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[Thursday Endoscopy Conference 20171019]

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1. AGC

ÀÇ¿Ü·Î BGU °°´Ù°í ¸»¾¸ÇϽŠºÐÀÌ ¸¹¾Ò½À´Ï´Ù. ±×·¯³ª edge°¡ sharp ÇÏ´Ù°í ¸ðµÎ BGU´Â ¾Æ´Õ´Ï´Ù. ¹Ù´ÚÀÌ ¾è°í ºÒ±ÔÄ¢Çϸç, ÁÖº¯ Á¡¸·ÀÌ edema Ä¡°í´Â ¾à°£ unevenÇÏ°í hyperemia°¡ »êÀçµÇ¾î ÀÖ½À´Ï´Ù. ¸Ö¸®¼­ fold°¡ ²ø·Á¿À´Â ulcer edge¿¡¼­ ³¡³ªÁö ¾Ê°í edemaó·³ ºÎÅùÇÑ ºÎÀ§¿Í Á¤»óºÎÀ§ÀÇ °æ°è¿¡¼­ ³¡³ª°í ÀÖ½À´Ï´Ù. ÀÌ ¸ðµç ¼Ò°ßÀº ¾ÏÀ» ½Ã»çÇÏ´Â °ÍÀÔ´Ï´Ù. Edge Çϳª¸¸ º¸°í ¾Ï°ú BGU¸¦ ±¸ºÐÇÏ¸é °ï¶õÇÕ´Ï´Ù.

Stomach, subtotal gastrectomy:
. Advanced gastric carcinoma (arising in an adenoma)
1. Location : lower third, Center at body and posterior wall
2. Gross type : Borrmann type 3
3. Histologic type : tubular adenocarcinoma, well differentiated
4. Histologic type by Lauren : intestinal
5. Size : 4.1x3 cm
6. Depth of invasion : invades serosa (pT4a)
7. Resection margin: free from carcinoma, safety margin: proximal 3.5 cm, distal 6.5 cm
8. Lymph node metastasis : metastasis to 1 out of 59 regional lymph nodes (pN1) (perinodal extension: present) (1/59: "3,5", 1/22; "4,6", 0/14; "5", 0/1; "6", 0/5; "7", 0/3; "9", 0/4; "8a", 0/2; "11P", 0/3; "12a", 0/2; "4sb", 0/0; "1", 0/3)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : present
12. Peritoneal cytology : negative
13. AJCC stage by 7th edition: pT4a N1


2. Duodenal adenoma or ampullary adenoma

½ÊÀÌÁöÀå ¼±Á¾ÀÌ ampulla of Vater¸¦ involveÇÑ °ÍÀÎÁö, ampulla of Vater ¼±Á¾ÀÌ ½ÊÀÌÁöÀåÀ» involveÇÑ °ÍÀÎÁö ¸íȮġ ¾Ê¾Ò½À´Ï´Ù. ¼ö¼ú ÈÄ º´¸® °á°ú´Â ampullary adenoma·Î ¹Þ¾Ò½À´Ï´Ù¸¸...

Ampulla, duodenum, common bile duct pancreas, PRPD :
. Histopathologic diagnosis: Ampullary adenoma
. Tubulovillous adenoma with high grade dysplasia;
1) size of adenoma: 3x2 cm (size of high grade dysplasia: 1 cm)
2) involvement of periampullary duodenum and distal portion of pancreatc duct mucosa
3) resection margin : free from adenoma
4) reactive regional lymph nodes


3. Amebic colitis

Chronic diarrhea with episodes of hematochezia

ÀÌÁú¾Æ¸Þ¹Ù´Â Àü¼¼°è Àα¸ÀÇ 10%°¡ °¨¿°µÇ¾î ÀÖÀ¸¸ç ÀÌ Áß 90%´Â ¹«Áõ»óÀÔ´Ï´Ù. ±â»ýÃæ ÁúȯÁß ¾Æ¸Þ¹ÙÁõÀº schistosomiasis¿Í ¸»¶ó¸®¾Æ¿¡ À̾î 3¹ø°·Î ¸¹Àº »ç¸Á¿øÀÎÀÔ´Ï´Ù.

