GI conference 경희대학교 의과대학 소화기내과

Case 1 Chief Complaint Present Illness 유O선 (M/44) 12325014 Admission date : 2013.02.13 Chief Complaint Rectal mass Present Illness M/44. 내원 1일전 술에 만취한 상태로 길에서 넘어진 이후 고대 안암 병원 방문하였으나 만취한 상태로 인해 집으로 강제 귀가시켰던 자로 집에서 자던 중 깨어나보니 상지 및 하지의 근력 약화 소견 있어 응급실 경유 입원하여 central cord syndrome으로 2013-2-14 post decomp. & fusion시행하였음. 입원 후 배뇨장애에 대하여 시행한 TRUS 상 rectal mass 발견되어 further evaluation 및 management 위하여 전과함. .

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/+/-/-) : 1년전 부터 약물 복용중 Operation Hx (-) Family history None Personal history Smoking (+) : 25py Alcohol (+) : 소주 2병 / 주 2~3회

Review of system Physical examination Fever(-) Chilling(-) Dizziness(-) General weakness(-) Itching(-) Jaundice(-) Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-) Abdominal pain(-) Melena/ Hematochezia/Hematemesis(-/-/-) Urinary difficulty (+) Physical examination V/S: 120/80 mmHg – 77/min – 18/min – 36.0 Alert mentality not so-ill looking Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen :Td(-) & rTd(-) U/E & L/E : Various degree weakness but no sensory loss

Initial Lab Findings CBC/DC 6,840/mm3 (59.1%) – 14.5g/dL – 40.0% - 233,000 /mm3 PT(INR) 13.1 sec (1.00) aPTT 32.0 sec Chemistry TB/DB 0.53/0.23 mg/dL Prot/Alb 6.3/3.9 g/dL AST/ALT 21/38 U/L BUN/Cr 17/0.7 mg/dL ALP/GGT 68/47 U/L Na/K/Cl 139/3.8/105 mmol/L Ca/P/Mg 8.6/4.2/2.0 mg/dL CRP 0.39 mg/dL

Work Up 2013.02.25 TRUS 2013.02.27 Rectal CT, Sigmoidoscopy 2013.02.28 Rectal MRI 2013.03.10 Follow up abdomen CT

Operation 2013.3.6 Robot assisted ISR (laparoscopic hybrid)

Leiomyoma (S-2013-03699) Diagnosis : Rectum, intersphinteric resection: Leiomyoma

Final Diagnosis Rectal Leimyoma

Pathology

Desmin

Diagnosis Rectum, intersphincteric resection: Leiomyoma, 6.5x5.2x4 cm Reactive hyperplasia, lymph nodes (0/13)

Anotrectal Leiomoyma: Case Report of Rare tumor with unusual Presentation. Indian J Surg Oncol. 2010; 4; 337-40

GI Conference Case 2

12328981 장 O 훈 (M/62) C.C > anal pain P. I > 평소 간헐적인 anal pain과 anal bleeding 있던 환자로 최근 pain 심해지고 weight loss 동반되어 외부병원에서 colonoscopy 시행하였으며 rectal cancer 관찰되어 수술위해 내원함. PMHx > DM / HTN / Tb / Hepatitis ( - / - / - / - ) OPHx > 2008년 왼쪽다리 인대수술 40년전 hemorrhoidectomy

Review of systems 1. General Fever ( - ), Chill ( - ), Fatigue ( - ), Wt. loss ( + ) 2. Cardiopulmonary Dyspnea ( - ), Cough ( - ), Sputum ( - ), Hemoptysis ( - ) PND ( - ), Chest Pain ( - ), Palpitation ( - ) 3. Abdomen A / N / V / D / C ( - / - / - / - / - ) Abd. discomfort ( - ) Hematemesis ( - ) Melena ( - ) Hematochezia ( + ) Stool Caliber Change ( - ) Anal pain (+)

Physical examination 1. General Alert mentality 2. Chest Symmetric expansion RHB without murmur, CBS without rale 3. Abdomen Abdomen : soft NABS Abd Td / rTd ( - / - ) Palpable mass ( - ) Muscle Guarding ( - ) CVA Td ( - / - )

Initial lab finding WBC : 4830 (seg. 59.5 %) Hb : 13.6 Hct : 39.4 Plt : 164000 TB / DB : 1.33 / - AST / ALT : 16 / 13 ALP / GGT : 48 / 19 BUN / Cr : 16 / 0.6 Na / K / Cl : 139 / 4.3 / 104

Work up 1. Image study 1) 2013.02.27 Pelvic MR(외부) 2) 2013.02.28 abdomen CT(외부) 3) 2013.02.28 Pelvic MR(추가,외부) 4) 2013.03.08 PET CT 2. Endoscopy 1) 2013.02.19 Sigmoidoscopy(외부) 2) 2013.03.05 EUS

Operation 2013.03.06 transanal excision

Impression Rectal cancer

Pathology

Diagnosis proximal: 0.3 cm, distal. 0.4 cm, deep: 0.3 cm) Rectum, transanal excision: Adenocarcinoma, well differentiated 1) Tumor size: 2.9 x 2.2 cm 2) Tumor invades submucosa (100 um from muscularis mucosae) 3) Clear resection margins (Safety margin, right: 0.3 cm, left: 0.3 cm, proximal: 0.3 cm, distal. 0.4 cm, deep: 0.3 cm) 4) Lymphovascular invasion: not identified

Anal Canal Histology Columnar Transitional Dentate L Squamous

Subepithelial Histologic change below ATZ Submucosal gland Submucosal vascular bed Loss of muscularis mucosae Submucosal muscle (Musculus submucosae Ani) Thickening of inner circular muscle (->Internal Sphincter)