Interesting Case of Acute Abdomen 대구가톨릭대학교 의과대학 소화기내과 류정일, 김병석, 권중구, 김은영, 김호각

M/18 C/C: Sudden onset abdominal pain for 2hrs P/I: 평소 건강 간헐적인 경미한 epigastric discomfort, loose stool 현재 군복무 중, 휴가 나와 내원 전날 밤 소주 반 병 마신 후 내원 당일 오전 mild epigastric pain 발생 저녁 8시경 sudden onset severe whole abdominal pain있어 LMC 방문, P/Ex에서 panperitonitis 의심되어 본원 응급실로 전원

ROS: fever(-), nausea(+), vomiting(-), extermity erythema(-) P/Ex: Acutely ill V/S: BP 110/70mmHg, PR 92회/분, RR 20회/분, BT 36.5℃ Abdomen: Whole abdomen Td(+), RTd(+) Bowel sound: decreased Lab: WBC 17000, Hb 10.7, PLT 673000, ESR 60 AST/ALT 36/36, T-bil 0.6, Pro/Alb 6.5/3.1 BUN/Cr 8/1.0, Na/K 132/3.0 ABGA 7.482/21/125/15.5/98%

X-ray

Abdominal CT

Presumptive Diagnosis Acute abdomen: Spontaneous small bowel perforation, Severe inflammation, IC valve area, cause?

Exploratory laparotomy Cecum과 terminal ileum에 inflammation, stricture with mass lesion. IC valve로부터 상방 약 2m 지점(jejunum)에 1cm 크기의 perforation 발견. Ileocolic, mesenteric lymphadenopathy Treatment: Ileocecectomy + jejunal segmental resection

Pathologic findings (1)

Pathologic findings (2) Jejunum Jejunum ileum ileum

Final Diagnosis Crohn’s disease presented with spontaneous free perforation of small bowel

Spontaneous free perforation and perforated abscess in 30 patients with Crohn’s disease 1960-1983, The Mount Sinai Hospital 1415명의 크론병 환자중 21명에서 천공발생 발병부터 천공까지의 mean duration : 3.3년 Site : small bowel perforation(10), large bowel perforation(10), simultaneous perforation of both ileum and cecum(1) jejunum 6.0%(3 of 50), ileum 0.7%(8 of 1156) Overall incidence of perforation in diseased segments of small bowel: 1.0%(11 of 1156) Ann Surg 1987; 205:72-76

Free perforation in Crohn’s disease : review of the Japanese literature Definition of free perforation: spontaneous rupture of the small or large bowel with the free flow of intestinal contents into the general peritoneal cavity Incidence : 1-2% in western  2.9-10.5% in Japan 126 pts with free perforation in Crohn`s disease Duration of disease before perforation : 25months Site : jejunum 7, ileum 102, colon 17, multiple 13 Tx : 98 resection with drainage, 22 resection with proximal ostomy postop Cx. : wound infection(6), intraabdominal abscess(4), anastomotic rupture(13), death (5) Mechanism is unknown. - bowel distension with intraluminal pressure ↑ proximal to obstruction - enteritis of small blood vessels Mortality : 41% 4% J Gastroenterol 2002; 37:1020-1027

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