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SMC 내시경퀴즈 21 회 성균관대학교의과대학내과이준행

Q21-1. 중부식도입니다. 소견과진단은?

A21-1. 식도암. 점막병소보다점막하병소가현저하였던경우 Esophagus and upper stomach, 3-field operation: Invasive squamous cell carcinoma, poorly differentiated, middle thoracic esophagus : 1) tumor size: 6x5 cm 2) extension to periesophageal soft tissue (adventitia) (pt3) 3) lymphovascular invasion: not identified 4) perineural invasion: present 5) resection margins: involved circumferential margin by carcinoma negative other resection margins, safety margin: proximal, 8.5 cm ; distal, 3.5 cm ; 6) no metastasis in 72 regional lymph nodes

Q21-2. 소견과진단은?

A21-2. Fundic gland polyposis in FAP

Q21-3. 소견과진단은?

A21-3. EGC IIb Early gastric carcinoma 1. Location : middle third, Center at body and anterior wall 2. Gross type : EGC type IIb 3. Histologic type : tubular adenocarcinoma, poorly differentiated 4. Histologic type by Lauren : mixed 5. Size : 5.3x3.2 cm 6. Depth of invasion : invades mucosa (muscularis mucosae) (pt1a) 7. Resection margin: free from carcinoma safety margin: proximal 3.7 cm, distal 5.8 cm 8. Lymph node metastasis : no metastasis in 48 regional lymph nodes (pn0) 9. Lymphatic invasion : not identified 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. Peritoneal cytology : negative

Q21-4. Rectum. 소견과진단은? 12 months later

A21-4. SMT-like rectal cancer

Q21-5. 소견과진단은? - Recurrent oral ulcer (+)

A21-5. Intestinal Behcet s disease 베체트장염진단가이드라인. 대한소화기학회지 2009;53:187-193

Acting 선생님은 PDF로되어있는문제를모두에게전달해주세요. 각자소견과진단 (first impression 하나만 ) 을 A4 용지에작성하여다음주월요일오후까지 acting 선생님께전달해주세요. Acting 선생님은목요일집담회때발표해주세요.

SMC 내시경퀴즈 22 회 성균관대학교의과대학내과이준행

Q22-1. 식도입니다. 소견과진단은?

A22-1. Herpetic esophagitis 6 years after subtotal gastrectomy - Valaciclovir 1,000mg 1 주처방함 Treatment for herpetic esophagitis is the same as other herpes simplex infections in the immunocompetent host, such as prompt initiation of a 7- to 10-day course of orally administered acyclovir or valacyclovir. Occasionally, severe odynophagia necessitates initial treatment with intravenous acyclovir, 250 mg/m2 every 8 hours and then changing to oral therapy when the patient can take oral medication. Given the relative rarity of esophageal involvement, however, no outcome data exist specifically on treating esophageal herpes simplex infection. Sleisenger textbook 2006

참고자료 : 보다전형적인 herpetic esophagitis

Q22-2. 소견과진단은?

A22-2. Diffuse large B cell lymphoma After chemotherapy

Q22-3. 소견과진단은?

A22-3. EGC Early gastric carcinoma 1. Location : lower third, Center at angle and posterior wall 2. Gross type : EGC type IIb 3. Histologic type : tubular adenocarcinoma, poorly differentiated 4. Histologic type by Lauren : diffuse 5. Size : 1x1 cm 6. Depth of invasion : invades mucosa (muscularis mucosae) (pt1a) 7. Resection margin: free from carcinoma, safety margin: proximal 3 cm, distal 5.5 cm 8. Lymph node metastasis : no metastasis in 37 regional lymph nodes (pn0) 9. Lymphatic invasion : not identified 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. AJCC stage by 7th edition: pt1a N0

Q22-4. 소견과진단은?

A22-4. Acute diverticulitis

Q22-5. 소견과진단은?

