06-강의혁

대한응급의학회지제 26 권제 1 호 Volume 26, Number 1, February, 2015 원 저 Surgical 응급실에급성복통으로방문한가임기여성의골반염과급성충수돌기염의감별을위한점수체계의외부적타당화연구 서울특별시보라매병원응급의학과 강의혁 이휘재 신종환 홍기정 정진희 External Validation of Scoring Systems for Pelvic Inflammatory Disease and Acute Appendicitis for Acute Abdominal Pain of Reproductive-aged Women in Emergency Department receiver operating characteristic curves were 0,832 and 0,950?for diagnosis of PID with PID risk score and acute appendicitis with appendicitis risk score, respectively. Conclusion: These scoring systems have appropriate diagnostic power for diagnosis of PID and acute appendicitis. Euihyuk Kang, M.D., Hui Jai Lee, M.D., Jong Hwan Shin, M.D., Kijeong Hong, M.D., Jin Hee Jung, M.D. Purpose: Differential diagnosis of acute abdominal pain of the childbearing age woman is a difficult challenge to the emergency physician. Clinical scoring systems for pelvic inflammatory disease (PID) and acute appendicitis have already been introduced. We want to validate these scoring systems externally. Methods: This study was conducted at a single urban teaching hospital emergency department from May 2011 to September 2013. Retrospective analysis of a prospectively collected registry for reproductive-aged women was performed. Results: A total of 1432 patients were registered. Among them, 322 patients diagnosed as PID (177 patients) or acute appendicitis (145 patients) were finally analyzed in this study. Among the PID and acute appendicitis scored, lower and higher cut-off points were 3 and 8 for PID risk score, and 6 and 10 for appendicitis risk score. PID risk score of PID patients was 7.0 (±1.9), acute appendicitis patients was 4.3 (±2.1), and other patients was 4.0 (±2.2) (p<0.001). Appendicitis risk score of PID patients was 5.7 (±1.9), acute appendicitis patients was 9.0 (±2.1), and other patients was 5 (±1.6) (p<0.001). The areas under the 책임저자 : 이휘재서울특별시동작구보라매로 5길 20 보라매병원응급의학과 Tel: 02) 870-2664, Fax: 02) 831-0207 E-mail: emdrlee@snu.ac.kr 접수일 : 2014년 8월 7일, 1차교정일 : 2014년 8월 12일게재승인일 : 2014년 10월 13일 38 Key Words: Abdominal pain, Women, Pelvic inflammatory disease, Appendicitis Department of Emergency Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea Article Summary What is already known in the previous study Diagnostic scoring system for predicting the risk for childbearing age women of PID and acute appendicitis differential diagnosis who visit the emergency room have been proposed. What is new in the current study These diagnostic scoring systems are validated externally and have appropriate diagnostic power for differential diagnosis of PID and acute appendicitis of childbearing age women. 서 복통은손상을제외할때흉통과함께응급방문의가장흔한원인중하나이다. 미국의통계에의하면연간 11% 의환자가복통을주소로응급실로방문하며, 이빈도는점차증가하고있다 1). 이처럼응급실방문의주요증상인복통의진단과치료는응급실진료에서중요한부분을차지하고있지만그진단은간단하지않다 2). 복강내의여러장기가다양한원인으로독립적혹은상호영향을미치며복통을유발하게되며복강내장기이외에도복벽이나피부, 다른신체부위의연관통, 심지어는전신질환의한증상으 론

