대한응급의학회지제 19 권제 1 호 Volume 19, Number 1, February, 2008 증 례 상장간정맥과간문맥혈전을동반한급성충수염 1 례 울산대학교병원응급의학과 김선휴 홍은석 김우연 안 @ 력 홍정석 cute ppendicitis with Superior Mesenteric Vein Thrombosis and Portal Vein Thrombosis Sun Hyu Kim, M.D., Eun Seok Hong, M.D., Woo Youn Kim. M.D., Ryeok hn, M.D., Jung Seok Hong, M.D. Superior mesenteric vein thrombosis and portal vein thrombosis are rare conditions that are difficult to diagnose due to vague symptoms, but they are usually fatal when they occur. ppendicitis is the one of the most common causes of superior mesenteric vein thrombosis, via venous drainage from the appendiceal area into the portal system. We report a case of superior mesenteric vein thrombosis and portal vein thrombosis secondary to appendicitis presenting with diarrhea, low abdominal pain, and jaundice. The patient was treated with antibiotics and anticoagulants, without fatal complications, but developed a chronic sequela of portal vein thrombosis. It is important to consider thrombosis of the superior mesenteric vein and portal vein in patients who have intra-abdominal infection with specific or non-specific symptoms. Key Words: Thrombosis, Superior mesenteric vein, Portal vein, ppendicitis Department of Emergency Medicine University of Ulsan College of Medicine, Ulsan University Hospital 책임저자 : 홍은석울산광역시동구전하동울산대학교울산대학교병원응급의학과 Tel: 052) 250-7111, Fax: 052) 250-8071 E-mail: cocahite@kornet.net 접수일 : 2007년 12월 5일, 1차교정일 : 2008년 1월 9일게재승인일 : 2008년 1월 31일 * 2007 년추계응급의학학술대회포스터전시함. 142 서론상장간정맥혈전은드물지만, 정맥염과문맥계통으로의정맥염등을일으키고, 진단이늦어지면장허혈, 패혈증등의치명적결과를일으킬수있다 1). 상장간정맥및간문맥혈전의진단은증상의발열, 복통, 식욕부진, 오심, 황달, 설사등에이르는비특이적인증상과징후로인해초기진단이어렵다 2,3). 상장간정맥혈전은복부초음파나복부전산화단층촬영등의영상검사에의해주로진단되고있으며, 치료는대개적절한항생제와항응고제투여로시작되고, 수술적처치가필요한경우도있다 4,5). 상장간정맥혈전의주요원인으로는복강내또는골반강내감염이보고되고있고, 특히충수돌기나회장의정맥계는직접문맥계로연결이되기때문에충수돌기염이정맥혈전과, 정맥염의해부학적주요원인으로알려져있다 1,6,7). 저자들은최근우하복부통증의원인을진단하는과정에서시행한복부전산화단층촬영에서, 충수돌기염과동반된상장간정맥혈전을발견하였고, 이차적으로나타난간문맥혈전을경험하였기에보고하는바이다. 증례특이과거력없던 42세남환은내원 2일전부터발생한황달과우하복통을주소로내원하였다. 환자는내원 5일전회를취식한이후에발생한설사로퀴놀론계항생제복용하였으나설사가지속되었고, 내원 2일전부터황달이생기면서심해지는양상과, 우하복통을심하게호소하였다. 내원시신체검진소견에서혈압 120/80 mmhg, 맥박수분당 76회, 호흡수분당 20회, 체온 36.2 C 이었으며, 공막의황달소견을보였다. 장음은정상이었으나상복부와우하복부의압통소견을보였다. 초기말초혈액검사에서백혈구 7,460/mm 3, 혈색소 15.1 g/dl, 혈소판 58,000/ mm 3 이었고, 혈청생화학검사에서 ST/LT 68/65 IU/L, 총빌리루빈 / 직접빌리루빈 8.8/6.4 mg/dl, Glucose 127 mg/dl, mylase 69 IU/L, Lipase 117 IU/L이었다. 혈청전해질검사는 Na + /K + /Cl - 이각각 138/3.4/99 mmol/l
김선휴외 : 상장간정맥과간문맥혈전을동반한급성충수염 1 례 / 143 로정상소견이었고, C-반응성단백 31.9 mg/dl이었다. 소변검사에서 ilirubin 3+, RC 3-5/HPF의소견을보였다. 흉부및복부단순방사선촬영에서특이소견은보이지않았다. 내원후시행한복부전산화단층촬영에서두꺼워진충수돌기주위로염증침윤소견이관찰되었으나, 천공소견은없었고 (Fig. 1), 충수돌기에서연결되는장간정맥에서부 터상장간정맥에이르는혈전소견과상장간정맥벽이두꺼워진정맥염이동반된소견을보였다 (Fig. 1). 간실질과담도계, 췌장에는특이소견없었다. 환자는급성충수돌기염과이차적으로합병된상장간정맥혈전정맥염으로진단되어충수절제술을시행받고, 항생제를투여하였다. 입원치료중황달은호전되었다. 혈전에대해서헤파린 36,000 단위를 500 ml 생리식염수에섞어시간당 1,800 Fig. 1. Initial abdominal computed tomography scan of 42-year-old man with diarrhea and right lower quadrant pain shows () wall thickening of appendix, periappendiceal infiltration with no evidence of perforation and () thrombosis in superior mesenteric vein. Fig. 2. Follow-up computed tomography scan of the same patient on post-appendectomy 20th day shows () new formation of thrombosis in left intrahepatic portal vein and () improvement of superior mensenteric vein thrombosis.
