DOI: 10.4046/trd.2010.69.3.196 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2010;69:196-200 CopyrightC2010. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved. 장결핵으로인한성인장중첩증 1 예 Case Report 가톨릭대학교의과대학 1 내과학교실, 2 외과학교실강혜선 1, 강지영 1, 강현희 1, 김현진 1, 임근준 1, 김승경 1, 이상학 1, 문화식 1, 박종경 2 A Case of Adult Intussusception Induced by Intestinal Tuberculosis Hye Sun Kang, M.D. 1, Ji Young Kang, M.D. 1, Hyeon Hui Kang, M.D. 1, Hyun Jin Kim, M.D. 1, Keun Joon Lim, M.D. 1, Seung Kyoung Kim, M.D. 1, Sang Haak Lee, M.D. 1, Hwa Sik Moon, M.D. 1, Jong Kyung Park, M.D. 2 Departments of 1 Internal Medicine, 2 Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea Intussusception primarily occurs in children and is uncommon in adults. Moreover, intussusception caused by intestinal tuberculosis is very rare. We report a case of intussusception induced by intestinal tuberculosis. A 53-year-old man presented to our hospital with complaints of cough and sputum for 2 weeks. We started anti-tuberculosis medication as the patient s sputum acid-fast staining was positive. After 4 days of treatment, the patient developed abdominal cramping pain. Imaging studies showed ileo-ileal type intussusception. The patient underwent segmental resection of the small bowel and intestinal tuberculosis was confirmed on histological examination. He recovered after surgery and was discharged on anti-tuberculosis medication. Key Words: Intussusception; Adult; Tuberculosis, Gastrointestinal 서 론 증 례 장중첩증은상부장이하부장으로망원경같이말려들어가는질환으로소아에서는비교적흔한질환이나성인에서의발생은전체장중첩증의 5% 만을차지할정도로흔하지않다. 소아에서는대부분특발성으로발생하지만성인에서는 90% 정도에서 2차적인원인에의해발생하는것으로알려져있다. 원인질환으로는악성종양, 폴립, 멕켈곁주머니 (Meckel's diverticulum), 협착, 양성종양등이알려져있으며장결핵에의한경우는매우드물다 1,2. 저자등은활동성폐결핵으로항결핵제치료중인성인환자에서장결핵에의한장중첩증이발생한증례를경험하였기에이를문헌고찰과함께보고하는바이다. Address for correspondence: Sang Haak Lee, M.D. Department of Internal Medicine, St. Paul's Hospital, The Catholic University of Korea College of Medicine, 620-56, Jeonnong 1-dong, Dongdaemoon-gu, Seoul 130-709, Korea Phone: 82-2-958-2445, Fax: 82-2-968-7250 E-mail: mdlee@catholic.ac.kr Received: Feb. 28, 2010 Accepted: Apr. 5, 2010 환자 : 53세, 남자주소 : 기침, 가래현병력 : 평소특이병력없이지내던자로, 2주전시작된기침, 가래로본원외래내원하여시행한흉부 X-ray 검사에서활동성폐결핵이의심되는소견보여입원하였다. 과거력및가족력 : 10갑년의흡연자이학적소견 : 내원시활력징후는혈압 110/70 mm Hg, 체온 37.9 o C, 맥박수 80회 / 분, 호흡수 22회 / 분으로미열소견보였고청진시오른쪽상부폐하에서는수포음이들렸으며오른쪽하부폐하에서는호흡음이감소되었다. 결막의빈혈이나공막의황달소견은관찰되지않았고만져지는림프절은없었다. 복부는평탄하고유연하였으며만져지는종물은없었고특별한장음항진이나압통소견은없었다. 검사실소견 : 말초혈액검사에서백혈구 5,600/mm 3, C-반응성단백질 4.71 mg/dl, 적혈구침강속도 18 mm/ hr로상승되어있었다. 혈액화학검사에서총단백 6.2 g/ dl, 알부민 3.2 g/dl, 요소질소 25.4 mg/dl, 크레아티닌 196