강의혁외 : 응급실에급성복통으로방문한가임기여성의골반염과급성충수돌기염의감별을위한점수체계의외부적타당화연구 / 39 로복통이생길수있다. 복통의원인을감별하고적절한치료를시행하는것은쉬운일이아니며더욱이가임기여성의경우복통의원인이다양한산부인과적질환에의한경우도있어임상적접근이더욱어렵고복잡하다 3-7). 특히하복부의압통이심한골반염과급성충수돌기염의경우신체검진, 혈액검사, 단순복부촬영만으로는그감별이쉽지않아복부초음파, 복부전산화영상촬영및산부인과적검진등의추가적인검사들을시행하게되며이는응급실체류시간의증가및의료비용의증가를유발하며방사선노출량과빈도증가에의한위험을증가시키게된다 3). 몇몇연구자들이응급실에내원한가임기여성의감별진단을위한연구를시행하였으며 3-7), Park 등 8) 은가임기여성의골반염과급성충수돌기염의감별진단을위하여응급실에내원한환자의병력, 임상증상, 혈액검사소견을이용하여골반염과급성충수돌기염의위험도를예측하는진단점수체계를제안한바있으나아직이의유용성에대한검증은이루어져있지않은상황이다. 따라서본연구에서는기존에 Park 등에의해제시된진단점수체계를다른환자군에적용하여외부적타당도여부를평가하여그활용성여부를평가하고자하였다. 대상과방법본연구는연간약 54,000명의환자가방문하는지역응급의료센터인서울의한대학병원응급의료센터에서 2011년 5월부터 2013년 9월까지전향적으로수집된레지스트리를이용하여연구를시행하였다. 가임기연령의여성환자가복통을주소로연구기관의응급센터에내원하는경우환자의동의를구한이후안드로이드태블릿을이용하여환자가직접적으로임상정보를입력하도록하였다 7). 상기레지스트리의내용은기존의다른연구에언급되어있으며여기서간단히기술하면나이, 결혼여부등의기본정보, 산과력, 이전골반염이환력등의산부인과적과거력, 자궁내장치 (intrauterine device, IUD) 유무, 1개월이내성관계여부, 생리통과생리시진통제사용유무, 소화기계증상, 요로계증상등의정보를수집하였다 8). 응급실진료가종료된이후에본연구진들이추가적으로후향적의무기록리뷰를통하여 37.8도이상의발열유무, 복부압통과반발통, 늑척추간압통등의각종신체검진소견, 백혈구, C반응성단백질, 소변검사등의각종검사결과, 외래기록과병리검사결과를토대로한최종진단등의자료를수집하였다. 최종진단은응급의학과전문의가의무기록을검토하여확인하였다. 골반염은산부인과의사가 2010년에개정된 CDC 2010 STD Treatment Guidelines-Pelvic inflammatory disease 에따라서진단을내린이후의무기록상의최종퇴원진단명 을근거로레지스트리에입력하였다 8). 급성충수돌기염의진단은복부초음파혹은복부전산화영상촬영에서급성충수돌기염의소견을보이며이에대하여충수돌기절제술을시행받은이후의무기록상병리학적으로확진된경우로하였다. 이미폐경이되어임신가능성이없거나, 기존에이미알고있는질환과관련된복통으로판단되는경우, 기존에복부에수술력이있는환자는연구대상에서제외하였다. 골반염및급성충수돌기염의점수체계는 Park 등이지역응급의료센터를방문한가임기여성중골반염과급성충수돌기염으로진단받은환자를대상으로임상증상및혈액검사를다변량분석을통하여제시한점수체계를사용하였다 (Table 2) 8). PID risk score는 11점의점수체계로구성되어있으며 8점이상은고위험군으로분류하였으며 7~3점은중등도, 2점이하는저위험군으로분루하였다. Appendicitis risk score는총 14점의점수체계로 10점이상은고위험군, 9~6점은중등도, 5점이하는저위험군으로분류하였다. 본연구는 SPSS version 20 (SPSS Inc., Chicago, IL), R 3.0.3 (R Foundation for Statistical Computing, Vienna, Austria) 을이용하여통계분석을시행하였다. 통계적인방법으로는연속성변수에대하여는정규분포를따르는경우에는티검증 (t-test) 및분산분석 (analysis of variance, ANOVA) 를사용하였으며정규분포를따르지않는경우에는만-위트니검정 (Mann-Whitney test) 및크러스칼-왈리스검정 (Kruskal-Wallis test) 을사용하였다. 범주형자료에대하여는카이제곱검정 (chi-square test) 을사용하였으며필요에따라서피셔의정확검정 (Fisher s exact test) 을사용하였다. 통계적으로유의한차이가있다고판단하는기준은 p<0.05인경우로하였다. 결과연구기간동안 1558명의가임기여성복통환자가설문을작성하였으며이중 127명이추적관찰이되지않거나진단이불명확하여최종적으로 1432명의환자가연구에등록되었다. 이중 177명이골반염혹은골반염관련질환 (Fitz-Hugh-Curtis 증후군등 ) 으로진단되었으며, 145 명의급성충수돌기염으로진단되었다. 골반염과급성충수돌기염및그외다른질환으로진단된환자들의기본자료들에대하여는 Table 1에표시하였다. 평균연령과결혼유무, 생리통유무는각군간에통계적으로유의한차이를보이지않았다. 하지만생리시진통제사용의빈도는급성충수돌기염이있었던환자에서낮게나타났다. 골반염환자에서는이전골반염병력과요로계증상을가진경우가많았으며자궁내장치의사용빈도가높고소화기계증상이적게나타났다. 급성충수돌기염으로진단받은환자에서는

40 / 대한응급의학회지 : 제 26 권제 1 호 2015 반발통, 소화기계증상이많고백혈구수치가상승한경우가많았으며 1개월이내성관계비율이적고발열이있었 던빈도가적었다 (Table 1). PID risk score는골반염환자에서는 7.0 (±1.9), 급성 Table 1. The clinical characteristics of PID and acute appendicitis. PID* Acute appendicitis Others (n=177) (n=145) (n=1109) p value Age (mean±sd ) 28.6±7.6 30.1±8.9 28.9±7.9 <0.185 Married (n, %) 056 (31.6%) 052 (35.9%) 319 (28.8%) <0.134 History of PID (n, %) 091 (51.4%) 049 (33.8%) 357 (32.2%) <0.001 Dysmenorrhea (n, %) 145 (81.9%) 114 (78.6%) 