대한내과학회지 : 제 89 권제 5 호 2015 http://dx.doi.org/10.3904/kjm.2015.89.5.548 검진내시경상구불결장의상피하병변으로관찰된충수염 1 예 부산대학교의학전문대학원양산부산대학교병원내과 최유이 김수진 강대환 김형욱 최철웅 오숙경 신영신 Asymptomatic Perforated Appendicitis Presenting as a Subepithelial Sigmoid Colon Lesion at Screening Colonoscopy Yu Yi Choi, Su Jin Kim, Dae Hwan Kang, Hyung Wook Kim, Cheol Woong Choi, Sook Kyoung Oh, and Young Shin Shin Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea Acute appendicitis is common in all age groups. Although many patients with acuteappendicitis present with migrating abdominal pain, the initial presentation can be atypical and nonspecific. Unusual manifestations can lead to diagnostic delay, which is associated with increased morbidity and mortality. Colonoscopic findings suggestinga diagnosis of asymptomatic appendicitis include hyperemia and bulging at the appendiceal orifice area with surrounding mucosal edema, and drainage of pus from the appendiceal orifice. We report a case of asymptomatic perforated appendicitis and periappendiceal abscess that presented as a subepithelial sigmoid colon lesion at screening colonoscopy. On colonoscopy, a subepithelial lesion with pustular drainage surrounded by hyperemic mucosa was seen at the sigmoid colon. Computed tomography revealed appendicitis and a periappendiceal abscess with adjacent sigmoid colon wall thickening. The patient underwent an appendectomy, with a final diagnosis of a perforated appendicitis with a periappendiceal abscess. (Korean J Med 2015;89:548-552) Keywords: Appendicitis; Colonoscopy; Colon, Sigmoid 서론충수염은전형적으로배꼽부위에서우하복부로옮겨지는복통, 발열, 오심, 구토등의증상을보일수있어자세한문진과신체검사만으로도진단이가능하다. 그러나비특이적인증상을호소하는경우가있으며, 충수의위치나충수염 의양상에따라다양하게나타난다. 충수염으로인한천공이생겼을경우전신상태가급격히악화되어응급수술이필요한경우가흔하나, 국소적인충수주위농양을형성하며뚜렷한증상을일으키지않는경우도있다 [1]. 모호한복통으로내원한환자에서염증성장질환, 과민성장증후군, 대장암등을감별하기위한검사로대장내시경을시행하다우연히 Received: 2014. 10. 14 Revised: 2015. 4. 13 Accepted: 2015. 7. 6 Correspondence to Su Jin Kim, M.D. Division of Gastroenterology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea Tel: +82-55-360-1535, Fax: +82-55-360-1536, E-mail: pmcac@daum.net Copyright c 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 548 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- Yu Yi Choi, et al. Appendicitis presenting as a sigmoid SEL - 충수염이진단되기도한다. 이러한경우관찰되는대장내시경소견은충수돌기개구부의융기, 발적과부종, 화농성삼출물등이대표적이다 [2]. 