144 / 대한응급의학회지 : 제 19 권제 1 호 2008 단위씩수술직후부터투여하였고, 수술후 7일째부터감량투여하면서 12일째투여를중단하였다. 와파린은수술 5일째부터초기용량 5 mg으로헤파린과병용투여하였으며, 수술 13일째부터단독투여하였다. 입원중시행한혈액및대변균배양검사에서균은검출되지않았다. 수술후 20일째시행한복부전산화단층촬영에서상장간정맥혈전의호전소견보였으나 (Fig. 2), 좌간내문맥혈전이새롭게관찰되었다 (Fig. 2). 환자가초기에보였던황달소견은문맥염의초기진행에따른합병증으로진단되어졌으나, 담도에대한추가검사를시행하지않아명확한원인규명은하지못했다. 환자는와파린 2 mg의유지용량으로경구처방후수술후 24일째퇴원하였고, 수술 4개월후에추적검사한복부전산화단층촬영에서상장간정맥혈전은소실되었으나 (Fig. 3), 좌간내문맥혈전에의한만성후유증의소견으로볼수있는좌측간실질의수축소견을보였다 (Fig. 3). 고찰상장간정맥혈전은상행성으로문맥의혈전을동반할가능성이높고, 상행성패혈성정맥염을일으킬가능성이높은치명적인복강내감염의합병증형태로발생할수있다. Plemmons 등 1) 은다양한원인의혈전정맥염에서그치명률을 11% 에서 32% 까지보고한바있다. 상장간정맥혈전자체보다는이차적인감염으로흔히병발하는패혈성합병 증으로의진행이더욱위험한결과를초래한다. 상장간정맥과간문맥의혈전정맥염을일으키는주요원인으로는충수돌기염이게실염다음의원인으로보고된바있으며, 그외에도췌장염, 담낭염, 골반감염등이알려져있다 1). 문맥염을일으키는흔한원인균으로는 acteroides Fragilis, Eschericia Coli, Proteus Mirabilis, Klebsiella Pneumoniae, Enterobacter Species 등이있고 8), 음식과연관해서는회장과대장에염증을일으키는 Yersinia, Salmonella, Campylobacter 등이원인균주로알려져있다 9-11). 본증례에서는환자병력에서회를먹은이후로설사가지속되었고복통이발생하여혈액및대변균배양검사를시행하였으나균은검출되지않았고, 수술후충수돌기에대한조직배양검사는시행하지않아위에서언급한원인균과의연관성에대해서는밝혀내지못했다. 내원시환자에게서보였던황달은주로직접빌리루빈이상승된폐쇄성황달소견을보였으나, 본증례에서는초기전산화단층촬영에서담도폐쇄를시사할만한소견이없었고, 수술및입원과정에서황달의호전소견으로담도에대한추가적인검사는시행하지않아, 황달에대한정확한원인규명은하지못했다. 상장간정맥혈전및간문맥의혈전정맥염에서복강내감염과동반해서나타날경우, 감염의발생시기와혈전의발생까지의소요시간에관해밝혀진바는없으며, 혈전정맥염의경우증상의비특이성으로인해초기진단이쉽지않다. 혈전정맥염과관련해전형적인증상은없으며, 발열, 우상복부의복통, 오심, 구토, 식욕부진, 체중감소, 황 Fig. 3. Follow-up computed tomography scan of the same patient on post-appendectomy 4th month shows () retracted left intrahepatic portal vein, moderate shrinkage of left intrahepatic parenchyme due to chronic seqeula of left intrahepatic portal vein thrombosis and () normal patency of superior mensenteric vein.
