가톨릭대학교 성빈센트병원 소화기내과 이 정 록 대한소화기내시경학회 월례집담회 증례
Chief complaint Lower abdominal pain and bloody stool for 2 days 32/M 김 O 섭 Present illness 30/M 환자 4 년 전 SLE & lupus nephritis 로 진단 후 사 이클로포스파마이드를 내원 13 개월 전까지 투여 받았던 환자로 내원 2 일 전 부터 발생한 하복부 통증과 혈변을 주소로 내원
Review of System Generalfever (+), chilling (-) sweating (-), poor oral intake (-), wt.loss (-) Cardiovascularchest pain(-), cyanosis(-) Respiratorycough (-), sputum (-) rhinorrhea (-), dyspnea (-) Gastrointestinalnausea (-), vomiting (-) abdominal pain (+), bloody stool (+), constipation (-) Genitourinaryfoamy urine (-), red urine (-)
Past History DM/HBP/TB/Hepatitis (-/-/-/-) SLE & lupus nephritis (4 years ago) Familial History Non specific Social History Non specific
Physical examination V/S : 120/70 mmHg - 65/min – 22/min – 37.8 o C M/S : Alert G/A : Acutely ill-looking appearance Head & Neck : Normocephaly No cervical LAP, No neck v. engorgement Eye : Isocoria with PLR (+/+) Icteric sclera (-/-) ENT : P/I (-/-), T/E (-/-) Chest : RHB without murmur CBS without rale
Physical Examination Abdomen Extremities : Grossly free Skin : Grossly free Soft & flat Normactive bowel sound No palpable mass No organomegaly Td/rTd(+/-)
Laboratory finding CBC WBC 8,710 /mm3 (seg 85%) Hb14.7 g/dL Hct43.5 % Platelet95,000 /mm3 BC TP(a) 7.2/3.9 mg/dL AST/ALT21/28 U/L ALP 165 mg/dL γGTP 44 IU/L TB(d) 1.2/0.4 mg/dL BUN/Cr 27.4/1.1 mg/dL Na/K/Cl 141/4.2/99 mEq/L Ca/P 9.0/4.0 mg/dL U/A Non specific
Disease activity in SLE (1) ESR48 mm/hr CRP6.79 mg/dL Antinuclear Ab1:200 C3108 mg/dL APL Ab2.0 (N: <10) Anti-smith AbPositive Anti-dsDNA Ab43.91 IU/mL (N: <5.30)
Disease activity in SLE (1) 4mm/hr 6.79 mg/dL
Radiologic finding
Initial Sigmoidoscopy
#HD 7 th f/u Sigmoidoscopy
Final Diagnosis Ischemic colitis associated with vasculitis