날짜 : 2013 년 2 월 16 일 ( 토 ) 장소 : 삼성서울병원암센터 B1 강당의사협회평점 : 6 평점 08:20-08:30 개회사 Session 1. 간 08:30-09:00 조주연 간기능해석과협진보기 09:00-09:30 최문석 만성 B형간염환자보기 09:30-10:00 백용한 간경변환자의진료 10:00-10:30 곽금연 간암환자의진료 10:30-11:00 Coffee Break Session 2. 하부위장관 11:00-11:30 김은란 빈틈없고안아픈대장내시경비법 11:30-12:00 민양원 염증성장질환 12:00-12:30 장동경 대장종양성병변의진단과치료 12:30-13:30 Lunch Time Session 3. 췌담도 13:30-14:00 이규택 응급실에서담도환자보기 14:00-14:30 이종균 응급췌장질환 14:30-15:00 이광혁 췌담도질환에서내시경검사 15:00-15:30 Coffee Break Session 4. 상부위장관 15:30-16:00 김정환 내시경관찰법및내시경소견의기술법 16:00-16:30 민병훈 진정관련및심혈관합병증 16:30-17:00 박정호 식도기능검사의이해

2013 gastroenterology Winter School Session 3. 췌담도 목차 응급실에서담도환자보기 7 응급췌장질환 27 췌담도질환에서내시경검사 45

2013 gastroenterology Winter School 응급실에서담도환자보기 이규택

2013 gastroenterology Winter School 7 응급실에서담도환자보기 - Winter School 2013 - Kyu Taek Lee M.D. Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea F/66 1. 1997 년 mitral stenosis 있어 valve replacement 후에 warfarin 과 aspirin 복용중. 본원에서 1997 년 IHD stone 과 CBD stone 으로치료받음. 2009 년 1 월 27 일낮부터발생한우상복부동통과오한및발열로밤 11 시에응급실내원 - 의식 (alert), V/S (38.0 O C - 96/min 145/70 mmhg) - WBC; 12,410 (seg:88.7%), ESR (64), PT (30%, 2.64), T.B.(2.0), AST/ALT (325/90) - CT: IHD stone with CBD stone with underlying recurrent pyogenic cholangitis

8 2013 gastroenterology Winter School F/66 2. 2009 년 1 월 28 일오후 3 시경 ERCP 방앞에대기, 간호사가대기환자상태가나쁨을보고함. - 의식 (drowsy, obey command 는가능 ), Dyspnea 있으면서 O 2 3 L 주면서 check 한 SPO 2 92% - 보호자에게패혈증으로진행하고있음을설명, 담즙배액술실시못하면사망하고시술중환자상태때문에 CPR 가능성높음을설명하고시술동의얻음. - CPR 장비준비하고, ENBD 필요한준비해놓고전처치없이 ERCP 시행 C.W. Acute suppurative cholangitis

2013 gastroenterology Winter School 9 ENBD (7 Fr) insertion, Proedure time: 3 min. Acute suppurative Cholangitis Charcot s triad : RUQ pain, jaundice, fever Prognosis: poor (when it is untreated) Conservative treatment with antibiotics (24 48 hr) in mild courses: can be tried but, who can guarantee? Biliary decompression by ERCP or PTC is essential for life saving: decreased mortality from 100% to 40%

10 2013 gastroenterology Winter School F/80 1. 2001 년 Distal CBD stone 으로본원에서 EST and removal of CBD stone 시술, 그후 F/U 없이지내다 2010 년 1 월 22 일부터심한복통과소화불량증세가있어서 1 월 23 일토요일오후 3 시 24 분에응급실내원 - 의식 (drowsy), V/S (38.9 O C - 105/min 123/68 mmhg), SPO2 (92%) - WBC; 6,460 (seg:85%), PLT (83,000), CRP (12.5) T.B.(5.9), AST/ALT (321/201), ALP (194) - CT: multiple CBD stones with cholangiohepatitis 2. 경과 F/80-4 시경 ER GI Fellow V/S stable 하다고 notify - 6 시 20 분 intubation (SPO2: 90% at O2 4l/min) - 6 시 30 분환자의식상태가 Drowsy 하다고 notify 오후 8 시 PTBD 시행 : ICU 입원하여 ventlator care & antibiotics - 1 월 24 일오후 10 시 48 분사망 ( septic shock due to cholangitis)