Tuberculosis and Respiratory Diseases Vol. 69. No. 3, Sep. 2010 Figure 1. Chest X-ray shows multiple nodules and fibrotic scars in the left and right upper lungs with fluid collection in the right hemithorax. Figure 3. Computed tomography scan of the abdomen shows invagination of ileum to ileum with multiple fluid-filled and dilated loops of the small bowel. Collapse of the terminal ileum and colon is also shown. Figure 4. A small intestine shows the ilio-ileal intussusception (29 cm in length) with thickened wall and hemorrhagic necrotic areas. Figure 2. Abdomen plain X-ray shows multiple air-fluid levels in the dilated loops suggesting small bowel obstruction. 0.8 mg/dl, 알라닌아미노전이효소 43 IU/L, 아스파르테이트아미노전이효소 37 IU/L이었다. 방사선소견 : 단순흉부방사선에서우측및좌측폐상부에서작은결절들과섬유성반흔소견이관찰되었으며, 우측의흉수소견도같이관찰되었다 (Figure 1). 치료및경과 : 내원 3일째객담항산균도말검사에서양성소견을보여항결핵제를투여하기시작하였다. 투약 4일째환자는우하복부의통증을호소하였고복부진찰에서우하복부의압통및반동압통을보였다. 복부단순방사선에서는소장가스의확장이동반된반월상공기음영이계단모양으로관찰되어기계적장폐쇄가의심되었다 (Figure 2). 복부조영증강전산화단층촬영에서는회장대회장함입소견과더불어액체저류를동반한소장의확장소견이관찰되었다 (Figure 3). 이상의검사결과로장중첩증으로진단하고응급개복술을시행하였다. 수술시회맹판막의 10 cm 상부에서 29 cm 길이의회장-회장장중첩증소견보여장분절절제술시행하였으며수술후얻어진육안조직에서는장전벽에걸친출혈성응고괴사및궤양소견이관찰되었다 (Figure 4). 병리학적으로는국소적인육아종성염증이관찰되어장결핵에합당한소견보 197
HS Kang et al: A case of adult intussusception by intestinal tuberculosis Figure 5. (A) Two granulomas are located in the muscularis propria and the subserosal area (H&E stain, 100). (B) Focal granulomatous inflammation is shown (H&E stain, 400). 였다 (Figure 5). 환자는수술후 5일째부터항결핵제를다시복용하였고이후증상호전되어퇴원하였다. 고찰성인에서장중첩증이발생하는정확한기전은아직알려져있지않으나장벽내병변이나자극물질등이정상적인연동운동을방해하여병변이있는장부위가원위부로함입 (invagination) 이시작된다고알려져있다 3. 특히소장장중첩증의약 30% 와대장장중첩증의 66% 가악성종양으로인한것으로되어있어성인에서장중첩증이발견된경우에는악성종양의가능성을항상생각해야한다 4. 장결핵에의한장중첩증은매우드물어상대적으로결핵이흔한국내에서도장결핵에의한장중첩증발생예는보고가많지않다 5-8. 성인장중첩증이발생하는부위는크게 1) 소장-소장 (entero-enteric), 2) 대장-대장 (colo-colic), 3) 회장-대장 (ileo-colic) 으로나눌수있으며소장-소장형과회장-대장형장충첩증의빈도수가높은것으로되어있다 4. 본환자에서의경우도흔한형태인소장-소장형장중첩증이었다. 임상양상은한연구결과에따르면 46% 의환자에서 3일미만의급성증세를나타내고나머지는 7 90일간의아급성에서만성경과를나타낸다. 쥐어짜는듯한복통, 혈성설사, 압통과같이소아에서의전형적인증상으로발현하는경우는드물다. 복부증상으로는복통이가장흔하며장폐색의위치와정도에따라오심, 구토, 혈변등다양 한증세가나타날수있다 9. 성인장중첩증의진단검사는전산화단층촬영이가장민감도가높은검사법이며진단적정확도는 58 100% 정도로보고되고있다. 본증례에서도복부전산화단층촬영을통해진단을내릴수있었는데, 불균일한과녁모양또는소시지모양의종괴가장중첩을시사하는특징적인소견이다. 전산화단층촬영은그이외에도장중첩증의위치, 종괴의성질, 주위조직과의관계, 악성의심시병기결정에도움이되며선두부 (leading point) 의유무판별에도도움이된다 1. 촉지되는종괴가있는경우에는초음파검사로도진단할수있으나비만한경우, 그리고장내에가스가많은경우에는진단에어려움이있을수있다 4. 단순복부촬영은일반적으로가장먼저시행하게되는검사인데본증례에서와같이장폐쇄를시사하는소견을보여주는경우가많고또한폐쇄부위에대한정보를얻을수있다. 성인장중첩증의치료는소아에서바륨이나공기로정복술을시행하는것과달리수술적치료가대부분요구된다. 특히 60세이상의환자에서회장-대장형, 대장-대장형의장중첩증이의심될경우악성종양의가능성을생각하여암수술에서하듯이표준장절제술및정상적인조직끼리의문합이필요하다 7,8. 중첩된장의정복술이위험한이유는암종의장내파종또는혈관내전이그리고장파열의가능성, 세균이나암세포의복강내파종가능성등을들수있으며, 특히장벽의염증또는허혈성변화가의심되는경우에정복술은시도되어서는안된다. 본환자에서도복막자극증세가있고환자의나이가 50대임을고 198
