장염완전정복 : 감염성장염 김태준 성균관대학교의과대학삼성서울병원소화기내과 제 17 회소화기병심포지움 47
Session 2. 하부 Lancet 2008 48 삼성서울병원
Pathogen % Infectious diarrhea S. aureus 6.1 E. coli 23.5 Shigella spp. 1.0 Salmonella spp. 4.0 C. perfringens 5.5 V. parahaemolyticus 4.4 C. jejuni 1.0 B. cereus 2.9 Norovirus 28.8 Others 23.7 Korea Centers for Disease Control and Prevention 2009 Enteric infection Relative risk by PPI use Salmonella 4.2-8.3 Campylobacter 3.5-11.7 C. difficile 1.2-5.0 C. Bavishi and H. L. DuPont. AP&T 2011 제 17 회소화기병심포지움 49
Session 2. 하부 50 삼성서울병원
Sleisenger and Fordtran s Gastrointestinal and Liver Disease (10 th ed) Shigella UC-like Yersinia CD-like 제 17 회소화기병심포지움 51
Session 2. 하부 Salmonellosis UC-like CD-like Infectious diarrhea Clinical presentation Present early (within 1 week) Fever Histopathology Edema Neutrophils of lamina propria Superficial cryptitis IBD Present later (>1 week after symptoms onset) Less fever, prior abdominal symptoms Surface erosion Basal yymphoplamacytosis Architectural crypt distortion 52 삼성서울병원
연중발생하며특히 6-8 월에많음 미국 : 연간약 26 만명의 STEC 감염환자가발생하여 30 명정도가 사망할것으로추산됨. 제 17 회소화기병심포지움 53
보존적치료 항생제는금기 소아에서용혈성요독증후군의위험을 높이는것으로알려짐 항생제가시가독소의합성및배출을증가시킴 투여해도악영향이없는항생제가있는지는 아직불분명함 제 17 회소화기병심포지움 55
장염완전정복 : 비감염성장염 홍성노 성균관대학교의과대학삼성서울병원소화기내과 Sung Noh Hong, M.D., Ph.D. Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine 56 삼성서울병원
장염 Inflammatory Bowel Diseases Idiopathic Ulcerative Colitis (UC) Crohn s Disease (CD) Indeterminate Colitis Non-IBD and noninfectious colitis Inflammatory Diseases of Colon other than Idiopathic IBD Infectious Enterocolitis Ischemic Colitis Diverticulitis Drug-Induced Colitis Antibiotics NSAID Intestinal Behcet s Disease Vasculitis Radiation procto-colitis GVHD Microscopic colitis Differential diagnosis with chronic diarrhea 제 17 회소화기병심포지움 57
Session 2. 하부 Differential diagnosis with chronic diarrhea Observation Point for DDx: Location of lesions CD Infectious enterocolitis Tuberculosis Yersinia enterocolitis Amebic colitis Behcet s colitis NSAID induced enteropathy Diverticulitis Appendicitis Appendiceal orifice inflammation : ulcerative proctitis Ischemic colitis Diverticulitis Infectious colitis UC Infectious enterocolitis PMC Shigellosis Radiation proctitis 58 삼성서울병원
Observation Point for Differential Diagnosis Description Location of lesions Continuity of lesions Features of ulcers Morphology & Direction Mucosal change adjacent to ulcers Inflammatory sequelae Scar (pseudopolyps, pseudodiverticulum, & patulous ICV) Stricture Fistula Hyperemia Edema Granularity Mucosal friability Erosion Aphthous ulcer Ulcer Character Inflammatory sequelae Ischemic colitis Typical symptom: sudden onset hematochezia and cramping natured LLQ pain Other manifestations : fever, necrosis, perforation, peritonitis, septic shock. Endoscopic findings Edematous and friable mucosa, segmental erythema, scattered erosions, longitudinal ulcerations, petechial hemorrhages, and purple hemorrhagic nodules segmental disease rectal sparing rapid spontaneous resolution 제 17 회소화기병심포지움 59
Session 2. 하부 Endoscopic findings of ischemic colitis Endoscopic Diagnosis of Intestinal Behcet s disease 베체트장염진단가이드라인, 대한소화기학회지 2009 60 삼성서울병원
Diagnosis of Intestinal Behcet s disease Diagnostic Criteria (Behcet s Disease DiagnosticResearch Criteria (ISGBD, Committee 1990 of Japan, ) 1987) MAJOR Recurrent oral ulceration Recurrent oral aphthous ulcerations PLUS TWO of the followings Skin lesion Recurrent Eye genital lesion ulceration Eye lesiongenital ulcer Skin lesion MINOR Close follow-up is necessary Positive pathergy Arthritis without test deformity and ankylosis GI lesion characterized by ileocecal ulcers Epididymitis Vascular lesion CNS symptom DIAGNOSIS Complete type: 4 major features Incomplete type: a. 3 major features b. 2 major+2 minor c. Typical ocular symptom+1 major or 2 minor Suspected type: a. 2 major features b. 1 major+2 minor Cheon et al. AJG 2009 NSAID induced enteropathy Approximately 10-12% of newly diagnosed colitis may be related to NSAID administration Clinical symptoms IDA ~ obstruction, massive bleeding, perforation Endoscopic finding of NSAID : Nonspecific 제 17 회소화기병심포지움 61