2013 gastroenterology Winter School 11 Two biliary conditions meet in ER Stone : pain, fever, jaundice - biliary colic, cholecystitis, cholangitis Jaundice : benign vs malignant

12 2013 gastroenterology Winter School Fate of Gallbladder Stone Management of GB stone (I) Principle of asymptomatic GB stones : wait & see Indication of treatment - symptomatic GB stones : biliary colic - associated complications: acute cholecystitis, gallstone pancreatitis, gallstone fistula - increased risk of gallstone complications : calcified or porcelain GB, previous attack of acute cholecystitis regardless of current symptomatic status, large sized GB stones (>3 cm), congenitally anomalous GB

2013 gastroenterology Winter School 13 Management of GB stone (II) Method of treatment - Laparoscopic cholecystectomy : Tx of choice - Oral dissolution therapy : Ursodeoxycholic acid (UDCA) decrease cholesterol saturation of bile dose; 8 10 mg/kg effective in functioning GB, patent cystic duct, cholesterol stone, Ix; symptomatic (< 10%), number < 3, size < 10 mm ERCP 가필요한경우 Imaging study (US, CT) 에서 CBD stone 이보일때 Imaging study 에서 CBD dilatation 이있으면서 LFT abnormality ( 특히 ALP 상승 ) 이있을때 * 단순히 amylase, lipase 만상승되어있고, CBD dilatation 이없거나 LFT 가정상화되었을때는불필요

14 2013 gastroenterology Winter School Clinical signs of Acute cholecystitis Triad (1) Biliary colic, RUQ tenderness - plateau and remains constant for more than 6-12 hours. - sometimes radiating to the back or the right shoulder. (2) Fever (3) Leukocytosis Nausea, vomiting Acute cholecystitis Murphy s sign: 우상복부촉진시심호흡하면동통과흡식중단 (inspiratory arrest) Jaundice, elevated liver enzymes - occurs in about 20% of cases, even in the absence of common duct stones. Higher fever, jaundice suggest common duct stones.

2013 gastroenterology Winter School 15 Diagnosis of Acute Cholecystitis US (best method) detects stone and thickened gallbladder wall 90-95% 에서 gallstone 이발견. Radionucleotide biliary scan (Confirm) nonvisualization of GB (fails to visualize the gallbladder at one hour) normal scan filling the gallbladder virtually eliminates acute cholecystitis CT : 합병증 ( 기종성담낭염, 천공 ) 의심, 다른질환 ( 췌장염, 기복증, 복강농양 ) 배제 Acoustic shadowing Positional change, Dependent position GB stone Thickened GB wall cholecystitis Pericholecystic fluid collection cholecystitis

16 2013 gastroenterology Winter School DISIDA Scan (Normal) GB 15 min. 45 min. Treatment of Acute Cholecystitis NPO and Hydration L-tube insertion : ileus (+) Pain control (meperidine, NSAIDs) IV antibiotics : 경한경우에그람음성균을겨냥한단일제제, 중한경우에그람음성, 양성, 혐기성균을모두겨냥한복합제제 Laparoscopic cholecystectomy treatment of choice, Call GS doctor in ER PTGBD : 중한경우나합병증 (GB empyema, GB abscess) 동반되었으나환자상태가수술불가능한경우

2013 gastroenterology Winter School 17 Acalculous cholecystitis 담석을동반하지않은급성담낭염 전체급성담낭염의 5-10% 원인 : stress (trauma, burn, major op.), vasculitis, infectious agents (Salmonella, cytomegalovirus, Cryptosporidium), obstructive (tumor, parasites, hypomotility) common situation: prolonged fasting, immobility, hemodynamic instability 치료 : 수술 (prompt cholecystectomy) 예후 : 나쁘다. 합병증 (perforation, gangrene, empyema) 이잘생김. Emphysematous cholecystitis 원인 ischemia or gangrene in GB wall, gas producing organism (Clostridium welchii, C. Perfrigens, E.coli ), old age, DM 진단 gas within GB lumen 치료 수술, 항생제

18 2013 gastroenterology Winter School Emphysematous cholecystitis 담도결석 (choledocholithiasis)