김선휴외 : 상장간정맥과간문맥혈전을동반한급성충수염 1 례 / 145 달, 설사등의다양한형태의임상증상으로나타난다. 동맥내혈전에비해정맥내혈전의경우증상의시작이급성보다는아급성으로잠행성진행의양상으로나타나는것도진단적어려움의하나이다. 본증례에서도환자는황달, 복통등의증상을호소하였으나, 이로인해혈전정맥염을의심하기는쉽지않았다. 장간정맥혈전의경우단순복부 X-선촬영에서소장의단일 loop 내의공기음영으로나타나는 rigid loop sign이나, 장벽의점막하출혈이나부종시보일수있는 thumb printing sign 등의소견시의심할수있으나전형적인소견은아니다 12-14). 최근들어영상진단기법의발전으로복부초음파와복부전산화단층촬영으로혈전의진단이가능해졌으며, 도플러초음파나자기공명영상도진단에유용하다 4,15). 복부초음파의경우정맥내혈전을볼수있으나장내공기로인한진단적어려움및시술자의능력에따라진단율이틀려질수있다. 전산화단층촬영의경우정맥내혈전은물론소장및고형장기의허혈성변화까지알수있어복부초음파보다는진단적가치가더높다. 혈전정맥염이의심되거나, 진단되는경우항생제의사용이중요하며, 특히문맥염이발생한경우간내농양의발생가능성에대해고려해야하고, 추적관찰및농양발생시 6 주이상의항생제치료및추가적인시술에대해서도고려를해야한다 16). 혈전정맥염에서항응고제는혈류의유지및장허혈의예방차원에서사용되기는하나, 그효과에대해서는확실히밝혀진바가없다 17,18). 본증례에서는항생제를 2주간사용하였고, 헤파린과와파린을투여하여상장간막정맥의혈전의소실소견은보였으나, 좌측간실질의수축소견으로나타난좌간내문맥내혈전의만성적경과를보였다. 상장간정맥이나간문맥의혈전은매우드물게나타나지만, 충수의정맥계가상장간맥과간문맥으로연결되기때문에충수염시에염증이진행하면서혈전을동반한정맥염을일으킬수있다. 전형적인증상이없는혈전정맥염의경우진단이지연될수있으며, 적절한항생제투여를통한치료가동반되지않으면패혈증등의치명적인상황으로이어질수있어, 충수염의경우정맥혈전증의가능성에대해서도반드시고려해야한다. 참고문헌 01. Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995;21:1114-20. 02. Singh P, Yadav N, Visvalingam V, Indaram, ank S. Pylephlebitis-diagnosis and management. m J Gastroenterol 2001;96:1312-3. 03. bdu R, Zakhour J, Dallis DJ. Mesenteric venous thrombosis-1911 to 1984. Surgery 1987;101:383-8. 04. althazar EJ, Gollapudi P. Septic thrombophlebitis of the mesenteric and portal veins: CT imaging. J Comput ssist Tomogr 2000;24:755-60. 05. Farin P, Paajanen H, Miettinen P. Intraoperative US diagnosis of pylephlebitis (portal vein thrombosis) as a complication of appendicitis: a case report. bdom Imaging 1997;22:401-3. 06. Kasper DL, Sahani D, Misdraji J. Case records of the Massachusetts General Hospital. Case 25-2005. 40- year-old man with prolonged fever and weight loss. N Engl J Med 2005;353:713-22. 07. Nishimori H, Ezoe E, Ura H, Imaizumi H, Meguro M, Furuhata T, et al. Septic thrombophlebitis of the portal and superior mesenteric veins as a complication of appendicitis: report of a case. Surg Today 2004;34:173-6. 08. Lim HE, Cheong HJ, Woo HJ, Kim WJ, Kim MJ, Lee CH, et al. Pylephlebitis associated with appendicitis. Korean J Intern Med 1999;14:73-6. 09. laser MJ. Infections due to Campylobacter and related species. In: Kasper DL, Fauci S, Longo DL, raunwald E, Hauser SL, Jameson LJ, editors. Harrison s principles of internal medicine. 16th ed. New York: McGraw-Hill; 2005. p.907-9. 10. Dennis DT, Campbell GL. Plague and other Yersinia infections. In: Kasper DL, Fauci S, Longo DL, raunwald E, Hauser SL, Jameson LJ, editors. Harrison s principles of internal medicine. 16th ed. New York: McGraw-Hill; 2005. p.921-9. 11. Lesser CF, Miller SI. Salmonellosis. In: Kasper DL, Fauci S, Longo DL, raunwald E, Hauser SL, Jameson LJ, editors. Harrison s principles of internal medicine. 16th ed. New York: McGraw-Hill; 2005. p.897-902. 12. Nelson SW, Eggleston W. Findings on plain roentgenograms of abdomen associated with mesenteric vascular occlusion with possible new sign of mesenteric venous thrombosis. m J Roentgenol Radium Ther Nucl Med 1960;83:886-94. 13. Schwartz S, oley S, Lash J, Sternhill V. Roentgenologic aspects of reversible vascular occlusion of colon and its relationship to ulcerative colitis. Radiology 1963;80:625-35. 14. oley SJ, Schwartz S, Lash J, Sternhill V. Reversible vascular occlusion of colon. Surg Gynecol Obstet 1963;116: 53-60. 15. Condat, Pessione F, Helene Denninger M, Hillaire S, Valla D. Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy. Hepatology 2000;32:466-70. 16. Vanamo K, Kiekara O. Pylephlebitis after appendicitis in a
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