반결장절제술 (right hemicolectomy) 방법이있는데, 이러한수술들은각각재발을방지하거나암과구별이되지않을때시행할수있으며 [71] 단점으로는이환율및사망률이증가할수있다는것이다. 현재까지보고에의하면회맹장절제술 (ileocecectomy) 방법이낮은단계의합병증을동반하고재발인경우에우반결장절제술 (right hemicolie

5 - 서검석외 1 인. 대장게실염의진단및치료 - ctomy) 에비해수술합병증도덜하고더선호되는반면 [72,73] 합병증이동반된게실염과대장암이배제되지않을때는우반결장절제술시행을권고하고있다. 재발방지를위한생활방식변경및약제사용전통적으로식이섬유가풍부한식이는재발성급성대장게실염의예방에효과가있을것으로생각되어왔으나 [52,74] 최근에효과적인지않다는상반된최근보고도있어 [75] 예전처럼중요성은감소하였지만많은양의식이섬유가가질수있는잠재적이점때문에미국에서는예방적측면에서권장하고있다 [52]. 비만과흡연은게실염의합병증을발생을증가시키는위험인자로작용하므로 [76,77] 체중감량과금연을환자들에게권고하여야한다. 최근에는항생제, 항염증제, 유산균약제가효과적일것으로생각하고있는데, 게실염치료후 rifaximin 을간헐적으로투여하면재입원율을 50%, 재발성게실염을 73% 감소시킨다는보고가있다 [78]. 이러한효과는병합요법에의해서항진되는데, 5-aminosalicylic acid ( 메살라진 ) 과 rifaximin 을같이사용하면 rifaximin 단독보다효과적이고 [79,80] 유산균제와 5-aminoslicylic acid를같이사용하면유산균단독보다효과적이었다 [81]. 요약하면풍부한식이섬유섭취, 체중감량, 금연, 항생제, 유산균제제및항염증제가재발을예방하는데효과적일수있을것으로생각하며향후이를입증하기위해전향적연구가필요할것이다. 결론대장게실염, 특히우측대장게실염은한국인에서비교적흔한질환이며치료전정확한진단은올바른치료방법선택및예후에영향을미치는필수적인요소이다. 많은수의환자들이응급실로내원하는데, 대부분복부 CT 검사를통하여진단할수있고급성기에대장내시경이필요한경우는드물다. 합병증이동반되지않은대장게실염의경우항생제정주를통해안전하고효과적으로치료를시행할수있으며외래에서증상평가및염증지표 ( 예 : 백혈구, C-reactive protein) 검사를통해경구항생제투여를지속할것인지결정하여야한다. 심한합병증이동반되었을때그리고대장암과의감별이되지않을때는수술을고려하여야한다. 결론 적으로대장게실염의수술에따른합병증도항상고려해야하므로수술전정확한진단및효과적인치료를위해내과, 영상의학과, 외과의상호토의에의해치료방향을결정하는것은좋은예후를확보하기위한필수적인과정일것으로생각한다. 중심단어 : 대장 ; 게실염 ; 전산화단층촬영 ; 진단 ; 치료 REFERENCES 1. Young-Fadok TM, Roberts PL, Spencer MP, Wolff BG. Colonic diverticular disease. Curr Probl Surg 2000;37: Hildebrand P, Kropp M, Stellmacher F, Roblick UJ, Bruch HP, Schwandner O. Surgery for right-sided colonic diverticulitis: results of a 10-year-observation period. Langenbecks Arch Surg 2007;392: Sugihara K, Muto T, Morioka Y, Asano A, Yamamoto T. Diverticular disease of the colon in Japan: a review of 615 cases. Dis Colon Rectum 1984;27: Lee IK. Right colonic diverticulitis. J Korean Soc Coloproctol 2010;26: Kim SY, Oh TH, Seo JY, et al. The clinical factors for predicting severe diverticulitis in Korea: a comparison with Western countries. Gut Liver 2012;6: Morris CR, Harvey IM, Stebbings WS, Speakman CT, Kennedy HJ, Hart AR. Epidemiology of perforated colonic diverticular disease. Postgrad Med J 2002;78: Stollman N, Raskin JB. Diverticular disease of the colon. Lancet 2004;363: Biondo S, Golda T, Kreisler E, et al. Outpatient versus hospitalization management for uncomplicated diverticulitis: a prospective, multicenter randomized clinical trial (DIVER Trial). Ann Surg 2013 May 31 [Epub] /SLA.0b013e a O'Connor ES, Leverson G, Kennedy G, Heise CP. The diagnosis of diverticulitis in outpatients: on what evidence? J Gastrointest Surg 2010;14: Martin ST, Stocchi L. New and emerging treatments for the prevention of recurrent diverticulitis. Clin Exp Gastroenterol 2011;4: Chen SC, Chang KJ, Wei TC, Yu SC, Wang SM. Can cecal diverticulitis be differentiated from acute appendicitis? J Formos Med Assoc 1994;93: Shyung LR, Lin SC, Shih SC, Kao CR, Chou SY. Decision making in right-sided diverticulitis. World J Gastroenterol 2003;9: Shin JH, Son BH, Kim H. Clinically distinguishing between appendicitis and right-sided colonic diverticulitis at initial

