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EndoTODAY ³»½Ã°æ ±³½Ç


[Clostridum difficile infection (CDI). Pseudomembranous colitis. À§¸·¼º Àå¿°]

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1. Epidemiology & clinical pictures

¹Ì±¹¿¡¼­ nosocomial C. difficile °¨¿°Àº Áõ°¡ÇÏ°í ÀÖ½À´Ï´Ù.

±¹³»¿¡¼­µµ Áõ°¡ÇÏ°í ÀÖ½À´Ï´Ù.

¿©·¯ risk factor°¡ ÀÖ½À´Ï´Ù.

ƯÁ¤ À¯ÀüÀÚÇü¿¡ °¨¿°µÇ¸é ÈξÀ ½ÉÇÑ °æ°ú¸¦ ¹â´Â´Ù°í ÇÕ´Ï´Ù.

¸¹Àº Á¾·ùÀÇ Ç×»ýÁ¦¿Í °ü·ÃµÇ¾î ÀÖ½À´Ï´Ù.

Proton pump inhibitor¿Í °ü·Ã¼ºÀÌ ³ô½À´Ï´Ù. ¾à 3-4¹è À§ÇèÇÕ´Ï´Ù.

¹«Áõ»ó carrier ºÎÅÍ ÁßÁõ Áúȯ±îÁö ´Ù¾çÇÑ ÀÓ»ó»óÀ» º¸ÀÏ ¼ö ÀÖ½À´Ï´Ù.

2022³â Á÷¿ø Çʼö±³À°À» ¹Þ´Ù°¡ ÀÌ ¹®Á¦¸¦ Ʋ·È½À´Ï´Ù. C. difficile infectionÀº Á¢ÃË°¨¿°ÀÌ µË´Ï´Ù. º´½Ç¿¡¼­ ȯ°æ¼Òµ¶À» Àß ÇØ¾ß ÇÕ´Ï´Ù. ÀϹÝȯ°æ¼Òµ¶Á¦°¡ ¾Æ´Ñ ¶ô½º³ª ¹ÙÀÌ¿À½ºÆÌÀ¸·Î ¼Òµ¶ÇØ¾ß ÇÕ´Ï´Ù.


2. Endoscopy

CRF ȯÀÚ¿¡¼­ ¹ß°ßµÈ À§¸·¼º ´ëÀå¿°

NTMÀ¸·Î Åõ¾àÁßÀΠȯÀÚ¿¡¼­ ¹ß°ßµÈ À§¸·¼º ´ëÀå¿°

À§¸·¼º ´ëÀå¿°ÀÇ white patchµéÀº ºñ±³Àû ±ÕÀÏÇÑ °ÍÀÌ Æ¯Â¡ÀÔ´Ï´Ù. ±×·¯³ª ¾Æ·¡ Áõ·Êó·³ ¼­·Î Å©±â°¡ ´Ù¸¥ °æ¿ìµµ ÀÖ½À´Ï´Ù.


3. Diagnosis

Toxins A and B bind to, and are endocytosed by, intestinal epithelial cells. It is thought that only the enzyme domain enters the cytosol from acidic endosomal compartments. In the cytosol, the toxins glucosylate Rho GTPases, which inhibits Rho protein functions and Rho signalling pathways. The tight junctions, and therefore the barrier function, of the epithelium are disturbed, which results in diarrhoea. Epithelial cells produce inflammatory factors, including interleukin-8 (IL8) and macrophage inflammatory protein 2 (MIP2). Toxins that reach subepithelially located monocytes and macrophages might stimulate release of cytokines. Similarly, toxins A and B induce activation of intestinal neuronal cells to release corticotropin-releasing hormone (CRH) and substance P, which also activates macrophages and monocytes. Neutrophil invasion occurs, which induces a dramatic inflammatory response.

¿À·¡µÈ ½½¶óÀ̵åÀÔ´Ï´Ù. °ú°Å¿¡´Â toxin°ú ¹è¾çÀ¸·Î Áø´ÜÇß´Ù´Â ³»¿ëÀÔ´Ï´Ù. 2014³â ÀÌÈÄ¿¡´Â toxin°ú PCR·Î Áø´ÜÇÏ°í ÀÖ½À´Ï´Ù. ÀÓ»ó»óÀÌ ¶Ñ·ÇÇÏ°í toxinÀÌ ¾ç¼ºÀ̸é PCRÀ» ÇÏÁö ¾Ê°í Ä¡·áÇÕ´Ï´Ù. ÀÓ»óÀûÀ¸·Î Àǽɵǰí toxinÀÌ À½¼ºÀ̸é PCRÀ» ½ÃÇàÇÕ´Ï´Ù.

