불응성 궤양. EndoTODAY 이준행

[Refractory ulcer. 불응성 궤양]

1. Refractory ulcer (2007년 미국 연수 중 www.pediatricsconsultantlive.com 기고)

Abstract: Undiagnosed or persistent Helicobacter pylori infection and surreptitious or unrecognized NSAID use are the most common causes of refractory peptic ulcers. The use of antibiotics, bismuth, or proton pump inhibitors (PPIs) suppresses the H pylori bacterial load and may obscure the diagnosis. H pylori infections have also become more difficult to cure because of increased antibiotic resistance. For refractory infection, select an antibiotic based on in vitro susceptibility testing. When this is not available, combination therapy with a PPI, tetracycline, metronidazole, and bismuth is often effective. To detect surreptitious or inadvertent NSAID use, review the drug history in detail. When there is any doubt about such use, check platelet cyclooxygenase function.

2. 원인

김선문 교수님 세미나 강의록

[Cases]

DM, gout, rheumatoid arthritis, celecoxib와 prednisolone 등 복용 중.
수년 동안 모양이 거의 비슷하였음.

신장이식 환자. 방광암 치료 받음. 불응성 궤양이었고 조직검사에서 CMV가 나왔음. Ganciclovir 효과가 명확하지 않았고 PPI 사용하고 있음. 6-12 개월 간격의 내시경 검사에서 PPI 사용했음에도 불구하고 궤양 지속됨.
불응성 궤양으로 오셨으나 Helicobacter 제균치료 후 호전되었음

[불응성 궤양으로 의뢰되었으나 암으로 결론이 난 증례]

signet ring cell carcinoma (2015)
Refractory ulcer로 의뢰되었으나 암으로 결론 (2016)
Stomach, total gastrectomy: Early gastric carcinoma
1. Location : upper third, Center at cardia and lesser curvature
2. Gross type : EGC type IIc
3. Histologic type : tubular adenocarcinoma, poorly (solid) differentiated
4. Histologic type by Lauren : diffuse
5. Size : 2.8x1.1 cm
6. Depth of invasion : invades submucosa (sm1) (pT1b)
7. Resection margin: free from carcinoma, safety margin: proximal 0.4 cm, distal 16.3 cm
8. Lymph node metastasis : no metastasis in 35 regional lymph nodes (pN0)
9. Lymphatic invasion : not identified
10. Venous invasion : not identified
11. Perineural invasion : not identified
12. Associated findings : gastritis cystica profunda
13. Peritoneal cytology : negative
14. AJCC stage by 8th edition: pT1b N0

[References]

1) 불응성 궤양의 진단과 치료 김흥업 (내시경학회세미나)

2) 불응성 궤양 김선문 (내시경학회세미나)

3) EndoTODAY 소화성 궤양