GI endoscopy conference

Case 1 - Stomach

Case 1 11668713 (F/63) 윤 O 란 63세 여자 DM,HTN으로 본원 내분비내과 f/u 중인 자로 본원에서 2009년부터 2년마다 위내시경 시행하던 중 2015.8.3 EGD에서 AGC 소견 보임 DM/HTN (+/+)

EGD – 2015.08.03 CLO (-) Stomach; Moderate atrophic change with nodularity was noted at the antrum and body. About 2cm sized irregularlly raised with central depressive ulcerative lesion was noted at the LC side of midbody. --> Express biopsy was perforemd ( Exp. Bx X 6 ) 1. Moderate atrophic gastritis with intestinal metaplasia 2. AGC, Bormmann type II, suspected 3. CLO(-) Bx> Stomach, mid body, lesser curvature, endoscopic biopsy: Adenocarcinoma, moderately differentiated

Abdomen CT – 2015.8.5 CT scan에서 stomach의 abnormal wall thickening or mass like lesion보이지 않음. Left gastric LNs가 small size로 보임. Left kidney에 cyst가 있음. Periampullary diverticulum이 있음. Liver의 focal lesion or duct diatation없음. GB, pancreas, spleen에 이상 없음. Ascites or LN enlargement 없음. ====== [Conclusion] ====== No visible gastric wall thickening on CT scan. Periampullary diverticulum. A left renal cyst.

Pathology (2015.08.03) 오른쪽이 lumen 쪽 mucosa , 왼쪽이 muscularis mucosa 입니다. 가운데 부분 보면 cancer cell 들을 볼 수 있는데 MM층에 cancer cell 의 invasion을 보이며 확대해서 보면 atypical gl proliferation을 보여 adenocarcinoma 소견 보입니다.

Pathology (2015.04.10) Diagnosis : H&E X 400 Diagnosis : Stomach, mid body, lesser curvature, endoscopic biopsy: Adenocarcinoma, moderately differentiated

이전 위내시경 – 2013.07.10 Esophagus: Z-line blurring was seen. Stomach; Mild atrophic change with nodularuty was noted at the antrum and body. A single erosion was noted at the post wall of midbody (Bx X4). 1. Reflux esophagitis, LA-minimal change 2. Mild atrophic gastritis with intestinal metaplasia 3. Gastric erosion Diagnosis : Stomach, mid body, posterior wall, endoscopic biopsy: Chronic gastritis with intestinal metaplasia

이전 위내시경 – 2007.12.10 E: (-) S: mild atrophic change c intestinal metaplasia, antrum & body multiple linear erosive change, body D: (-) 1. mild atrophic gastritis c intestinal metaplasia 2. gastric erosion

이전 위내시경 – 2009.03.09 CLO (+) Stomach; Mild atrophic change with diffuse intestinal metaplasia was noted at the antrum and body. Duodenum; Ulcer scar at the bulb. 1. Mild atrophic gastritis with IM 2. DU S2 3. CLO(+) -> 제균치료 후 2009/7/29 UBT(-)

이전 위내시경 – 2011.03.02 Stomach; A small erosion was seen at GC side of proximal antrum. (Bx-A) Another erosion in vicinity of that lesion. (Bx-B) Mild atrophic change with diffuse intestinal metaplasia was noted at the antrum and body. 1. Mild atrophic gastritis with intestinal metaplasia Rec> Gastroscopy annual F/U Bx> A. Stomach, antrum, greater curvature, endoscopic biopsy: Chronic gastritis B. Stomach, antrum, greater curvature, endoscopic biopsy: Chronic gastritis with intestinal metaplasia -> 육안상 EGC 의심되어 다시 EGD 시행

이전 위내시경 – 2011.05.19 Stomach; A small erosion was seen at GC side of proximal antrum. (Bx, 2 pieces) Mild atrophic change with diffuse intestinal metaplasia was noted at the antrum and body. 1. Reflux esophagitis, minimal change 2. Mild atrophic gastritis with intestinal metaplasia 3. Gastric erosion R/O dysplasia Bx> Stomach, proximal antrum, greater curvature, endoscopic biopsy: Chronic active gastritis with intestinal metaplasia