6 - The Korean Journal of Medicine: Vol. 85, No. 6, presentation. Yonsei Med J 2007;48: Longstreth GF, Iyer RL, Chu LH, et al. Acute diverticulitis: demographic, clinical and laboratory features associated with computed tomography findings in 741 patients. Aliment Pharmacol Ther 2012;36: Sher ME, Agachan F, Bortul M, Nogueras JJ, Weiss EG, Wexner SD. Laparoscopic surgery for diverticulitis. Surg Endosc 1997;11: Wasvary H, Turfah F, Kadro O, Beauregard W. Same hospitalization resection for acute diverticulitis. Am Surg 1999; 65: Kaiser AM, Jiang JK, Lake JP, et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005;100: Ambrosetti P. Acute diverticulitis of the left colon: value of the initial CT and timing of elective colectomy. J Gastrointest Surg 2008;12: Al-Sahaf O, Al-Azawi D, Fauzi MZ, El-Masry S, Gillen P. Early discharge policy of patients with acute colonic diverticulitis following initial CT scan. Int J Colorectal Dis 2008;23: Destigter KK, Keating DP. Imaging update: acute colonic diverticulitis. Clin Colon Rectal Surg 2009;22: Schwerk WB, Schwarz S, Rothmund M. Sonography in acute colonic diverticulitis: a prospective study. Dis Colon Rectum 1992;35: Pradel JA, Adell JF, Taourel P, Djafari M, Monnin-Delhom E, Bruel JM. Acute colonic diverticulitis: prospective comparative evaluation with US and CT. Radiology 1997;205: Liljegren G, Chabok A, Wickbom M, Smedh K, Nilsson K. Acute colonic diverticulitis: a systematic review of diagnostic accuracy. Colorectal Dis 2007;9: Ambrosetti P, Jenny A, Becker C, Terrier TF, Morel P. Acute left colonic diverticulitis: compared performance of computed tomography and water-soluble contrast enema: prospective evaluation of 420 patients. Dis Colon Rectum 2000;43: Kircher MF, Rhea JT, Kihiczak D, Novelline RA. Frequency, sensitivity, and specificity of individual signs of diverticulitis on thin-section helical CT with colonic contrast material: experience with 312 cases. AJA Am J Roentgenol 2002;178: Ambrosetti P, Becker C, Terrier F. Colonic diverticulitis: impact of imaging on surgical management: a prospective study of 542 patients. Eur Radiol 2002;12: Heverhagen JT, Sitter H, Zielke A, Klose KJ. Prospective evaluation of the value of magnetic resonance imaging in suspected acute sigmoid diverticulitis. Dis Colon Rectum 2008;51: Ajaj W, Ruehm SG, Lauenstein T, et al. Dark-lumen magnetic resonance colonography in patients with suspected sigmoid diverticulitis: a feasibility study. Eur Radiol 2005; 15: Buckley O, Geoghegan T, McAuley G, Persaud T, Khosa F, Torreggiani WC. Pictorial review: magnetic resonance imaging of colonic diverticulitis. Eur Radiol 2007;17: Öistämö E, Hjern F, Blomqvist L, Von Heijne A, Abraham- Nordling M. Cancer and diverticulitis of the sigmoid colon: differentiation with computed tomography versus magnetic resonance imaging: preliminary experiences. Acta Radiol 2013;54: Schout PJ, Spillenaar Bilgen EJ, Groenen MJ. Routine screening for colon cancer after conservative treatment of diverticulitis. Dig Surg 2012;29: Oh KH, Han KH, Kim EJ, et al. Colon cancer after acute diverticulitis treatment. Ann Coloproctol 2013;29: Almy TP, Howell DA. Medical progress: diverticular disease of the colon. N Engl J Med 1980;302: Panish JF. Limitations and complications of colonoscopy. Gastrointest Endosc 1980;26(2 Suppl):20S-21S. 35. Elmi A, Hedgire SS, Pargaonkar V, Cao K, McDermott S, Harisinghani M. Is early colonoscopy beneficial in patients with CT-diagnosed diverticulitis? AJR Am J Roentgenol 2013;200: Lau KC, Spilsbury K, Farooque Y, et al. Is colonoscopy still mandatory after a CT diagnosis of left-sided diverticulitis: can colorectal cancer be confidently excluded? Dis Colon Rectum 2011;54: Holme O, Bretthauer M, de Lange T, et al. Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study. Endoscopy 2013;45: Sakhnini E, Lahat A, Melzer E, et al. Early colonoscopy in patients with acute diverticulitis: results of a prospective pilot study. Endoscopy 2004;36: Detry R, Jamez J, Kartheuser A, et al. Acute localized diverticulitis: optimum management requires accurate staging. Int J Colorectal Dis 1992;7: Thompson WG, Patel DG. Clinical picture of diverticular disease of the colon. Clin Gastroenterol 1986;15: Schechter S, Mulvey J, Eisenstat TE. Management of uncomplicated acute diverticulitis: results of a survey. Dis Colon Rectum 1999;42: Weizman AV, Nguyen GC. Diverticular disease: epidemiology and management. Can J Gastroenterol 2011;25: Perkins JD, Shield CF 3rd, Change FC, Farha GJ. Acute diverticulitis: comparison of treatment in immunocompromised patient. Arch Surg 1991;126: Roberts P, Abel M, Rosen L, et al. The standards task force

7 - Geom Seog Seo, et al. Diagnosis and treatment of colon diverticulitis - of the American Society of Colon and Rectal Surgeons: practice parameters for sigmoid diverticulitis: supporting documentation. Dis Colon Rectum 1995;38: Roberts PL, Veidenheimer MC. Current management of diverticulitis. Adv Surg 1994;27: Ferzoco LB, Raptopoulos V, Silen W. Acute diverticulitis. N Engl J Med 1998;338: Wong WD, Wexner SD, Lowry A, et al. Practice parameters for the treatment of sigmoid diverticulitis: supporting documentation: the Standards Task Force: the American Society of Colon and Rectal Surgeons. Dis Colon Rectum 2000;43: Salem TA, Molloy RG, O Dwyer PJ. Prospective, five-year follow-up study of patients with symptomatic uncomplicated diverticular disease. Dis Colon Rectum 2007;50: Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg 2008;32: Laméris W, van Randen A, van Gulik TM, et al. A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 2010;53: Buchs NC, Konrad-Mugnier B, Jannot AS, Poletti PA, Ambrosetti P, Gervaz P. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg 2013;100: Rafferty J, Shellito P, Hyman NH, Buie WD; Standards Committee of American Society of Colon and Rectal Surgeons. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49: Klarenbeek BR, Samuels M, van der Wal MA, van der Peet DL, Meijerink WJ, Cuesta MA. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010;251: Faria GR, Almeida AB, Moreira H, Pinto-de-Sousa J, Correia-da-Silva P, Pimenta AP. Acute diverticulitis in younger patients: any rationale for a different approach? World J Gastroenterol 2011;17: Song ME, Jung SA, Shim KN, et al. Clinical characteristics and treatment outcome of colonic diverticulitis in young patients. Korean J Gastroenterol 2013;61: Schauer PR, Ramos P, Ghiatas AA, Sirinek KR. Virulent diveticular disease in young obese men. Am J Surg 1992;164: Sheth AA, Longo W, Floch M. Diverticular disease and diverticulitis. Am J Gastroenterol 2008;103: Etzioni DA, Mack TM, Beart RW Jr, Kaiser AM. Diverticulitis in the United States: : changing patterns of disease and treatment. Ann Surg 2009;249: Klarenbeek BR, Veenhof AA, Bergamaschi R, et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009;249: Klarenbeek BR, Bergamaschi R, Veenhof AA, et al. Laparoscopic versus open sigmoid resection for diverticular disease: follow-up assessment of the randomized control Sigma trial. Surg Endosc 2011;25: Kang JY, Hoare J, Tinto A, et al. Diverticular disease of the colon: on the rise: a study of hospital admission in England between 1989/1990 and 