926 (83.5%) <0.324 Pain killer use during mensturation (n, %) 090 (50.8%) 055 (37.9%) 532 (48.0%) <0.045 Recent Coitus (within 4 weeks) (n, %) 128 (72.3%) 056 (38.6%) 539 (74.6%) <0.001 IUD in situ (n, %) 014 (07.9%) 010 (06.9%) 031 (02.8%) <0.001 fever ( 37.8) (n, %) 007 (06.7%) 003 (03.6%) 049 (07.2%) <0.001 Rebound tenderness (n, %) 044 (24.9%) 063 (43.4%) 150 (13.5%) <0.001 GI symptom (n, %) 083 (46.9%) 091 (62.8%) 765 (69.0%) <0.001 Urinary symptom (n, %) 045 (25.4%) 015 (10.3%) 188 (17.0%) <0.033 Leukocytosis (n, %) 079 (44.6%) 110 (75.9%) 377 (34.0%) <0.001 PID risk score (mean±sd) 07.0±1.9 04.3±2.1 04.0±2.2 <0.001 Appendicitis risk score (mean±sd) 05.7±1.9 09.0±2.1 05.3±1.6 <0.001 PID risk (n, %) Low (score 0~2) 004 (02.3%) 030 (20.7%) 302 (27.2%) <0.001 Intermediate (score 3~7) 094 (53.1%) 101 (69.7%) 720 (64.9%) <0.001 High (score 8~11) 079 (44.6%) 014 (09.7%) 087 (07.8%) <0.001 Appencitis risk (n, %) Low (score 1~5) 099 (55.9%) 008 (05.5%) 717 (64.2%) <0.001 Intermediate (score 6~9) 070 (39.5%) 80 (55.2%) 370 (33.4%) <0.001 High (score 10~14) 008 (04.5%) 57 (39.3%) 027 (02.4%) <0.001 SD: standard deviation IUD: intrauterine device GI: gastrointestinal Fig. 1. Distribution map between PID risk score and appendicitis risk score according to the diagnosis of PID and acute appendicitis.

강의혁외 : 응급실에급성복통으로방문한가임기여성의골반염과급성충수돌기염의감별을위한점수체계의외부적타당화연구 / 41 충수돌기염환자에서는 4.3 (±2.1), 기타복통환자의경우 4.0 (±2.2) 으로통계적으로유의하게골반염환자에서높게측정되었다 (p<0.001). Appendicitis risk score는골반염환자에서는 5.7 (±1.9), 급성충수돌기염환자에서는 9.0 (±2.1), 기타복통환자에서는 5.0 (±1.6) 으로역시통계적으로유의하게급성충수돌기염환자에서증가되어있었다 (p<0.001) (Table 1, Fig. 1). 전체환자중골반염진단에대하여 PID risk score를이용하여분할점 (receive operator characteristics (ROC) curve) 를구해보았을때곡선하영역 (area under curve, AUC) 은 0.832로측정되었다. 급성충수돌기염진단에대하여 Appendicitis risk score를이용하여 ROC curve를확인해보았을때 AUC는 0.905로측정되었다 (Fig. 2, 3). 고찰가임기여성의복통감별은쉽지않은문제이며, 특히수술이필요한급성충수돌기염과골반염의감별은임상적으로어려운문제이다. 따라서이전연구에서가임기여성에서의골반염과급성충수돌기염을감별하기위한몇몇시도가이루어져왔다 3-5). Webster 등은가임기여성에대한후향적연구에서급성충수돌기염에조금더유효한임상적예측인자로식욕부진과마지막생리시작일로부터 14일이후에발생한통증을들었고, 골반염에유효한임상적예측인자로질분비물의병력, 비뇨기계증상, 이전골반염의병력, 우측하복 Table 2. Scoring system of PID* and acute appendicitis. Predictor variables of PID* Predictor variables of acute appendicitis Pain onset 2 days 02 Pain onset 2 days 02 Fever (>37.8) 01 No fever 02 Abortion history (+) 01 No abortion history 01 Vaginal secretions (+) 01 No vaginal secretions 01 Taking a painkiller for dysmenorrhea 01 No medication for dysmenorrhea 01 Sexual contact within one month 01 No sexual contact within one month 02 Diffuse lower or bilateral tenderness 01 Localized RLQ tenderness 02 Migration of pain 01 No migrating pain 01 GI Symptoms (+) 01 No GI Symptoms 01 WBC count <10000/μL 01 WBC count >10000/μL 01 Total score of PID 11 Total score of acute appendicitis 14 GI: gastrointestinal WBC: white blood cell Fig. 2. ROC curve of PID risk score. Fig. 3. ROC curve of appendicitis risk score.