°¡Àå Áß¿äÇÑ ½½¶óÀ̵åÀÔ´Ï´Ù. Áø´ÜÇÏ¸é ´õ ÀÌ»ó °Ë»ç¸¦ ³¾ ÇÊ¿ä°¡ ¾ø½À´Ï´Ù. °¡À̵å¶óÀο¡µµ "Repeat testing should be discouraged"¶ó°í °­ÇÏ°Ô ÃßõµÇ°í ÀÖ½À´Ï´Ù. "Testing for cure"µµ ÇÏÁö ¸»¶ó´Â °ÍÀÔ´Ï´Ù. ºÒÇÊ¿äÇÑ ÃßÀû°Ë»ç ÇÏÁö ¸¿½Ã´Ù. °Ë»ç ÀÚÁÖ ³½´Ù°í ȯÀÚ°¡ ÁÁ¾ÆÁö´Â °ÍÀÌ ¾Æ´Õ´Ï´Ù.

Radiology. 2022-3-11. »ï¼º¼­¿ïº´¿ø ½Ä´ç ¾Õ °Ô½ÃÆÇ

Pathology


»ï¼º¼­¿ïº´¿ø¿¡¼­´Â 2014³â 7¿ù C. difficile¿¡ ´ëÇÑ À¯ÀüÀÚ °Ë»ç°¡ ½Å¼³µÇ¾ú½À´Ï´Ù. Áø´Ü°Ë»çÀÇÇаú·ÎºÎÅÍÀÇ ¸ÞÀÏÀ» ¿Å±é´Ï´Ù. º¸´Ù ÀÚ¼¼ÇÑ ³»¿ëÀº ¿©±â¸¦ ÂüÁ¶ÇϽñ⠹ٶø´Ï´Ù.

- C. difficile °¨¿°Áõ Áø´ÜÀ» À§ÇØ ±âÁ¸¿¡ »ç¿ëÇÏ´ø µ¶¼ÒÇ׿ø/¹è¾ç°Ë»ç(BL4225 Clostridicum difficile Toxin & Culture)¿Í º°µµ·Î µ¶¼ÒÀ¯ÀüÀÚ(BL4226 C.difficile toxin gene, detection) °Ë»ç°¡ ½Å¼³µÊ
- µ¶¼ÒÇ׿ø °Ë»ç ´ëºñ ¹Î°¨µµ°¡ ¿ì¼öÇÔ(Toxin Ag ~50% vs Toxin Gene ~90%)
- ½Å¼Ó ºÐÀÚÁø´Ü°Ë»ç·Î¼­ ¿ÀÀü Áß ÀǷڽà ´çÀÏ º¸°í µÊ(±Ý¿äÀÏ ¿ÀÈÄ ¹× ÁÖ¸»/°øÈÞÀÏ Á¦¿Ü)
- ´Ü, ±âÁ¸ÀÇ µ¶¼ÒÇ׿ø ¹× ¹è¾ç °Ë»ç´Â ±Þ¿©°Ë»ç(34,455¿ø)ÀÎ ¹Ý¸é Toxin Gene °Ë»ç´Â ºñ±Þ¿©°Ë»ç(84,000¿ø)ÀÓ
- µû¶ó¼­, C. difficile °¨¿°ÁõÀÌ ÀÇ½ÉµÇ¾î ½Å¼ÓÇÏ°Ô Áø´ÜÇÏ°íÀÚ ÇÒ °æ¿ì ÁÁÀº °Ë»çÀÓ

2018³â 6¿ù


4. Treatment

Ä¡·á¾àÀº °á±¹ metronidazole ȤÀº vancomycin °æ±¸Åõ¿©ÀÔ´Ï´Ù. ±×·±µ¥ ÃÖ±Ù °¡À̵å¶óÀο¡¼­´Â primary·Î vancomycinÀ» °æ±¸ Åõ¿©ÇÏ°í, ¸¸¾à vancomycinÀÌ available ÇÏÁö ¾ÊÀ» ¶§ °æÁõ ȯÀÚ¿¡ ÇÑÇÏ¿© metronidazoleÀ» ¾²µµ·Ï ÇÏ°í ÀÖ½À´Ï´Ù.

¿À·¡µÈ ±¹³» °¡À̵å¶óÀÎÀ̹ǷΠmetronidazoleÀÌ primary·Î ¾ð±ÞµÇ¾î ÀÖ½À´Ï´Ù. ±×·¯³ª ÀÌÁ¦´Â vancomycin (ȤÀº fidaxomicin) °æ±¸ Åõ¿©°¡ primary optionÀÔ´Ï´Ù. ±¹³» °¡À̵å¶óÀÎ °³Á¤ÀÌ ÇÊ¿äÇÕ´Ï´Ù.

