부울경소화기내시경학회 10월집담회 메리놀병원소화기내과 R3. 이홍직
Case Presentation Patient : 최 O 수 ( M / 53 ) C.C) melena & hematemesis
Case Presentation P.I) 2001. 3 : bladder cancer radical cystectomy /c ileal conduit reconstruction (urostomy) 2013. 4. 3 : 4.2 부터 melena 있었고 4.3 새벽냉면대접 3개분량 (?) hematemesis 있어응급실통해입원.
Case Presentation P.Hx) DM / HTN / Tb / Hepa ( -/-/-/- ) Bladder cancer op(2001. 3) F.Hx) N-S S.Hx) smoking : 1P*30Y = 30PY alcohol : daily 소주 3병
Case Presentation ROS) F/C/H/D (-/-/-/-) C/S/R/D (-/-/-/-) Chest pain/palpitation(-/+) Frequency / UOD ( -/- ) A/N/V/D/C (+/-/-/-/-)
Case Presentation P.Ex) acute ill looking appearance anemic / anicteric / dehydrated tongue ABD : soft & flat, T/RT(-/-), audible B/S Otherwise N-S Initial vital sign) 140/90-126(HR)-20(RR)-36.2
Chest AP
Case Presentation ECG : Sinus tachycardia (HR 108) Plain Abdomen : N-S ileus
Initial Lab. IDA & r/o AKI
Initial Lab. UTI
Case Presentation Impression 1. r/o UGI bleeding 2. AKI d/t hypovolemia(bleeding) & UTI 3. UTI Plan 1. 응급 GFS 2. Transfusion & hydration 3. Antibiotics
2013. 4. 3 GFS
2013. 4. 3 Celiac angio embolization of left gastric arterial bleeding
2013. 4. 3 Celiac angio embolization of left gastric arterial bleeding
2013. 4. 4 f/u GFS
Progression 2013. 4. 4 f/u lab) Hb 11.1 f/u vital) stable Impression UGI bleeding d/t ulcer bleeding Post-embolization ischemic ulcer(body LC~PW) Plan PPI & GFS f/u
2013. 4. 11 GFS
EGD Case Presentation
2013. 4. 11 GFS
2013. 4. 11 GFS 2.Stomach 2.Stomach : 04.Gastric ulcer/lblc/h1/bx*1/(a) : 27.R/O Ischemic Ulcer/MBPW/Bx*1(B) DIAGNOSIS; Gastric mucosa,ab, endoscopic biopsy ; Chronic active gastritis,a. Granulation tissue,b. ** Remark:A specimen 에서 some atypical gland 가보이므로반드시 clinical follow up 을 recommend 드리는바입니다.
2013. 4. 11 CT of ABD
2013. 4. 11 CT of ABD 판독소견 hypodense wall thickening on gastric upper body, LC side - 4 gastrohepatic LNs enlargment ==> R/O stomach cancer (cancer 라면, T2N2Mx) DDx. gastric ulcer with mural edema several enlarged LNs on para-aortic LNs, aortocaval LN, retrocaval LNs ==> reactive LNs vs. malignant LNs
2013. 6. 3 GFS
2013. 6. 3 GFS 2.Stomach : 27.Ulcer Scar/LB LC~PW portion/bx*1 DIAGNOSIS; Gastric mucosa,body, endoscopic biopsy ; Highly suspicious of adenocarcinoma
2013. 7. 1 GFS
2013. 7. 1 GFS D E G F
2013. 7. 1 GFS biopsy result *ABC : UBPW 의이전 ischemic area 의 biopsy *DEFG : lower body LC~PW side DIAGNOSIS; Gastric mucosa,abcdefg, endoscopic biopsy ; Chronic gastritis,abcdeg. Adenocarcinoma,tubular type,moderately differentiated,f.
Biopsy result
2013. 7. 10 CT ABD recheck no evidence of focal wall thickening or enhancing lesion on stomach - no evidence of perigastric fat infiltration or - no lymphadenopathy ==> 만일 stomach cancer 라면, T2 미만 N0Mx
2013. 7. 10 PET CT no visible hypermetabolic primary tumor focus on PET/CT scan no evidence of distant metastasis ileostomy state
Progression 2013. 7.23 GS Adm Subtotal gastrectomy B-II Stage IA (T1aNoMo)
Post op. specimen F
Biopsy Result DIAGNOSIS; Stomach,subtotal gastrectomy; Adenocarcinoma,tubular type,moderately differentiated. a, early gastric carcinoma. b, confined within the mucosa. c, free of the tumor cells in both surgical margins. d, no metastasis of the tumor cells in the perigastric lymph nodes ---lesser curvature(0/7) and greater curvature(0/3). e, no metastasis of the tumor cells in the submitted lymph node, No.12a(0/0). No evidence of tumor cell infiltration,submitted omentum
Final Diagnosis Eearly Gastric Cancer (presenting as ulcer bleeding)
Disease Review Gastric Ulcer and Ulcerative Gastric Cancer, 이시형대한소화기내시경학회세미나 2012
함몰형병변 위궤양은양성궤양에서부터악성궤양까지다양한병리소견이존재한다. 융기형병변에비해양성, 악성의감별은어렵다 ( 존재진단보다질적진단이어렵다 ) 조기위암의악성주기가존재한다
Cycle of Benign gastric ulcer A1 A2 H1 S2 S1 H2
Cycle of EGC presenting as gastric ulcer III (A1) III+IIc(A2) IIc+III(H1) IIc~IIb(S2) IIc+IIb(S1) IIc+III~IIc(H2)
조기위암의악성 Cycle 항궤양제치료후궤양이호전되더라도조기위암일수있다는것을의미
Concept of the Malignant Cycle in EGC
양성궤양과 IIc 형조기위암의감별점 암세포 : 함몰된부위에침윤
양성궤양과 III 형조기위암의감별점 백태 : 균일, 깨끗불균일백태, 궤양저에섬모양의재생상피, 부정형의궤양변연암세포 : 궤양의가장자리에국한
조직검사 양성궤양과위암과의감별 : 반드시조직검사를통해서확진 조직검사를잘하기 - 정확한병변관찰 - 색소내시경 : indigocarmin, methylene blue NBI( 올림푸스 ), FICE( 후지논 ), I scan( 펜탁스 ) - 4~6 회생검등검체량증가 - 정확한위치 - 궤양 : 가장자리 4 곳 + 궤양저
조직검사 조직검사를잘하기 - 궤양저에요철, 과립모양, 결절모양, 궤양변연이불규칙, 부정형 우선적생검 - 조직검사후의출혈방향고려 - EGC 의심시 ~ IIc 형 : 가장자리 + 함몰부 ~ III 형 : 함몰부위에는암세포침윤이없음 가장자리
Conclusion - 초기양성위궤양으로진단되었다고하더라도이후위암으로진단될수있다 - 생검을통한조직학적소견이병소의전체를대변하지못한다 - 악성궤양도양성궤양처럼호전과악화를보이는생활사를가질수있으므로치료후반드시추적내시경검사와조직검사를시행하여야한다