A22-5. FAP with colon cancer 0 16 33 39 42 50 Adenoma Symptom Cancer Death Feldman: Sleisenger's GI and Liver Disease, 7th:2002;p2199

SMC 내시경퀴즈 23 회 성균관대학교의과대학내과이준행

Q23-1. Dysphagia 환자의상부식도

A23-1. 상부식도암 Esophagus, 13cm from incisor, biopsy: SQUAMOUS CELL CARCINOMA, MODERATELY DIFFERENTIATED

Q23-2. 소견과진단은?

A23-2. EGC Early gastric cancer 1. Location : lower third, Center at low body and greater curvature 2. Gross type : EGC type IIc 3. Histologic type : tubular adenocarcinoma, well differentiated 4. Histologic type by Lauren : intestinal 5. Size : 2.4x1.8 cm 6. Depth of invasion : invades mucosa (muscularis mucosae) (pt1a) 7. Resection margin: free from carcinoma, safety margin: proximal 5 cm, distal 5 cm 8. Lymphatic invasion : not identified 9. Venous invasion : not identified 10. Perineural invasion : not identified 11. Lymph node metastasis : no metastasis in 37 regional lymph nodes (pn0)

Q23-3. 소견과진단은?

A23-3. BGU 2 months later

Q23-4. 소견과진단은?

A23-4. Colon MALToma Dense infiltration of small lymphocytes with lymphoid follicle formation and multifocal lymphoepithelial lesions, suggestive of EXTRANODAL MARGINAL ZONE LYMPHOMA OF MALT

Q23-5. 소견과진단은?

A23-5. Solitary rectal ulcer syndrome Chronic benign condition Characterized by single or multiple shallow ulcers surrounded by a hyperemic margin Located in the majority of cases on the anterior or anterolateral rectal wall Not all cases are associated with ulceration Polypoidal or patchy granular hyperemic lesions have been described.

A23-5. Solitary rectal ulcer syndrome Endoscopic findings shallow ulcer with a white base surrounded by a rim of erythematous mucosa size : a few milimeters to several centimeters broad-based polypoidal lesions : 25% patchy granular or velvety hyperemic mucosa : 18%

SMC 내시경퀴즈 24 회 성균관대학교의과대학내과이준행

Q24-1. 소견과진단은? 심달도는?

A24-1. 조기식도암 Invasive squamous cell carcinoma, poorly differentiated with basaloid feature, lower thoracic esophagus : 1) tumor size: 1.3x1.0 cm 2) extension to submucosa (sm3) 3) endolymphatic tumor emboli: not identified 4) perineural invasion: not identified 5) resection margins: free from carcinoma 6) no metastasis in 41 regional lymph nodes 7) treatment effect: no prior treatment

Q24-2. 소견과진단은?

A24-2. Gastric amyloidosis

Q24-3. 소견과진단은?

A24-3. Extrinsic compression by hepatic hemangioma

Q24-4. Stomach 입니다. 소견과진단은?

A24-4. Acute phlegmonous gastritis

Q24-5. 소견과진단은?

A24-5. Acute appendagitis

SMC 내시경퀴즈 25 회 성균관대학교의과대학내과이준행

Q25-1. 소견과진단은?

A25-1. Barrett adenocarcinoma 1. Location : [1] esophagus, [2] upper third, center at cardia (gastroesophageal junction) and greater curvature 2. Gross type : EGC type IIa 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : 1.2x0.8 cm 6. Depth of invasion : extension to mucosa (muscularis mucosa) (pt1a) 7. Resection margin: free from carcinoma8. Lymph node metastasis : no metastasis in 22 regional lymph nodes (pn0) 9. Lymphatic invasion : not identified 10.Venous invasion : not identified 11.Perineural invasion : not identified 12.Associated findings : Barrett esophagus

Q25-2. 소견과진단은?