2018³â °¡À̵å¶óÀÎÀÔ´Ï´Ù. Vancomycin °æ±¸ Åõ¿©°¡ primary optionÀ¸·Î ¸íÈ®È÷ ¾ð±ÞµÇ¾î ÀÖ½À´Ï´Ù.

Àç¹ß¿¹¿¡ ´ëÇÑ Ä¡·á¿øÄ¢ÀÔ´Ï´Ù.

Probiotics´Â ÇѸ¶µð·Î È¿°ú°¡ ¾ø½À´Ï´Ù.

À¯¸ÁÇÑ Ç×»ýÁ¦°¡ Àִµ¥ 2018³â ÇöÀç ±¹³»¿¡´Â µé¾î¿ÀÁö ¾Ê¾Ò½À´Ï´Ù. °¡°Ý¶§¹®ÀÎ ¸ð¾çÀÔ´Ï´Ù.


5. Fecal transplantation

ÇöÀç·Î¼­ refractoryÇÑ °æ¿ì ÃÖ¼±ÀÇ Ä¡·á´Â fecal transplantationÀÔ´Ï´Ù. Áø´Ü°Ë»çÀÇÇаú¿¡¼­ stool preparationÀ» ÇÏ°í ¼ÒÈ­±â³»°ú¿¡¼­ infusion¸¸ ÇÏ´Â °æ¿ìµµ ÀÖ°í, ¸ðµç °úÁ¤À» ¼ÒÈ­±â³»°ú¿¡¼­ ½ÃÇàÇÏ´Â °æ¿ìµµ ÀÖ½À´Ï´Ù.

¹®Çå¿¡ º¸°íµÈ ÀÎÇÏ´ë Áõ·ÊÀÔ´Ï´Ù.

C. difficile °¨¿°Àº ¼ÕÀ§»ý°ú °ü·ÃµÇ¾î ÀÖ½À´Ï´Ù. Spore¸¦ ÅëÇÏ¿© ¿Å±â¹Ç·Î ¾ËÄڿ÷δ ºÎÁ·ÇÏ°í ±ú²ýÇÏ°Ô ºñ´©·Î ±â°èÀûÀ¸·Î ¾Ä¾î¾ß ÇÕ´Ï´Ù.


[FAQ]

[2018-9-10. Fellow ¼±»ý´ÔÀÇ Áú¹®]

CDI Áø´Ü ÈÄ Ä¡·á¸¦ Çϸ鼭 toxin assay³ª PCR °Ë»ç¸¦ ¹Ýº¹ÇÏ´Â °ÍÀº Àǹ̰¡ ¾ø´Â °ÍÀº Àß ¾Ë°Ú½À´Ï´Ù. ±×·¡¼­ÀÎÁö ¾Ë ¼ö ¾øÀ¸³ª °£È¤ sigmoidoscopy follow upÀÌ ÀǷڵǰí ÀÖ½À´Ï´Ù. ¾î¶»°Ô ÇÏ´Â °ÍÀÌ ÁÁÀ»±î¿ä?

[2018-9-10. ¿©·¯ ¼±»ý´Ôµé°ú ³íÀÇ ÈÄ ÀÌÁØÇà ´äº¯]

CDI Ä¡·á¸¦ ½ÃÀÛÇÏ°í Áõ¼¼°¡ È£ÀüµÇ¸é sigmoidoscopy°¡ ÇÊ¿äÇÏÁö ¾Ê½À´Ï´Ù. ¸¸¾à ¼³»ç°¡ ´Ù½Ã ½ÃÀÛÇÏ¿´´Âµ¥ CDI°¡ ¹®Á¦ÀÎÁö Ȥ½Ã ´Ù¸¥ ¿øÀÎÀº ¾ø´ÂÁö ¾Ë°íÀÚ sigmoidoscopy°¡ ó¹æµÇ¸é °Ë»çÇØ µå¸± ¼ö ¹Û¿¡ ¾øÀ» °Í °°½À´Ï´Ù. °¡±ÞÀû ÃßÀû°Ë»ç´Â ÇÏÁö ¸»µµ·Ï ±ÇÇغ¸±â´Â ÇÏ°Ú½À´Ï´Ù.


[References]

1) Clostridium difficile infection - ÀÏ¿ø³»½Ã°æ±³½Ç ¿ù¿äÁ¡½ÉÁý´ãȸ 2016-4-11

2) EndoTODAY fecal transplantation

© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.