Review – interval cancer Cancer that is diagnosed between the time of screening and postscreening EGD Considering colorectal cancer, some consensus and quality indicators have recently been established However, little is known about the characteristics, incidence, and cause of interval gastric cancer (IGC)

Review – interval gastric cancer 순천향 천안병원 Digestive disease & science (2015) 60:936-943

Review – interval gastric cancer Digestive disease & science (2015) 60:936-943

Review – interval gastric cancer 1997~2009,1991~1996 건대병원 및 강북삼성병원에서 AGC 진단받은 총 2310 case 중 같은 병원에서 6개월 이내에 EGD 받았던 케이스가 16케이스 였습니다. 이것으로 분석했습니다

Review – interval gastric cancer

Review – interval gastric cancer

Review – interval gastric cancer

Case 2 - duodenum

Case 2 12340431 (F/48) 강 O 숙 Adm 2015.06.19 48세 여자 DM,DM gastropathy로 내분비내과 외래 f/u 중인 자로nausea,vomiting 증세 지속되어 EGD 시행함 Alcohol/Smoking (-/-) DM/HTN (+/-)

EGD – 2015.07.31 Stomach; Mild erythematous change was seen at the antrum and body. Duodenum; About 1 cm sized elevated lesion covered with normal mucosa was noted at the bulb. -> Biopsy was performed (Express Bx X1). 1. Mild erythematous gastritis 2. Duodenal SET, suspected

What is your diagnosis? Subepithelial tumor? Leiomyoma? Lipoma? GIST? Carcinoid tumor?

외부 위내시경 – 2013.3.27 병리 사진 이후에 chest CT/abd CT/PET CT 시행하였으나 CT에서 duedenum에 wall thickening이나 mass like lesin은 보이지 않았고 복강내 LN enlargemente 없고 타장기로의 metastasis 없었음. PET에서는 duodenal bulb의 NET에 uptake 없었고 전이소견 없었습니다. 8/26(수) GS에서 wedge resection op 예정입니다.

Pathology H&E X 100 H&E X 200 Immunohistochemical finding: Chromogranin (+), Synaptophysin (+), CD56(+), Ki-67 (< 2%) 100배율 현미경 사진 보시면 hyperchromic하고 vesicular한 nucleus가진 tumor가 포도송이 모양으로 보입니다. 면역형광염색 결과 CD 56, chromogranin, synaptophysin 3개 모두 양성 소견 보여 neuroendocrine tumor로 진단되었습니다. 육안적으로 mitotic figure는 없었고 ki-67 염색에서 proliferation index 2% 미만으로 grade 1 으로 진단되었습니다.

Immunohistochemical finding CD 56 (+) Synaptophysin (+) Chromogranin (+) Immunohistochemical finding: Chromogranin (+), Synaptophysin (+), CD56(+), Ki-67 (< 2%) 100배율 현미경 사진 보시면 hyperchromic하고 vesicular한 nucleus가진 tumor가 포도송이 모양으로 보입니다. 면역형광염색 결과 CD 56, chromogranin, synaptophysin 3개 모두 양성 소견 보여 neuroendocrine tumor로 진단되었습니다. 육안적으로 mitotic figure는 없었고 ki-67 염색에서 proliferation index 2% 미만으로 grade 1 으로 진단되었습니다. Pathology Duodenum, bulb, endoscopic biopsy : Neuroendocrine tumor, grade 1

Review - NETs NETs : gastrointestinal neuroendocrine tumor(carcinoid tumor) + pancreatic endocrine tumor GI-NETs frequently are classified according to their anatomic areas of origin(i.e.,foregut, midgut, hindgut) Tumors with similar areas of origin share functional manifestations, histochemistry, and secretory products 해부학적 기원에 따라 foregut/midgut/hidgut로 분류 – 기원이 유사한 경우 기능적 특성,조직화학적 특성,분비산물이 유사하기 때문 NANETS (North American Neuroendocrine Tumor Society) Guidelines 2010