저자들은복부불편감없이단순검진목적으로시행한대장내시경검사에서충수돌기개구부는정상이며구불결장에융기된상피하병변이관찰되어추가로시행한복부전산화단층촬영에서충수염과충수주위농양을진단하고치료한증례를경험하였기에문헌고찰과함께보고하는바이다. 증례 53세여자가건강검진을목적으로대장내시경검사를받기위해내원하였다. 환자는약한달전설사, 변비등의소화기증상을동반하지않은하복부복통이있어인근의원에서 2-3일간의약물치료를받고호전되었던병력이있었고, 고혈압, 당뇨병으로약물치료중이었다. 약 3년전에폐경이되었고, 그외사회력, 가족력에서특이소견은없었다. 내원당시환자는의식이명료하였고호소하는증상은없었다. 생체징후는혈압 110/80 mmhg, 맥박수 76회 / 분, 체온 36.6 로정상이었다. 두경부, 흉부진찰에서특이소견없었고복부진찰에서도간비종대가없고뚜렷한압통부위도관찰되지않았다. 대장내시경검사에서충수돌기개구부에는특이소견없었으나항문피부선 15 cm 상방의구불결장에서약 2.0 1.5 cm 크기로점막발적과부종이있는상피하병 변이관찰되었고, 중심부에화농성분비물이동반되어있었다 (Fig. 1). 구불결장의상피하병변에대한평가를위해시행한복부전산화단층촬영결과충수돌기가비대되어있고주변지방조직과인접한구불결장까지염증의침윤이현저하게관찰되었다 (Fig. 2). 구불결장내강으로배농되는충수주위농양으로진단하고충수돌기절제술을시행하기위해외과로전과되었다. 수술전시행한말초혈액검사에서백혈구 5,540/mm 3 ( 중성구 51.8%), 혈색소 13.2 g/dl, 헤마토크리트 37.8%, 혈소판 357,000/mm 3 이었고, 혈청생화학검사에서 AST 19 IU/L, ALT 21 IU/L, 총단백 8.1 g/dl, 알부민 4.7 g/dl, alkaline phosphatase 184 IU/L, BUN 10.4 mg/dl, creatinine 0.63 mg/dl, C-reactive protein 0.24 mg/dl로정상소견이었다. 응급복강경수술을시행하였으며, 복강경으로관찰할때충수돌기가천공되어주변에국소농양이형성되어있었고, 인접한구불결장과그물막에유착되어있었다. 뚜렷한누공은관찰되지않았고, 충수를주변조직과박리한뒤충수절제술을시행하였다. 충수돌기의크기는 3.5 0.5 cm이었고, 절제한조직의병리결과충수염으로확진되었다 (Fig. 3). 수술후 14일째시행한구불결장경에서점막의발적과부종이호전되었고, 반흔외에는정상점막소견을보였다 (Fig. 4). 환자는이후특이합병증없이외래에서경과관찰중이다. A B Figure 1. At colonoscopy, (A) the appendiceal orifice appeared normal. (B) Purulent discharge was observed emanating from an opening 15 cm from the anus, with surrounding bulging edematous hyperemic mucosa. - 549 -
대한내과학회지: 제 89 권 제 5 호 통권 제 663 호 2015 A B C D Figure 2. Contrast-enhanced computer tomography of the abdomen and pelvis shows (A, B) a distended appendix (arrow) about 9 mm in diameter with circumferential wall thickening and enhancement in the coronal view and (C, D) periappendiceal fat stranding and fluid collection (arrow) with adjacent sigmoid colon wall thickening in the axial view. Figure 3. Grossly, the resected specimen had a relatively normal serosal surface on the lower half of the appendix (black arrows), while the upper half of the appendix (white arrows) included an appendiceal abscess covered with a yellowish-tan exudate both externally and internally. At the tip of the appendix, there was a perforated abscess and peritonitis adhesive to the sigmoid colon (white arrow with black outline). Figure 4. Sigmoidoscopy two weeks after the surgery showed improvement in the raised hyperemic lesion and no purulent discharge. - 550 -