2013 gastroenterology Winter School 19 담도결석 (choledocholithiasis) 대부분 (85%) 은 cholesterol stone 으로 GB stone 이내려온것 (GB stone 의 10-15% 가담도로내려감 ). CBD 자체에서형성되는담석은대부분 pigment stone (hemolysis, parasite infestation, congenital anomaly..) 으로수술후에재발을잘함. 합병증 cholangitis, obstructive jaundice (ALP direct bilirubin aminostrasferase 순으로 ), pancreatitis, secondary biliary cirrhosis, malabsorption Management of Bile Duct Stones Principle in management of common bile duct stones - treat all cases irrespective of symptoms - methods of treatment : Endoscopic sphincterotomy (EST) ; Tx of choice Open CBD exploration Principle in management of intrahepatic bile duct stones - Hepatectomy: limited to one lobe, associated with atrophy and stricture - Percutaneous transhepatic cholangioscopy-lithotripsy ( PTCS-L )

20 2013 gastroenterology Winter School CBD stone extraction after EST Jaundice Patient in ER Obstructive Jaundice vs Cholestatic Jaundice - History : abdominal pain, fever, prior biliary surgery, older age - P/Ex : fever, abdominal tenderness, palpable abdominal mass, abdominal scar - Lab : Predominant elevation of serum ALP relative to aminotransferase, PT normal or normalizes with vitamine K administration, elevated serum amylase or lipase

2013 gastroenterology Winter School 21 Decision tree for Obsructive Jaundice History, P/Ex, routine Lab ALP or AST/ALT elevated Biliary tract obstruction a consideration? US or CT dilated bile duct ERCP or PTC Drainage procedure in malignant obstruction - PTBD in intrahepatic bile duct obstruction - Endoscopic drainage (ENBD, ERBD) in extrahepatic bile duct obstruction PTBD

22 2013 gastroenterology Winter School ENBD ERBD (Plastic stent)

2013 gastroenterology Winter School 23 응급실에서유의사항 금요일밤에급성담관염이의심되는환자가응급실에내원했는데어떻게 draiage 를할까? Drainage 가필요한환자가 Antiplatelet or anticoagulant drugs (aspirin, warfarin, ticlopidine, clopidgrel ) 을복용하고있는데, 빨리시술이필요하면?

2013 gastroenterology Winter School 응급췌장질환 이종균

2013 gastroenterology Winter School 27 응급췌장질환 - 급성췌장염 이종균 성균관대학교의과대학내과학교실 응급실에급성췌장염의심환자가왔을때꼭파악해야할사항들 1. 급성췌장염이맞는가? 2. 원인이무엇인가? 3. 정도가심한가? 4. 동반된합병증이있는가? 5. 적절한치료는무엇인가?

28 2013 gastroenterology Winter School Acute abdomen with hyperamylasemia perforated viscus (esp. peptic ulcer) acute cholecystitis and biliary colic acute intestinal obstruction mesenteric vascular occlusion peritonitis dissecting aortic aneurysm connective tissue disorders with vasculitis diabetic ketoacidosis ectopic pregnancy Diagnosis of acute pancreatitis Severe constant abdominal pain Serum amylase and/or lipase > 3N image finding exclusion of other causes

2013 gastroenterology Winter School 29 Symptoms Abdominal pain Low grade fever Tarchycardia Hypotension Shock hypovolemia secondary to exudation of blood and plasma proteins into the retroperitoneal space increased formation of kinin peptides, which cause vasodilation and increased vascular permeability systemic effects of proteolytic and lipolytic enzymes released into the circulation Respiratory distress Skin discoloration Laboratory findings Amylase onset; 2-12 hours, duration; 3-5 days unrelated to severity salivary gl., liver, intestine, kidney, fallopian tube tumor - lung, esophagus, breast, ovary normal in acute pancreatitis after 5 days acute exacerbation in chronic pancreatitis hypertriglyceridemia Lipase Longer duration, more specific to pancreas

30 2013 gastroenterology Winter School Radiologic findings Chest X-ray - pleural effusions, atelectasis, ARDS Simple abdomen - ileus - sentinel loop ; isolated dilated loop of small bowel overlying the pancreas - colon cutoff sign - dilation of the transverse colon Ultrasonography Limited visualization of pancreas by intestinal gas or adipose tissue Single best noninvasive test for detecting cholelithiasis

2013 gastroenterology Winter School 31 CT Diagnosis Exclusion of other surgical abdomen Severity of pancreatitis Local complications Causes of acute pancreatitis Support diagnosis Prevent progression and recurrence

32 2013 gastroenterology Winter School Alcoholic pancreatitis 수년간에걸친알코올섭취에의해발생 하루평균 60 gm, 3 년이상, 1 주내음주 증상은처음이라도조직학적으로는만성변화 Gallstone pancreatitis 의심소견 : 담석, 담관확장, cholestatic LFT 대부분작은담석 : 90% 는자연배출 중증췌장염또는 48 시간내에호전되지않는경우에는내시경적괄약근절개술 담석성췌장염은대부분만성화되지않는다