Session 2. 하부 Radiation proctitis Radiation therapy for prostate cancer in men and cervical cancer in women Significant rectal bleeding generally develops in 9 months after radiation injury Endoscopic findings mucosal friability, pallor, telangiectasias, fistula, and ulcerations Endoscopic therapy with APC Observation Point for DDx: Continuity of Lesions Features of continuity Common IBDs Continuous from rectum UC PMC Shigellosis Campylobacter colitis UC PMC Continuous at 1-2 segments Ischemic colitis Radiation colitis Antibiotics-associated hemorrhagic colitis Yersinia enterocolitis Skip lesions CD Tuberculous colitis Amebic colitis Shigellosis Campylobacter jujuni From Messmann Atlas of Colonoscopy. 62 삼성서울병원
Observation Point for DDx: Continuity of Lesions Features of continuity Common IBDs Continuous from rectum Continuous at 1-2 segments Skip lesions UC PMC Shigellosis Campylobacter colitis Ischemic colitis Radiation colitis Medocation-associated hemorrhagic colitis Yersinia enterocolitis CD Tuberculous colitis Amebic colitis Ischemic colitis Hemorrhagic colitis (h/o Breast cancer) Radiation colitis Yersinia enterocolitis Observation Point for DDx: Continuity of Lesions Features of continuity Common IBDs Continuous from rectum Continuous at 1-2 segments Skip lesions UC PMC Shigellosis Campylobacter colitis Ischemic colitis Radiation colitis Medocation-associated hemorrhagic colitis Yersinia enterocolitis CD Tuberculous colitis Amebic colitis CD Tuberculous colitis Amebic colitis 제 17 회소화기병심포지움 63
Session 2. 하부 Observation Point for DDx: Features of ulcers Morphology & Direction Longitudinal ulcer Circular ulcer Deep & steep ulcer Common IBDs CD Ischemic colitis Tuberculosis Severe ischemic colitis CD Behcet s colitis Mucosal change adjacent to ulcers Discrete ulcer Inflammatory ulcer Common IBDs Most chronic colitis - CD - Tuberculosis - Behcet s colitis - CMV colitis - Chronic amebic Colitis Most acute colitis - UC Non-IBD and noninfectious colitis Rare forms of colitis which include colitis not caused by infectious agents or chronic IBD are often troublesome for both the patient and the physician, especially during the often protracted diagnostic process. Only a few randomized controlled studies have been performed in the recently characterized and rare forms of colitis and, most therapeutic principles are still empirical. 64 삼성서울병원
악성질환과감별이필요한상부위장관질환들 - 내시경소견을중심으로민병훈성균관대학교의과대학삼성서울병원소화기내과 악성질환과감별이필요한상부위장관질환들 - 증례와내시경소견을중심으로 삼성서울병원소화기내과 민병훈 제 17 회소화기병심포지움 127
Session 4. 상부 Tuberculous Esophagitis 인접한결핵성종격동림프절염의식도침범 결핵식도염의가장흔한원인 Subcarinal LN, Tracheobronchial LN, Paratracheal LN 중부식도에결핵식도염호발 Tuberculous Esophagitis - Endoscopic findings 궤양형 >> 비후형, 과립형 변연이융기되고가운데는깊이파인궤양성종괴형태 식도암과유사 명확한궤양경계 중부식도에호발 128 삼성서울병원
Tbc Esophagitis mimicking Eso Cancer - Differential diagnosis from esophageal cancer 내시경소견상식도암이의심되나생검조직에서비특이적진단이연속해서나올경우 Bx: Inflamed granulation tissue 병리과연락 : 항산균 (AFB) 염색, Caseation necrosis 경험적 (empirical) 항결핵제투여 진단겸치료 1 mo 5 mo Sentinel Polyp Associated with GERD Near gastroesophageal junction (GE junction) Inflammatory polypoid lesions at gastric cardia On gastric fold Risk of malignancy: nearly none 제 17 회소화기병심포지움 129
Session 4. 상부 Endoscopic Differential Diagnosis - Not clear cut Biopsy is essential!!! Sentinel Polyp Barrett s Cancer/Dysplasia Associated finding Reflux esophagitis Barrett s esophagus Shape Protruding in many cases Flat elevated in many cases Location On gastric fold Distal esophagus After PPI treatment Ultra short Barrett s esophagus Endoscopic Differential Diagnosis - Not clear cut Biopsy is essential!!! Sentinel Polyp Barrett s Cancer/Dysplasia Associated finding Reflux esophagitis Barrett s esophagus Shape Protruding in many cases Flat elevated in many cases Location On gastric fold Distal esophagus Sentinel polyp at presentation After PPI treatment 130 삼성서울병원