A25-2. Gastric carcinoid Stomach, mid body, greater curvature, wedge resection :. Carcinoid tumor (well differentiated neuroendocrine tumor): 1) tumor size: 0.8x0.8cm 2) mitosis: 0/10 HPFs 3) confined to submucosa 4) no endolymphatic tumor emboli 5) no perineural invasion 6) negative resection margins. Synaptophysin: Positive in tumor cells. Chromogranin : Positive in tumor cells. Ki-67: Positive in about 5% of tumor cells. D2-40: Demonstrates no endolymphatic tumor emboli

Q25-3. 소견과진단은?

A25-3. Tenia asciatica 할머니의영향으로어릴때부터돼지생간을많이먹어온 43세남자환자입니다. 1년전부터칼국수같은모양의운동성기생충이항문으로나오는것을주소로내원하였습니다. 대장내시경에서는전형적인 tape worm이발견되었고아시아조충 (Taenia asiatica) 로진단되었습니다. 아시아조충은과거무구조충 (Taenia saginata) 으로분류되었던것입니다. 무구조충의중간숙주는소이며소고기육회등을먹어서감염됩니다. Cysticercosis는일으키지않습니다. 그러나이상하게도우리나라를비롯한아시가여러나라에분포하는무구조충은소가전혀없는지역에서발견되었습니다. 주로대만에서이에대한연구가활발히진행되었고중간숙주를돼지로하는무구조충의아형 (Taenia saginata taiwanensis) 으로분류되었다가최종적으로아시아조충으로명명되었습니다. 우리나라에서는주로돼지간을날로먹는습성이있는지역에서발견됩니다. Praziquantel 10 mg/kg로잘치료됩니다.

Q25-4. 소견과진단은?

A25-4. Chronic ischemia related with AAA

Q25-5. s/p total gastrectomy due to AGC. 소견과진단은?

A25-5. Colon metastasis from stomach cancer

SMC 내시경퀴즈 26 회 성균관대학교의과대학내과이준행

Q26-1. 상부식도. 소견과진단은?

A26-1. Inlet patch

Q26-2. 소견과진단은?

A26-2. Lymphangioma

Q26-3. 소견과진단은?

A26-3. Cavernous hemangioma

Q26-4. 소견과진단은?

A26-4. Mesenteric phlebosclerosis 만성복통으로내원하신 70대여자입니다. 내시경과 CT 후 mesenteric phlebosclerosis는 chronic ischemic colitis를일으키는원인미상의드문질환으로진단되었습니다. 내시경에서는궤양과함께꺼무접접한점막으로관찰되었습니다 (Rectum쪽은정상이었음 ). Imaging 에서는 right colon의 vessel에 linear calcification이보였습니다. Dis Colon Rectum 2003;46:209-20에보고된 7 증례에대한기술을요약하면아래와같습니다. All seven patients had calcifications in the small mesenteric veins and their intramural branches. No evidence of vasculitis or portal hypertension was recognized. Clinical findings included abdominal pain and diarrhea of a gradual onset and chronic course. A positive fecal occult blood test and mild anemia were often found. The patients had linear calcifications and stenosis in the right colon, which were discovered by plain abdominal radiography and barium enema, respectively. Endoscopic findings included edematous, dark colored mucosa and ulcerations. Four patients underwent a subtotal colectomy because of persistent abdominal pain or ileus. The histopathologic findings were macroscopically characterized by a dark purple or dark brown colored colonic surface, the swelling and disappearance of plicae semilunares coli, and marked thickening of the colonic wall, while they were microscopically characterized by marked fibrous thickening of the venous walls with calcifications, marked submucosal fibrosis, deposition of collagen in the mucosa, and foamy macrophages within the vessel walls.

Q26-5. Rectum. 소견과진단은?