2013 gastroenterology Winter School 33 Pancreas divisum Hypertrigyceridemia Serum TG > 500~1000mg/dL Release of free fatty acids may damage acinar cells or capillary endothelium Hyperlipoproteinemia, alcohol abuse, DKA

34 2013 gastroenterology Winter School Autoimmune Pancreatitis (AIP) Autoimmune mechanism Serum IgG4 > 135 mg/dl Lymphoplasmacytic sclerosing pancreatitis (LPSP) Other organ involvement Good response to steroid Mild pancreatitis vs. Severe pancreatitis interstitial edema mortality < 2% parenchymal necrosis systemic organ failure or local complications such as necrosis, pseudocyst, abscess mortality 10~15%

2013 gastroenterology Winter School 35 Ranson Criteria Modified Criteria At admission (Alcoholic) (Biliary) Age > 55 years > 70 years WBC > 16,000/mm 3 > 18,000/mm 3 Glucose > 200 mg/dl > 220 mg/dl LDH > 350 IU/L > 400 IU/L AST > 250 IU/L > 440 IU/L During initial 48 h Hct decrease > 10 % > 10 % BUN increase > 5 mg/dl > 2 mg/dl Calcium < 8 mg/dl < 8 mg/dl PO2 < 60 mm Hg < 60 mm Hg Base deficit > 4 meq/l > 5 meq/l Estimated fluid sequestration > 6 l > 6 l APACHE II scoring system

36 2013 gastroenterology Winter School CT severity index Grade of Acute Pancreatitis Points A. Normal pancreas 0 B. Pancreatic enlargement alone 1 C. Peripancreatic fat infiltration 2 D. One peripancreatic fluid collection 3 E. Two or more fluid collection 4 Degree of pancreatic necrosis No necrosis 0 < one third 2 one third one half 4 more than one half 6 CT Severity Index (CTSI) Morbidity Mortality 0-3 8% 3% 4-6 35% 6% 7-10 92% 17% (Balthazar EJ, Radiology, 1990) Risk factors that adversely affect survival Organ Failure cardiovascular: SBP< 90 mmhg, HR > 130/min pulmonary: PaO 2 60 mm Hg renal: oliguria or increasing BUN/Cr GI bleeding: > 500 ml/24 hr Pancreatic necrosis Obesity (BMI>29); age >70 Hemoconcentration (Hct > 44%) CRP > 150mg/L 3 Ranson criteia, 8 APACHE-II score

2013 gastroenterology Winter School 37 Complications Local necrosis +/- infection pseudocyst abscess pancreatic ascites bleeding Systemic ARDS hypotension renal GI bleeding DIC metabolic CNS Interventional Window Relative Incidence Onset 12 24 36 48 60 72 84 90 of Pain Hours

38 2013 gastroenterology Winter School Cause of death in severe AP Days No. of patients Cause of death 1-10 13 cardiac failure (11) MOF (2) 11-20 3 cardiac failure (1) gangrene of small intestine (1) MOF caused by infected necrosis (1) 21-30 2 MOF (1) cardiac failure caused by infected necrosis (1) 45-153 3 MOF caused by infected necrosis (3) MOF; multiple organ failure MOF 2 wk Infected necrosis (Appelros S, Eur J Surg, 2001) Guideline for prophylactic antibiotics Severe pancreatitis and greater than 30% necrosis Selection of antibiotics spectrum, penetration of pancreatic tissue (Imipenem), 2 nd or 3 rd generation Cephalosporin, Quinolone Duration: 2 weeks Increased risk of fungal or multi-resistant organisms

2013 gastroenterology Winter School 39 Management of mild pancreatitis Rest NPO for 2-3 days Pain contol Management of severe pancreatitis ICU care hemodynamic monitoring (V/S, U/O, CVP) mechanical ventilation with PEEP Aggressive fluid resuscitation prevent pancreatic ischemia 5~ 10 L/day, colloids : crystalloids 1:3 NPO and TPN or enteral tube feeding Prophylatic antibiotics Early ERCP in severe gallstone pancreatitis Prevention and management of complications

40 2013 gastroenterology Winter School ERCP in acute biliary pancreatitis Early ERCP coexistent cholangitis severe pancreatitis change of severity sign from mild to severe EUS or MRCP mild to moderate severity Improving, intermediate probability of CBD stone Cholecystectomy without ERCP mild low probability of CBD stone