Review - NETs 대부분(70%)은 기관지,공장.회장,결장.직장 등의 3 곳에서 기원한다 가장 흔한 3부위에서 metastasis (malignancy 반영) -> jejuno-ileum(58%0 > lung/bronchus(6%) > rectum(4%) Harrison’s principle of internal medicine, 19th

Review – NETs of duodenum Clinical endoscopy 2013;46:450-455

Review – NETs of duodenum Primary duodenal NETs account for less than 2% of all gastrointestinal NETs Most duodenal NETs are asymptomatic and generally diagnosed during upper gastrointestinal endoscopy for unrelated symptoms Duodenal NETs are usually hormonally silent Upper gastrointestinal endoscopy is the only method of choice to detect early duodenal NETs No consensus guidelines exist for the endoscopic management of duodenal NETs Endoscopic Treatment for Early Foregut Neuroendocrine Tumors, Clinical endoscopy 2013;46:450-455

Review – NETs of duodenum World J Gastroenterol 2011 July 16; 3(7): 133-139

Case 3 - duodenum

Case 3 55세 남자 특이병력 없는 자로 melena 있어 당일날 본원 소화기내과 진료 시행함 최 O 성 55세 남자 특이병력 없는 자로 melena 있어 당일날 본원 소화기내과 진료 시행함 Alcohol/Smoking (+/+) : 소주 1병/주3회, 40py DM/HTN (-/-)

위내시경 – 2015.8.17 Stomach; Moderate erythematous change was seen at the antrum and body. About 3 mm sized angiodysplastic lesion was noted at the cardia --> 물로 씻어서 병변 부위를 수 초간 관찰하였으나 oozing 등의 출혈 양상은 보이지 않아 bleeding focus 가능성은 떨어질 것으로 생각됨. Duodenum; 3rd portion 까지 EGD scope 삽입해 관찰하였으나, 특별히 bleeding focus 로 판단할 만한 병변 및 소견은 관찰되지 않았음. 1. No evidence of active bleeding 2. Moderate erythematous gastritis 3. Gastric angiodysplasia

대장내시경 – 2015.8.18 Terminal ileum 까지 관찰하였으며, Terminal ileum 과 Cecum 및 ascending colon, proximal transverse colon 에서 다량의 melena 가 관찰됨. 장 점막은 전체적으로 pale and edematous 하게 관찰되었으나, polyp 등의 병변은 관찰되지 않았음.

Bleeding CT – 2015.8.18

풍선소장내시경 – 2015.8.18 Enteroscope: Proximal jejunum에 active oozing 소견을 보이는 Dieulafoy's lesion이 관찰되며, 이 부위가 출혈의 main focus로 생각되어 지혈술 시행함. 노출된 혈관 주변으로 epinephrine (5cc) 주입 후 hemoclipping (X3)으로 성공적으로 지혈함. 1. Dieulafoy's lesion bleeding, small bowel, Forrest Ib - Hemostasis by epinephrine and hemoclipping (X3)

Review – Obscure GI bleeding

Review – Obscure GI bleeding PE - push enteroscopy SE – spiral enteroscopy Digestive Endoscopy 2015; 27: 285-294

Case 4 - ileum

Case 4 12463194 (M/52) 임 O 구 52세 남자 외부 병원에서 시행한 복부CT에서 terminal ileum mass 보여 further evaluation 위해 소화기내과 입원함 Alcohol/Smoking (+/+) : 소주,3병,주5회, 35pyrs DM/HTN (+/-)