A26-5. Rectal neuroendocrine tumor 1. Name of Procedure: transanal endoscopic microsurgery 2. Site of Tumor: rectum 3. Diagnosis: Neuroendocrine tumor 4. WHO classification(2010): Neuroendocrine tumor(g2) 5. Multiplicity: Single 6. Size: 0.8x0.6 cm 7. Extent: Proper Muscle (pt2) 8. Grading: Mitotic Count(/HPF): 0-1, Ki-67 labeling index: G2 3-20% 9. Resection Margins: Negative AJCC stage: stage IIA (pt2 N0 M0)

SMC 내시경퀴즈 27 회 성균관대학교의과대학내과이준행

Q27-1. 소견과진단은?

A27-1. Right pyriform sinus cancer

Q27-2. 소견과진단은? Depth of invasion 은?

A27-2. SM cancer 1. Location : lower third, Center at antrum and lesser curvature 2. Gross type : EGC type IIa+IIc 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : 1.6x1 cm 6. Depth of invasion : invades submucosa (sm3) (pt1b) 7. Resection margin: free from carcinoma 8. Lymph node metastasis : metastasis to one out of 31 regional lymph nodes (pn1) 9. Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. AJCC stage by 7th edition: pt1b N1

Q27-3. 위암환자의복강경입니다. 소견과진단은?

A27-3. 무증상공단검진내시경에서발견된위암 (signet ring cell carcinoma) 환자의 diagnostic laparoscopy 에서발견된복막의 seeding nodules

Q27-4. 십이지장입니다. 소견과진단은?

A27-4. 브루너샘과형성 Brunner's gland hyperplasia (Johann Conrad Brunner, 1653-1727, Swiss anatomist) is the hypertrophy of tubuloalveolar glands in the submucosal layer of the duodenum. They are most numerous in the duodenal bulb proximal to the pyloric canal and their number decreases gradually in the second and third part of the duodenum. They are not usually present in the jejunum or the ileum. It has been reported that their number increases in patients with cystic fibrosis, uraemia and Zollinger Ellison syndrome. Hyperplasia of Brunners glands probably represents a response of the duodenal mucosa to peptic ulcer disease.

Q27-5. 급성설사. 대장입니다. 소견과진단은?

A27-5. 감염성장염. 상세원인모름

SMC 내시경퀴즈 28 회 성균관대학교의과대학내과이준행

Q28-1. 소견과진단은?

A28-1. Diaphragmatic eventration

Q28-2. 진단은?

A28-2. 양성위궤양

Q28-3. 소견과진단은?

A28-3. Duodenal MALT lymphoma RT

Q28-4. 대장. 소견과진단은?

A28-4. Cavernous hemangioma

Q28-5. 소견과진단은? - History of prostate cancer treatment

A28-5. Radiation-induced proctitis

SMC 내시경퀴즈 29 회 성균관대학교의과대학내과이준행

Q29-1. 소견과진단은?

A29-1. Reflux esohpagitis LA-D, hiatal hernia

Q29-2. 젊은환자위암입니다. 심달도는?

A29-2. T4 였습니다. 매우심했습니다. Advanced gastric carcinoma 1. Location : middle third, Center at body and greater curvature 2. Gross type : Borrmann type 3 3. Histologic type : tubular adenocarcinoma, poorly differentiated 4. Histologic type by Lauren : mixed 5. Size : 6.5x6 cm 6. Depth of invasion : invades serosa (pt4a) 7. Resection margin: free from carcinoma 8. Lymph node metastasis : metastasis to 48 out of 67 regional lymph nodes (pn3b) 9. Lymphatic invasion : present(+++) 10. Venous invasion : present(extramural) 11. Perineural invasion : present 12. AJCC stage by 7th edition: pt4a N3b

Q29-3. 십이지장입니다. 소견과진단은?

A29-3. Duodenal varix - 절대로조직검사하면안됩니다.

Fatal duodenal varix bleeding

Q29-4. 십이지장입니다. 소견과진단은?

A29-4. Angiodysplasias APC ablation 으로치료하였습니다.