42 / 대한응급의학회지 : 제 26 권제 1 호 2015 부압통, 경부자극시의압통, 검진시에질분비물이존재하는경우와소변검사상양성소견으로소개하였다 4). Morishita 등 3) 은골반염과급성충수돌기염으로진단된가임기여성을대상으로후향적분석을시행하여복통의이동여부, 복부압통의유무, 구역구토의유무를이용하여골반염과급성충수돌기염을구분하는간단한알고리즘을제시한바있다. 하지만상기연구는골반염과급성충수돌기염만을구분하여분석한결과로복통의이동여부, 압통여부, 구역구토의여부만으로급성복통을가지는환자에서임상에적용하는데에는어려움이있으며골반염과관련이있을것으로추정되는산부인과적병력이나증상에대한고려가제외되어있어그한계가있다 4,11,12). Park 등 8) 은국내에서전향적으로수집된자료들을이용하여후향적으로다변량분석을시행하였으며부인과적증상을포함한 10가지의임상증상및검사결과를통하여골반염과충수돌기염을진단하기위한자세한점수체계를제시하였고, 당시연구집단에대해 ROC curve 를그렸을때, PID risk score는 0.896, Appendicitis risk score 는 0.910의높은 AUC 값을보여준바가있다. 본연구에서는상기점수체계를이용하여다른시기에전향적으로수집한자료를이용하여점수를계산하여위험도분류를시행하였으며실제로최종진단과비교하여점수체계의적절성여부를평가해보는외적타당도연구를시행하였다. 각각의점수체계에대하여 ROC curve를그려보았을때 PID risk score의 AUC는 0.832, appendicitis risk score는 0.905로측정되어높은진단적가치를보여주었다 (Fig. 2, 3). Park 등 8) 에의하여제시된점수에따른위험도분류를적 용하였을때, 골반염환자의경우 PID risk score가저위험으로측정된경우는 1.7% 였으며, Appendicitis risk score 가고위험으로측정된경우는 4.6% 였다. 골반염으로진단받았으며, PID risk score가저위험이며 Appendicitis risk score가고위험으로측정된경우는 0.6% 였다. 급성충수돌기염으로진단된환자에서 PID risk score가고위험으로측정된경우는 9.7%, Appendicitis risk score가저위험으로측정된경우는 5.6% 였다. PID risk score가고위험이면서 Appendicitis risk score가저위험인경우는없었다. 골반염및급성충수돌기염환자의각점수별분포를살펴보면골반염환자의경우 PID risk score가높게측정되며급성충수돌기염환자의경우 Appendicitis risk score가높게측정됨을확인할수있었다 (Fig. 1, Table 3, 4). 상기결과를종합할때 Park 등에의하여제기된골반염및급성충수돌기염의점수체계및이를이용한위험분류체계가응급실초기검사이후골반염과급성충수돌기염의감별을위한접근에도움이될것으로판단된다. 특히나 Morishita 등에의하여제시된점수체계가골반염과급성충수돌기염환자만을대상으로하였으며, 산부인과적인병력이나증상에대한고려가되어있지않으며타당도가검증되지않았음을감안할때본점수체계가비교우위에있다고하겠다. 점수확인을위한항목은 10가지로적은수는아니지만증상의발현시기, 발열여부, 복통의증상및부위, 간단히확인할수있는산부인과적인병력, 백혈구수치로이루어져응급실에서간단하게확인할수있을것으로기대된다. 이러한점수체계를골반염위험도가높게측정되는환자들에서는질경유초음파검사를포함한부인과적검진을 Table 3. Risk stratification of PID & appendicitis risk for PID patient. Appendicitis risk Low intermediate High n (%) n (%) n (%) PID* risk Low 02 (01.1%) 01 (00.6%) 1 (0.6%) Intermediate 46 (26.0%) 41 (23.2%) 7 (4.0%) High 51 (28.8%) 28 (15.8%) 0 (0.0%) Table 4. Risk stratification of PID & appendicitis risk for appendicitis patient. Appendicitis risk Low Intermediate High n (%) n (%) n (%) PID* risk Low 3 (2.1%) 16 (11.1%) 10 (06.9%) Intermediate 5 (3.5%) 54 (37.5%) 42 (29.2%) High 0 (0%)0. 10 (06.9%) 04 (02.8%)