¼ÒÈ­°ü¿¡ ±â»ýÇÏ´Â ¾Æ¸Þ¹Ù´Â ÀÌÁú¾Æ¸Þ¹Ù, ´ëÀå¾Æ¸Þ¹Ù (Entamoeba coli), ¿Ö¼Ò¾Æ¸Þ¹Ù (Endolimax nana), ¿äµå¾Æ¸Þ¹Ù(Iodoamoeba butschii) µîÀÌÁö¸¸ º´¿ø¼ºÀÌ ¶Ñ·ÇÇÑ °ÍÀº ÀÌÁú¾Æ¸Þ¹Ù »ÓÀÔ´Ï´Ù.

ÁÖ·Î À½½ÄÀ» ÅëÇÏ¿© ¸Å°³µË´Ï´Ù. À½½Ä¹°ÀÇ ÀÌÁú¾Æ¸Þ¹Ù ¾¾½ºÆ®°¡ ¿øÀÔ´Ï´Ù. ±Þ¼º¾Æ¸Þ¹ÙÁõÀÇ ´ëÇ¥ÀûÀÎ Áõ»óÀº °¨¿° 2-6ÁÖ°æ ½ÃÀ۵Ǵ ÀÌÁúÀε¥ ¼³»çº¯Àº ÁÖ·Î Á¡¾×°ú Ç÷¾×ÀÌ°í fecal materialÀº º°·Î ¾ø½À´Ï´Ù. tenesmus, ÇϺ¹ºÎÀÇ µ¿Åë°ú ´õºÒ¾î º¯¼Ò ³»¿ÕÀÌ ÇÏ·ç¿¡µµ 10-12ȸ¿¡ À̸£¸ç ´ëº¯Àº »ý¼± ³»ÀåÀÇ ½âÀº ³¿»õ°¡ ³³´Ï´Ù. °¨¿°ÀÌ ¿À·¡µÇ¸é º¯ºñ, loose stool, º¹ºÎÆظ¸°¨, ÇϺ¹ºÎÀÇ µÐÅëµî ºñƯÀÌÀûÀÎ Áõ»óÀ¸·Î º¯ÇÏ´Â °æÇâÀÌ ÀÖ½À´Ï´Ù.

¾Æ¸Þ¹Ù Àå¿°ÀÇ ´ëÀå³»½Ã°æ Ãʱâ¼Ò°ßÀº small ulcers with heaped up margins and normal intervening mucosaÀÔ´Ï´Ù. ±Ë¾çÀº Á¡¸·ÇÏÃþÀ¸·Î extensionµÇ¾î Ư¡ÀûÀÎ Çöó½ºÅ© ¸ð¾çÀÇ ±Ë¾ç(undermining ulcer)À» Çü¼ºÇÕ´Ï´Ù. ÇÑ´Ù. Á¶Á÷°Ë»ç¿¡¼­´Â inflammatory cellÀÌ °ÅÀÇ °üÂûµÇÁö ¾Ê´Âµ¥ ÀÌ´Â ¾Æ¸Þ¹ÙÀÇ È¿¼Ò°¡ neutrophilÀ» Æı«Çϱ⠶§¹®ÀÌ´Ù. Trophozoite¸¸ ´ë°Å °üÂûµÇ´Â ¼ö°¡ ¸¹½À´Ï´Ù.

Ç÷°üÀ̳ª ¸²ÇÁ°è¸¦ µû¶ó °£, º¹¸·, ³ú, ÇǺÎ, Æó µî ´Ù¸¥ Àå±â¿¡¼­ Àå¿Ü¾Æ¸Þ¹ÙÁõÀ» ÀÏÀ¸Å°±âµµ Çϴµ¥ °£³ó¾çÀÌ °¡Àå ÈçÇϸç 96%°¡ °£ÀÇ ¿ì¿±¿¡ À§Ä¡ÇÕ´Ï´Ù.