2013 gastroenterology Winter School 41 Infected necrosis 30~50% mortality rate Suspicion newly developed signs of organ failure fever after initial response to conservative tx. gas (+) on CT scan Surgical necrosectomy & lavage Endoscopic necrosectomy in localized necrosis 급성췌장염의심시파악해야할사항 1. 급성췌장염이맞는가? 다른질환배제필요 2. 원인이무엇인가? 뚜렷한원인이없으면다른진단가능성염두 원인교정및재발방지 3. 정도가심한가? 치료가다르다 4. 동반된합병증이있는가? 사망원인 다발성장기부전, 감염 5. 적절한치료는무엇인가? 수액, 항생제, ICU, 조기시술적응증

2013 gastroenterology Winter School 췌담도질환에서내시경검사 이광혁

2013 gastroenterology Winter School 45 췌담도질환에서내시경 2013.02. winter school 성균관대학교의과대학내과학교실삼성서울병원소화기내과이광혁 ERCP (Endoscopic Retrograde CholangioPancreatography) EUS (Endoscopic UltraSound) ERCP EST CBD stone removal ERBD ENBD Photodynamic therapy Endoscopic papillectomy EUS EUS-FNA EUS-TCB EUS-guided therapy Drainage Anastomosis Ablation Injection

46 2013 gastroenterology Winter School Close observation of Complications Change of abdominal pain, Vital sign, P/E Perforation: Simple abdomen, chest PA Pancreatitis: Amylase/Lipase Bleeding: CBC Infection: Cholangitis, Cyst infection Perforation Endoscopic perforation surgery Instrumental perforation supportive Pancreatitis Same as acute pancreatitis from other causes Severity assessment

2013 gastroenterology Winter School 47 Need an Expert? Yes! 우리나라 전임의 1년은위및대장내시경수기익힌뒤 최소한 1년은투자해야 Advanced endoscopic course in USA ERCP Fellowship: 1 year EUS Fellowship: 1 year For diagnosis EUS, MRCP >? ERCP

48 2013 gastroenterology Winter School Endoscopic Sphincterotomy (EST) Therapeutic intent Complication Perforation Bleeding Techniques Depth - 1/2-2/3 outside AOV Direction - 12 o clock position Limit - Oral protrusion Speed - Control Accessories in ERCP Catheter Papillotome Guide-wire Stent Metal Plastic Balloon Dilatation Retrieval Basket Lithotripsy

2013 gastroenterology Winter School 49 Plastic stent Removable Benign stricture Exchange 3 months Shapes Palliative management of malignant biliary obstructions Percutaneous drainage Endoscopic drainage

50 2013 gastroenterology Winter School Treatment of distal obstruction Placement of self-expanding metal stent is the treatment of choice from some randomized trials. Covered metal stent Prevention of tumor ingrowths Cholecystitis or Obstruction of branched duct Parallel Y stent Bilateral stent Photodynamic therapy Endoscopic papillectomy AOV adenoma Pancreatic duct stent

2013 gastroenterology Winter School 51 Endoscopic ultrasound High resolution and Tissue acquisition Esophagus Stomach Duodenum 2nd Intervention Radial type Vs Linear type EUS guided tissue diagnosis using linear EUS 22G 25G Needle Vs TruCut biopsy 19G therapeutic 19G Cutting sheath Specimen tray

52 2013 gastroenterology Winter School EUS guided tissue diagnosis EUS-FNA (aspiration) 1. 22G or 25G needle 2. No site limitation 3. Cytological analysis EUS-TCB (TruCut biopsy) 1. 19G needle stiff 2. Some site limitation 3. Histological analysis EUS-FNA (ProCore) 1. 22G or 25G needle 2. No site limitation 3. More tissue EUS-FNA for pancreatic cacner Scenario Metastatic Advanced unresectable Borderline resectable Resectable Undetectable Required Yes Yes Yes Maybe, yes Yes

2013 gastroenterology Winter School 53 Pancreatic Cystic Neoplasm Solid component Fluid analysis CEA Amylase Poor cytological yield Therapeutic applications Drainage and Anatomosis Pseudocyst, pancreatic absces Biliary tract, Pancreatic duct, Jejunum Ablation CPN block, cyst ablation, solid mass ablation Ethanol, chemotherapeutics, fiducial, biological agent