- 최유이외 6 인. 구불결장의상피하병변으로관찰된충수염 1 예 - 고찰일반적으로충수염환자는구심성내장신경의자극으로인한배꼽주위통증에이어오심, 구토를호소하며염증이점차진행되면서우하복부통증으로국소화되는경과를보인다. 이러한경과를보이는복부통증은충수염을의심할수있는가장전형적인증상이지만, 그외에도다양한임상양상을보일수있어여러가지임상소견을종합하여충수염을진단하게된다 [1]. 충수돌기의개구부막힘은충수염을유발하는기본적인기전이다. 충수돌기개구부의막힘이지속되면염증이점차진행되어농양형성이나천공이발생할수있다. 가끔은충수돌기개구부막힘이완화되어고름이맹장쪽으로배출되면전형적인충수염증상을유발하지않을수도있다. 천공된충수염은일반적으로복막염등을일으켜응급수술을요하지만, 천공을통해충수돌기의고름이고름집을형성하거나복강이아닌곳으로배액이되면염증의호전및악화를반복하면서충수주위농양, 복부종괴로촉지되는국소농양, 장관으로의누공등을형성하고복부통증이나발열이없는비전형적인증상을나타낼것으로생각된다 [1,3]. 본증례의경우충수염이천공되면서국소적인충수주위농양을형성하고, 이것이인접한구불결장내로배액되면서증상이호전되었던것으로생각된다. 충수염과충수주위농양에의한합병증으로충수와복강내장기와의누공이형성된증례가드물게보고되고있다 [1]. 맹장과인접한구불결장사이에형성된누공이대부분이며드물게위, 십이지장, 공장등에서도증례보고가있다 [4-6]. 본증례의경우한달전 2-3일간의복통을경험한병력이있고이후무증상으로지내다검진목적의대장내시경과추가적인복부전산화단층촬영을시행하여구불결장내강으로배농되는충수주위농양으로진단하였지만, 이러한검사가늦어졌다면앞서보고된증례와같이반복되는배농으로인해충수-구불결장루가형성되었을가능성이있다고생각한다. 대장내시경을통해충수염을진단한증례들을보고한문헌들을살펴볼때, 일반적으로는충수돌기개구부에서융기, 충혈, 부종, 화농성삼출물등의특징적인소견을나타내게된다 [2]. 본증례에서는충수주위농양이인접한구불결장내로배액되면서충수돌기개구부의염증이호전되어충수돌기개구부는정상소견을보였을것으로생각된다. 대장및직장의상피하병변은보고에따라차이가있지만, 한보고에따르면 86% 정도가종양성상피하병변으로 보고되고있다 [7]. 이번증례의대장내시경소견은구불결장점막의부종과충혈을동반한융기병변으로중심부에화농성분비물이배농되고조직겸자로눌렀을때부드럽고밀었을때밀리지않는 (rolling sign 음성 ) 비종양성상피하병변의가능성을우선고려하였다. 비종양성상피하병변으로자궁내막증과감별이필요하였으며, 복부전산화단층촬영에서충수염을진단할수있었다. 저자들이생각한내시경감별진단으로는자궁내막증외에도점막하혈종, 심층낭대장염, 게실염등을들수있다 [8-10]. 검진목적의대장내시경에서발견된상피하병변을통해충수염이진단된증례보고는이전에없었으며, 특히본환자와같이한달전발생했던복통의병력외전신염증반응이나복부증상없이천공된충수염과이로인한충수주위농양형성, 그리고인접구불결장내강으로의배액을보이는비전형적인합병증이동반된충수염의경우진단과치료가늦어질수있어이에본증례를문헌고찰과함께보고하는바이다. 요 본증례는검진목적의대장내시경에서충수돌기개구부가정상소견을보였지만, 구불결장의점막하병변으로나타난충수염의드문증례이다. 화농성배액이보이는점막하병변이구불결장에서관찰될때충수염의가능성또한감별진단으로고려해볼수있겠다. 약 중심단어 : 충수염 ; 대장내시경 ; 구불결장 REFERENCES 1. Maa J, Kirkwood KS. Appendix. In: Townsend CM, ed. Sabiston Textbood of Surgery. 19th ed. Vol. 1. Philadelphia: Elsevier Sounders, 2012;1279-1293. 2. Chang HS, Yang SK, Myung SJ, et al. The role of colonoscopy in the diagnosis of appendicitis in patients with atypical presentations. Gastrointest Endosc 2002;56:343-348. 3. Petro M, Minocha A. Asymptomatic early acute appendicitis initiated and diagnosed during colnoscopy: a case report. World J Gastroenterol 2005;11:5398-5400. 4. Morris-Stiff GJ, Islam KA. Appendico-colic fistula complicating appendicitis in cystic fibrosis. BMJ Case Rep 2010 Sep 7 [Epub]. http://dx.doi.org/10.1136/bcr.02.2010.2714. 5. Her JW, Hwang JS, Ahn SH, Park SK, Kim H. Epigastric appendiceal abscess with spontaneous drainage into the - 551 -
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