건양대학병원 소화기내과 김용문, 정승현, 김선문, 이태희, 임의혁, 허규찬, 최용우, 강영우 대한소화기내시경학회 제 69회 집담회 Case presentation 건양대학병원 소화기내과 김용문, 정승현, 김선문, 이태희, 임의혁, 허규찬, 최용우, 강영우

김 O 경 M/64 Chief complaint Rt. Upper & lower quadrant pain severity : severe period : two weeks characteristics : dull ache duration : continous aggrevating factor : postprandial, deep respiration

Present illness 상기 64세 남환은 특별한 과거력 없이 건강하게 지내던 분임. 내원 2주전부터 발생한 우상복부 및 우하복부 동통을 주소로 개인의원에서 진찰받음. 초음파검사결과 DCM with pericardial effusion 과 R/O GI mass 의심되었으며 증상 지속되어 추가검사 및 치료위해 본원으로 전원되어 입원함.

Past history Social Hx. & Family Hx. HTN/DM/Hepatitis/Pul.Tbc(-/-/-/-) Operation Hx(-) Trauma Hx(-) Gallstone Hx(-) 약 1달전 생선을 드신 것으로 기억함. Social Hx. & Family Hx. Smoking ; no Alcohol ; no Family Hx. ; non specific

Review of System General Gastrointestinal general weakness/malaise (-/-) poor oral intake/weight change (-/-) fever/chill (-/-) Gastrointestinal anorexia/nausea/vomiting (-/-/-) diarrhea/conspitation/tenesmus (-/-/-) dyspepsia/jaundice (-/-) hematemesis/melena/hematochesia (-/-/-)

Physical examination(1) General alert mental state ill-looking appearance Vital sign on admission BP : 100/80 mmHg RR : 20 rates/min PR : 74 rates/min BT : 36.5 ℃

Physical examination(2) HEENT not yellowish sclera slightly pale conjunctiva Abdomen not distented & soft normoactive bowel sound, tympanicity diffuse rigidity / muscle guarding(-/-) T/RT (+/-) : RUQ & RLQ areas Murphy’s sign (-) No hepatomegaly and no palpable mass

Lab.findings 일반혈액 WBC : 9670/uL Hb : 11.7g/dL HCT : 34.0% PLT : 423,000/uL 특수혈액 PT / aPTT : 15.4/ 45.7sec 면역혈청 HBs Ag/ anti-HBs ; negative/negative Anti-HIV : negative CRP 10.8 mg/dl 일반화학 Ca 8.97 mg/dl Na/K/Cl 131/4.5/96.5mg/dl BUN 11.9mg/dl Creatine 0.69mg/dl cholesterol 112mg/dl protein 7.4 g/dl albumin 3.25 g/dl ALP 106 IU/L glucose 105 mg/dl ALT 15 IU/L AST 14 IU/L bilirubin,total 0.51 mg/dl direct 0.10 mg/dl

Radiologic findings

Abdomen & pelvic dynamic CT

Colonoscopy

PCD

F/U Abdomen & pelvic dynamic CT

F/U Colonoscopy

F/U tubogram F/U tubogram Removal of catheter

Diagnosis Liver abscess that had a fistula with ascending colon secondary to fish bone

Surg Today. 1999;29(9):922-6 Successful treatment of a hepatic abscess that formed secondary to fish bone penetration by percutaneous transhepatic removal of the foreign body: report of a case. Horii K, Yamazaki O, Matsuyama M, Higaki I, Kawai S, Sakaue Y. Department of Surgery, Osaka City General Hospital, Osaka, Japan.

J Clin Gastroenterol. 2003 Jul;37(1):82-5.

감 사 합 니 다