´ëº¯°Ë»ç»ó heme test ¾ç¼º, paucity of neutrophils, presence of Charcot-Leyden crystal protein(double pyramid-shaped crystals normally found in the cytoplasm of eosinophils)µîÀÇ ¼Ò°ßÀÌ °¡´ÉÇÏÁö¸¸ ¸íÈ®ÇÑ Áø´ÜÀº ¿µ¾çÇü(±Þ¼º±â)°ú ¾¾½ºÆ®(¸¸¼º±â)¸¦ ãÀ¸¸é ºÙÀÏ ¼ö ÀÖ½À´Ï´Ù. ±Þ¼º½Ã¿¡´Â Ç÷¾×°ú Á¡¾×ÀÌ ¹¯¾î ÀÖ´Â ´ëº¯ÀÇ ÀϺθ¦ µû¼­ µÇµµ·Ï »¡¸® (30ºÐÀÌ»ó °æ°úÇÏ¸é °ÅÀÇ È®ÀÎÇÒ ¼ö ¾ø´Ù) Çö¹Ì°æÀ¸·Î ¿µ¾çÇüÀ» È®ÀÎÇØ¾ß ÇÑ´Ù. ¹éÇ÷±¸¿Í °ÅÀÇ ºñ½ÁÇÑ ¸ð¾çÀ» °¡Áö°í ÀÖÀ¸³ª È°¹ßÈ÷ ¿òÁ÷ÀÌ´Â À§Á·°ú ¼¼Æ÷Áú ³»ÀÇ Å½½ÄµÈ ÀûÇ÷±¸ µîÀ» ÂüÁ¶ÇÏ¿© µ¿Á¤ÇÒ ¼ö ÀÖ½À´Ï´Ù.

Å« º´¿ø¿¡¼­´Â ȯÀÚÀÇ °Ëü¸¦ °Ë»ç½Ç¿¡ Á¢¼öÇÏ¿© °á°ú¸¦ ±â´Ù¸®´Â°Ô »ó·ÊÀε¥ ÀÌ °æ¿ì¿¡´Â °ÅÀÇ ¾Æ¸Þ¹ÙÀÇ ¿µ¾çÇüÀ» È®ÀÎÇÒ ¼ö ¾øÀ¸¹Ç·Î Àǻ簡 Á÷Á¢ °Ëü¸¦ µé°í °Ë»ç½Ç·Î ´Þ·Á°¡¾ß ÇÑ´Ù. ¾Æ¸Þ¹ÙÀÇ ¿µ¾çÇüÀº ¹°, °ÇÁ¶, ¹Ù·ý µî¿¡ ÀÇÇÏ¿© ½±°Ô Æı«µÇ¹Ç·Î 3ȸ ÀÌ»óÀÇ °Ë»ç°¡ ÇÊ¿äÇÒ ¼ö ÀÖ½À´Ï´Ù. Six daily consecutive stoolÀ» ÃßõÇϱ⵵ ÇÕ´Ï´Ù.

¾Æ¸Þ¹Ù Àå¿°ÀÇ ³»½Ã°æ ¼Ò°ß. ÁöÀúºÐÇÏ°í ¾èÀº ¿©·¯ ±Ë¾çÀÌ »êÀçµÈ ¼Ò°ßÀ̾ú½À´Ï´Ù.

Á¶Á÷°Ë»ç ¼Ò°ß. ºÓÀº È­»ìÇ¥·Î Ç¥½ÃµÈ ¿¬ÇÏ°í Èñ²ô¹«·¹ÇÑ Å« ¼¼Æ÷°¡ ÀÌÁú¾Æ¸Þ¹Ù trophozoiteÀÔ´Ï´Ù. ±× ¾ÈÀÇ ºÓÀº °ÍÀº hemophogocytosis¸¦ ÇÑ ÀûÇ÷±¸°¡ collapseµÈ °ÍÀÔ´Ï´Ù.

2015³â ´ëÇѳ»½Ã°æÇÐȸ Á¦ÁÖÁöȸ ½ÉÆ÷Áö¾ö¿¡¼­ ¼ÛÇöÁÖ ±³¼ö´Ô²²¼­ º¸¿©ÁֽŠÁõ·Ê

¸ñ¿äÁ¡½ÉÁý´ãȸ 2015-10-29 Áõ·Ê. Ç÷º¯À¸·Î ³»¿øÇÏ¿´°í cecum°ú rectum¿¡ º´º¯ÀÌ ÀÖ¾úÀ½.


[References]

1) SMC Endoscopy Unit »ï¼º¼­¿ïº´¿ø ³»½Ã°æ½Ç

2) SMC Monday GI conference »ï¼º¼­¿ïº´¿ø ÀÏ¿ø³»½Ã°æ±³½Ç ¿ù¿äÁ¡½É¼ÒÈ­±âÁý´ãȸ

3) SMC Thursday endoscopy conference »ï¼º¼­¿ïº´¿ø ÀÏ¿ø³»½Ã°æ±³½Ç ¸ñ¿äÁ¡½É³»½Ã°æÁý´ãȸ

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