대장내시경 – 2015.2.26 1. IC valve 통해 terminal ileum 진입하자마자 관강을 거의 차지하는 huge mass 관찰되며 Ulcer 및 dirty exudates가 동반되어 있으며 conventional colonoscope (CF-H260, Distal End Diameter 13.2mm)의 통과는 가능함. --> Express biopsy 시행함 (Exp. Bx-A: X9). 2. A colonic polyp was noted and removed by polypectomy. B: X 1, RS (20cm from AV), IIa, 6 mm, polypectomy 1. Lymphoma, terminal ileum, suspected r/o terminal ileum cancer, less likely 2. Colonic polyp, removed state Polypectomy X 1 ileum

대장내시경 – 2015.2.26 1. IC valve 통해 terminal ileum 진입하자마자 관강을 거의 차지하는 huge mass 관찰되며 Ulcer 및 dirty exudates가 동반되어 있으며 conventional colonoscope (CF-H260, Distal End Diameter 13.2mm)의 통과는 가능함. --> Express biopsy 시행함 (Exp. Bx-A: X9). 2. A colonic polyp was noted and removed by polypectomy. B: X 1, RS (20cm from AV), IIa, 6 mm, polypectomy 1. Lymphoma, terminal ileum, suspected r/o terminal ileum cancer, less likely 2. Colonic polyp, removed state Polypectomy X 1 S-colon

What is your diagnosis? Ileum mass? Lymphoma? TB? Cancer?

외부 abdomen CT – 2015.2.24 Terminal ileum과 cecum에 걸쳐 약 10cm 길이의 homogeneously low attenuated mass가 관찰됨. Terminal ileum의 wall thickening도 동반되어 있으나 주변으로 fat infiltration은 뚜렷하지 않으며, obstruction도 동반되어 있지 않음. Celiac axis, SMA 주변으로 fat infiltration을 동반한 multiple enlarged lymph nodes가 있으며, ileocecal lymph nodes도 커져있음. 일부는 necrosis를 포함하고 있음. 이 외에도, multiple small left paraaortic lymph nodes가 관찰됨. Appendix는 정상적으로 관찰됨. C/W lymphoma involving terminal ileum and cecum (about 10cm in length). a/w multiple enlarged lymph nodes near the celiac axis, SMA, and Rt ileocecal area. Suggestive of adenomyomatosis at GB fundus. A small low attenuated lesion in S6 of the liver, too small to characterize.

Pathology H&E X 100 H&E X 400 Immunohistochemical CK (-), CD3 (-), CD20 (+), CD30 (-), CD56 (-), S-100 (-), CD10 (-), BCL-2 (+), BCL-6 (-), MUM-1 (+), Ki-67 (about 50%) EBV finding: - (HE x100) Large nucleus를 가진 atypical한 cell들이 diffuse하게 보입니다 (HEx400) 400배로 보시면 intermiate~large sized cell에 pleomorphic한 nucleus가 있고 nucleoli가 잘 보입니다. 이는 모두 atypical lymphocyte로 생각할 수 있고 따라서 DLBL을 먼저 떠올리게 됩니다

Pathology Pathology Terminal ileum, colonoscopic biopsy: CD 20 MUM-1 BCL-2 Ki-67 B cell marker인 CD 20, MUM-1 에서 diffuse하게 양성소견 보이며 B cell marker인 BCL-2에서도 양성 보입니다. Ki-67에서는 50% 정도의 proliferation을 보이는 DLBL 소견입니다. Pathology Terminal ileum, colonoscopic biopsy: Diffuse large B cell lymphoma

Review – diffuse B-cell lymphoma World J Gastroenterol 2014 september 28;20:12993-13005

Review – diffuse B-cell lymphoma Endoscopic pattern Gastric DLBL : ulcerative (with single or multiple), specially located at the gastric body or at the fundus 2) Small intestinal DLBL : ulcerative type(54%), polypoid type(25%), multiple polyposis type(5%), diffuse-infiltrating type(6%) 3) Colon DLBL : large ulcerated mass World J Gastroenterol 2014 september 28;20:12993-13005