1999/2000. Aliment Pharmacol Ther 2003;17: Schechter S, Eisenstat TE, Oliver GC, Rubin RJ, Salvati EP. Computerized tomographic scan-guided drainage of intra-abdominal abscesses: preoperative and postoperative modalities in colon and rectal surgery. Dis Colon Rectum 1994;37: Ambrosetti P, Chautems R, Soravia C, Peiris-Waser N, Terrier F. Long-term outcome of mesocolic and pelvic diverticular abscesses of the left colon: a prospective study of 73 cases. Dis Colon Rectum 2005;48: Woods RJ, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. Internal fistulas in diverticular disease. Dis Colon Rectum 1988;31: Small AJ, Young-Fadok TM, Baron TH. Expandable metal stent placement for benign colorectal obstruction: outcomes for 23 cases. Surg Endosc 2008;22: Keränen I, Lepistö A, Udd M, Halttunen J, Kylänpää L. Outcome of patients after endoluminal stent placement for benign colorectal obstruction. Scand J Gastroenterol 2010; 45: Krukowski ZH, Matheson NA. Emergency surgery for diverticular disease complicated by generalized and faecal peritonitis: a review. Br J Surg 1984;71: Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007;22: Kreis ME, Mueller MH, Thasler WH. Hartmann's procedure or primary anastomosis? Dig Dis 2012;30: Herzog T, Janot M, Belyaev O, et al. Complicated sigmoid diverticulitis: Hartmann's procedure or primary anastomosis? Acta Chir Belg 2011;111: Lane JS, Sarkar R, Schmit PJ, Chandler CF, Thompson JE Jr. Surgical approach to cecal diverticulitis. J Am Coll Surg 1999;188: Lo CY, Chu KW. Acute diverticulitis of the right colon. Am J Surg 1996;171: Yang HR, Huang HH, Wang YC, et al. Management of right colon diverticulitis: a 10-year experience. World J Surg 2006;30: Stollman NH, Raskin JB. Diagnosis and management of di

8 - 대한내과학회지 : 제 85 권제 6 호통권제 640 호 verticular disease of the colon in adults: Ad Hoc Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol 1999;94: Ünlü C, Daniels L, Vrouenraets BC, Boermeester MA. A systematic review of high-fibre dietary therapy in diverticular disease. Int J Colorectal Dis 2012;27: Dobbins C, Defontgalland D, Duthie G, Wattchow DA. The relationship of obesity to the complications of diverticular disease. Colorectal Dis 2006;8: Turunen P, Wikström H, Carpelan-Holmström M, Kairaluoma P, Kruuna O, Scheinin T. Smoking increases the incidence of complicated diverticular disease of the sigmoid colon. Scand J Surg 2010;99: Porta E, Germano A, Ferrieri A, Koch M. The natural history of diverticular disease of the colon: a role for antibiotics in preventing complications? a retrospective study. Riv Eur Sci Med Farmacol 1994;16: Tursi A, Brandimarte G, Daffinà R. Long-term treatment with mesalazine and rifaximin versus rifaximin alone for patients with recurrent attacks of acute diverticulitis of colon. Dig Liver Dis 2002;34: Tursi A. New physiopathological and therapeutic approaches to diverticular disease of the colon. Expert Opin Pharmacother 2007;8: Tursi A, Brandimarte G, Giorgetti GM, Elisei W, Aiello F. Balsalazide and/or high-potency probiotic mixture (VSL#3) in maintaining remission after attack of acute, uncomplicated diverticulitis of the colon. Int J Colorectal Dis 2007; 22:

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김범수 Analysis of Outcomes after Resection of Sarcomatous Hepatocellular Carcinoma Purpose: Sarcomatous hepatocellular carcinoma (HCC) is rare. Therefore, the clinicopathologic characteristics and prognosis