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)

Q29-5. 간이식환자입니다. 소견과진단은? Follow-up endoscopy

A29-5. Transplant-Associated Thrombotic Microangiopathy (TA-TMA) Nasal diffuse large B cell lymphoma 로항암치료를받고관해 상태중 acute hepatitis B with toxic hepatitis 로 living related liver transplatation 을받은분입니다. 설사로대장내시경을하 였고 "From D-colon to S-colon, several longitudinal ulcers with submucsal heamorrhage, edematous margin was noticed" 의소견이었으며조직검사는 "Suggestive of thrombotic microangiopathy with multifocal ischemic change" 로보고되었습니다. 진단은 Transplant-Associated Thrombotic Microangiopathy (TA-TMA) 로생각되었습니다. TA-TMA 의소견은 ischemic colitis 와유사할수있다고합니다.

SMC 내시경퀴즈 30 회 성균관대학교의과대학내과이준행

Q30-1. 소견과진단은? 8 years later

A30-1. Sentinel polyp + reflux esophagitis + hiatal hernia

Q30-2. M/D adenocarcinoma. Would you ESD?

A30-2. EGC, SM, Lymphatic (+) 1-3. Stomach, subtotal gastrectomy: Early gastric carcinoma 1. Location : lower third, Center at antrum and greater curvature 2. Gross type : EGC type IIc 3. Histologic type : tubular adenocarcinoma, moderately differentiated 4. Histologic type by Lauren : intestinal 5. Size : 1.7x0.8 cm 6. Depth of invasion : invades submucosa (sm2) (pt1b) 7. Resection margin: free from carcinoma 8. Lymph node metastasis : no metastasis in 24 regional lymph nodes (pn0) 9. Lymphatic invasion : present 10. Venous invasion : not identified 11. Perineural invasion : not identified 12. AJCC stage by 7th edition: T1b N0

Q30-3. 소견과진단은?

A30-3. Small bowel bezoar 수술함

Q30-4. 소견과진단은?

A30-4. Duodenal varix in Budd-Chiari syndrome 간문맥고혈압환자에서발생하는정맥류출혈은대량출혈및재출혈빈도가높아서빠르고정확한진단과치료가요구되는응급질환이다. 출혈부위는식도및위정맥류출혈이대부분이지만드물게는이소성으로십이지장, 공장, 회장, 충수돌기, 하행결장, 직장및 S자결장등에서도발생할수있다. 그중십이지장정맥류는이소성정맥류의 1/3을차지하고출혈은거의발생하지않는것으로알려져왔다. 그러나일단출혈하게되면생명의위협이될정도로심하다. 최근에는십이지장정맥류출혈시비수술적인방법으로내시경적경화술, 내시경적결찰술, 경정맥간내문맥-간정맥단락술 (transjugular intrahepatic portosystemic shunt) 등이보고되고있지만아직효율적인치료방법은정립되어있지않다.

Q30-5. 태어날때부터피부에 hemangioma 가다수있었습니다. 빈혈로검사를하였습니다. 진단은?

A30-5. Blue rubber breb nevus syndrome A rare disorder that consists mainly of abnormal blood vessels affecting the gastrointestinal tract by William Bean in 1958 a venous malformation, formerly, though incorrectly, thought to be related to the hemangioma skin, small bowel, distal large bowel >> brain, liver, muscle

Blue rubber breb nevus syndrome Fishman, S. J. Annals of Surgery 241(3) 2005

Blue rubber breb nevus syndrome Clinical manifestations presents soon after birth. Melena, hematochezia, intussusception, hemothorax, hemopericardium, pul HTN, dementia, paraparesis, ataxia Genetic link?? It may be associated with TEK tyrosine kinase. Medical treatment: iron supplementation, steroids, interferon, octerotide Treatment modalities for GI lesion: laser photocoagulation, band ligation, and polypectomy

Fishman, S. J. Annals of Surgery 241(3) 2005