Cardiac GC mimicking Sentinel Polyp - Cardiac GC is increasing Biopsy is essential!!! PM, 2.2 cm, P/D SM3, 2.2 cm, P/D Gastric Syphilis - Endoscopic findings 부정형의미란과얕은궤양 자발성출혈 전정부와위각부에호발 진행된경우점막의비후동반, 위근위부침범 AGC Borrmann type 4 와유사한내시경소견 제 17 회소화기병심포지움 131
Session 4. 상부 Gastric Syphilis mimicking AGC - Differential diagnosis from AGC 내시경소견상위암이의심되나생검조직에서비특이적진단이연속해서나올경우 Bx: Ulcer with plasma cell infiltration 매독에합당한혈청학적검사소견 선별검사 : Rapid plasma reagin (RPR) 확진검사 : FTA-ABS, TPLA 경험적 (empirical) Penicillin 투여 진단겸치료 1 mo EUS-guided Fine Needle Biopsy 43 gastric SET > 2 cm 22-gauge ProCore Outcomes Successful puncture: 100% Diagnostic: 86.0% Suggestive: 4.7% Nondiagnostic: 9.3% Diagnostic yield in SMC & AMC 80-90% Lee MJ, et al. Medicine 2015;94:e1622 Lee JH, et al. Scand J Gastroenterol 2016;51:486-93 132 삼성서울병원
Unroofing Biopsy N = 40 Diagnostic yield: 90% (36/40) No procedure-related complication Tae HJ, et al. Endoscopy 2014;46:845-50 Kim JS, et al. Surg Endosc 2016;30:5304-9 AGC mimicking Subepithelial Tumor - Differential diagnosis from GIST EUS CT AGC: disrupted mucosal & submucosal layer GIST: preserved mucosal & submucosal layer AGC: perigastric LN metastasis GIST: usually no perigastric LN metastasis 제 17 회소화기병심포지움 133
Session 4. 상부 EGC mimicking Subepithelial Tumor - Need for biopsy & follow-up Wedge resection No LN dissection Depth: Muscularis mucosa, 1.5 cm ESD 했다고생각하고추적관찰 1 년 1 개월 SM3, 1.8 cm, No LN meta Summary Tuberculous esophagitis 식도암의심내시경소견, 조직검사음성시감별필요 경험적 (empirical) 항결핵제투여 진단겸치료 Sentinel polyp Barrett s adenocarcinoma, Cardiac GC 와감별필요 내시경소견만으로감별어려운경우많음 첫검사에서는반드시조직검사시행필요!!! 134 삼성서울병원
Summary Gastric syphilis 위암의심내시경소견, 조직검사음성시감별필요 매독에합당한혈청학적검사소견 경험적 (empirical) Penicillin 투여 진단겸치료 AGC mimicking gastric subepithelial tumor EUS: disrupted mucosal & submucosal layer CT: perigastric LN metastasis 제 17 회소화기병심포지움 135
대장에서궤양이보일때 김영호 성균관대학교의과대학삼성서울병원소화기내과 대장내시경에서궤양이보일때 성균관대학교의과대학삼성서울병원 김영호 제 17 회소화기병심포지움 179
Meet the Professor Infectious Colitis Symptoms acute onset fever, vomiting, abd pain, frequent bowel movement Endoscopy severe hyperemia, profuse exudate rectal sparing, patchy distribution Infectious Colitis Regardless of the etiology, clinical symptoms are quite similar. It is hard to prove the existence of pathogens. Patients whose symptoms have not improved within 1 week should undergo a sigmoidoscopy or colonoscopy. 180 삼성서울병원
Ischemic Colitis Old age Sudden onset of abdominal pain & hemtochezia Endoscopy hyperemia, edema, ulceration rectal sparing resolved within 1-2 weeks Bx : coagulation necrosis Solitary Rectal Ulcer Syndrome A chronic course characterized by rectal bleeding, disordered defecation, tenesmus and mucorrhea Endoscopy anterior wall, 4 to 15 cm from the anal verge shallow ulcers with white, sloughy base surrounded by a thin rim of erythematous mucosa 제 17 회소화기병심포지움 181
Meet the Professor Solitary Rectal Ulcer Syndrome Histology characteristic obliteration of lamina propria by fibromuscular proliferation of the muscularis mucosa streaming of fibroblasts and muscle fibers up between crypts thickening of muscularis mucosa branching, distorted glandular crypts diffuse collagen infiltration of lamina propria Crohn s Disease Discontinuous, transmural inflammation from esophagus to rectum Aphthous ulcer Longitudinal ulcer Cobblestone appearance 182 삼성서울병원
크론병진단기준개정안 ( 일본후생청, 1995) Crohn s Disease 제 17 회소화기병심포지움 183
Meet the Professor Tubeculous colitis Transverse ulcer Patulous IC valve Inflammatory polyps Tuberculous Colitis 184 삼성서울병원
Diagnosis of Tuberculous Colitis_Korean Guideline Behçet s Disease Lee CR, et al. Inflammatory Bowel Disease 2001;7:243 제 17 회소화기병심포지움 185
Meet the Professor Behçet s Disease Typical colonoscopic finding ; Single or a few deep round/oval ulcers with discrete margin in ileocecal area Behçet s Disease 186 삼성서울병원