강의혁외 : 응급실에급성복통으로방문한가임기여성의골반염과급성충수돌기염의감별을위한점수체계의외부적타당화연구 / 43 먼저시행하는것을고려해야하겠고, 반대로급성충수돌기염위험도가높게측정되는환자들에서는복부전산화영상촬영이나복부초음파를통한진단을우선적으로고려할수있겠다. 본연구의제한점은다음과같다. 단일기관에서이루어진연구로이미진단이이루어진환자들을대상으로후향적으로점수체계를적용하여분석하여이를일반화하는데제한이있다. 이를극복하기위하여는본진단시스템을이용한다기관전향적연구가필요할것으로생각된다. 추가적으로빠른수술적치료를요하는다른산부인과질환들에대한분석이이루어지지못하였다는것도본연구의한계점이다. 하지만급성충수돌기염과골반염이그빈도가높고, 두진단을구분하기쉽지않아그감별이임상의들의중요한관심의대상임을고려할때본연구결과가의의가있다고하겠다 3,4). 다른산부인과적응급질환에대한감별을위하여추가적인연구가필요할것으로생각된다. 결 기존에제시된골반염및급성충수돌기염의진단을위한점수체계가급성복통으로응급실에방문한가임기여성의골반염과급성충수돌기염의진단에효과적으로적용될수있음을확인할수있었으며상기점수체계가복통으로응급실을방문한가임기여성환자의진료프로세스를개선하는데도움을줄수있을것으로기대된다. 론 참고문헌 01. Bhuiya FA, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS Data Brief. 2010;43:1-8. 02. Brown HF, Kelso L. Abdominal pain: an approach to a challenging diagnosis. AACN Adv Crit Care. 2014;25: 266-78. 03. Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. Clinical prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women ofchildbearing age. Am J Emerg Med. 2007;25:152-7. 04. Webster DP, Schneider CN, Cheche S, Daar AA, Miller G. Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age. Am J Emerg Med. 1993;11:569-72. 05. Dahlberg DL, Lee C, Fenlon T, Willoughby D. Differential diagnosis of abdominal pain in women of childbearing age. Appendicitis or pelvic inflammatory disease? Adv Nurse Pract. 2004;12:40-5. 06. Bongard F, Landers DV, Lewis F. Differential diagnosis of appendicitis and pelvic inflammatory disease A prospective analysis. Am J Surg. 1985;150:90-6. 07. Najem AZ, Barillo DJ, Spillert CR, Kerr JC, Lazaro EJ. Appendicitis versus pelvic inflammatory disease: A diagnostic dilemma. Am Surg. 1985;51:217-22. 08. Park JH, Shin JH, Song KJ, Kim JJ. A Model for Prediction of Pelvic Inflammatory Disease and Acute Appendicitis in Childbearing-aged Women who Visit the Emergency Department with Abdominal Pain. J Kor Soc Emerg Med. 2012;23:649-56. 09. Park YJ, Shin JH, Lee HJ, Hong KJ, Jung JH. The Usefulness of Tablet Computer for Self-surveys of Childbearing Aged Women Who Visit the Emergency Department with Abdominal Pain. J Kor Soc Emerg Med. 2014;25:103-8. 10. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010;59:1-110. 11. Paulson EK, Kalady MF, Pappas TN. Suspected Appendicitis. N Engl J Med. 2003;348:236-42. 12. Drake FT, Flum DR. Improvement in the diagnosis of appendicitis. Adv Surg. 2013;47:299-328.