Tuberculosis and Respiratory Diseases Vol. 69. No. 3, Sep. 2010 려하여장괴사또는악성종양의가능성을고려하여수술을시행하였다. 하지만, 수술전검사에서양성병변에의한장중첩증이확실할때는정복술및제한된장절제술만으로도장중첩증의재발이적어불필요한장절제를줄일수있다. 요즘은개복수술외에복강경을시행하여양성과악성병변을감별후정복술시행또는장절제술을시행하는치료도소개되고있다 10. 또한, 회장-대장 (ileo-colic) 형, 대장-대장 (colo-colic) 형의장중첩증의대부분선두부는대장내시경으로발견될수있기때문에대장내시경을통한조직검사로원인을확인하여불필요한장절제술을줄일수있다는보고가있다 3. 본환자에서는폐결핵을진단받고치료하던중급성복통과복막자극증세가나타나장괴사가의심되어바로개복수술을시행하였기때문에대장내시경이나복강경을시행하지는못했다. 활동성장결핵의진단은, 첫째, 조직검사에서건락성육아종이나항산균이발견된경우, 둘째, 조직배양에서결핵균이증명된경우, 셋째, 장이외의다른부위에활동성결핵병변이존재하고임상및내시경소견에서장결핵이의심되며항결핵요법에반응이있는경우, 넷째, 다른부위에증명된결핵은없지만임상및내시경소견에서장결핵이의심되고경험적항결핵제의투여로치유되어재발이없는경우중한가지이상을만족하여야한다 11. 본환자에서수술로절제한장조직은항산균염색검사에서는음성소견이었으나점막층에서부터점막하및근육판층까지육아종소견관찰되었고폐결핵으로이미진단된상태임을고려하여장결핵으로진단할수있었다. 장결핵의합병증으로는장폐쇄가전체의 12 60% 를차지할정도로가장흔하며장천공, 복막염, 누공형성, 장출혈등이생길수있다 12,13. 장결핵의치료는폐결핵의치료와마찬가지로항결핵제경구투여가필요하며, 합병증으로비후성병변이생겨종양과감별이되지않거나장천공, 장폐쇄등의합병증이발생하는경우에는본증례와같이수술적치료가필요하다 14. 감사의글 I would like to thank a number of people who have encouraged me to write this, including the following: Professor, Hwa Sik Moon, M.D., Assistant Professor, Sang Haak Lee, M.D., Fellow, Ji Young Kang, M.D., Kook Jin Lee, M.D., Hye Yeon Lee, M.D. - all from Department of Internal Medicine, St. Paul`s hospital, Catholic University of Korea. Also, my colleague - Su Jin Choi, M.D., Eun Hye Ji, M.D., Ka Young Kim. M.D. It would not have been possible without their help. Not least, perhaps, I should thank my long lasting friend - Joon Young Seok, my family - Mom, Dad, and my younger brother - for their patience and forbearance whilst I have spent many hours working on it. Finally, I always wish my patients will be up and around soon. 참고문헌 1. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009; 15:407-11. 2. Pollack CV Jr, Pender ES. Unusual cases of intussusception. J Emerg Med 1991;9:347-55. 3. Nakamura S, Yanagihara K, Izumikawa K, Seki M, Kakeya H, Yamamoto Y, et al. Severe pulmonary tuberculosis complicating Ileocecal intussusception due to intestinal tuberculosis: a case report. Ann Clin Microbiol Antimicrob 2008;7:16. 4. Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, et al. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol 2009;15:3303-8. 5. Hong ES, Kwon KS, Jeong S, Kim SH, Cho HG, Kim PS, et al. A case of intussusception induced by intestinal tuberculosis. Korean J Gastrointest Endosc 1998; 18:99-104. 6. Kim AR, Kim SN, Lee YH, Oh CK. A case of intestinal tuberculosis associated with intussusception. New Med J 1990;33:83-6. 7. Yang WJ, Yoon DS, Lee JJ, Park CJ, Kim DH. Clinical review of the intussusception in adults. J Korean Surg Soc 1998;55:388-93. 8. Park SH, Moon HY. Adult intussusception in Korea. J Korean Surg Soc 1992;43:829-37. 9. Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY. Adult intussusception in Asians: clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol 2007;22:1767-71. 10. McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. JSLS 2006;10:250-3. 11. Lee YJ, Yang SK, Myung SJ, Byeon JS, Park IG, Kim JS, et al. The usefulness of colonoscopic biopsy in the diagnosis of intestinal tuberculosis and pattern of con- 199
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