Multidisciplinary Bowel conference 경희대학교 병원 소화기내과

Case 1 Chief Complaint Lower abdominal pain Present Illness Admission date : 2016.01.14 Chief Complaint Lower abdominal pain Present Illness 47/M, 특이병력 없는 환자로 10개월여 전부터 lower abdominal pain 발생, 심할 때는 배에 mass 처럼 만져지기도 하고, 대변보면 증상 호전되는 양상으로 지속 되어 외래 내원함. 진단 과정에서의 병리학적 영상학적 검토

Past-medical history Personal history Alcohol (-) Smoking (-) DM / HTN / Tb / Hepatitis ( - / -/ - / - ) Op Hx (+): Appendectomy (10yrs ago) Personal history Alcohol (-) Smoking (-)

Work Up Endoscopy - 2015.02.24colonoscopy - 2015.12.21 colonoscopy Image study - 2015.12.08 Colon CT

Pathologic finding S-2015-19717 Diagnosis : Terminal ileum, colonoscopic biopsy: Diffuse large B-cell lymphoma, activated B-cell type Immunohistochemical finding (S-2015-19717, 1): CD3 (-), CD20 (+), BCL-2 (+), Cyclin D1 (-), Ki-67 (90%), CK (-), CD10 (-), BCL6 (+), MUM-1 (+), CD5 (-), TdT (-) EBV in situ: -

Diffuse large B-cell lymphoma, activated B-cell type Diagnosis Diffuse large B-cell lymphoma, activated B-cell type

Case 2 Chief Complaint Present Illness 10921341 강 O 배 (M/75) Admission date : 2015.12.07 Chief Complaint Hematochezia recent onset> 3days ago remote onset> 1yr ago Present Illness 75/M, Chronic alcoholics 로 1년여 전부터 hematochezia발생하였고, 2015.08 Sigmoid colon cancer c lung, liver metastasis (Adenocarcinoma, moderately differentiated, stage IV, EGFR(+1), K-ras(-)) 으로 진단되어 항암치료 mFOLFIRI+cetuximab 5차(2015.11.27) <1차:2015.08.11> 진행한 자로, 내원 3일전부터 hematochezia 재발, 하루 600cc이상으로 횟수와 양 증가하여 외래 통해 입원함. 대장암 항암치료중 출혈혈변- 내시경- 혈관 색전술- 허혈성대장염- 천공 향후 치료는? ★ 입원 이후 hematochezia 지속됨. Sigmoidosdopy 상 내시경적 지혈술 불가능함. Embolization 진행함. 이후 Ischemic colitis, bowel perforation, panperitonitis 있으나 op risk 높아 수술진행하지 못하고 보존적 치료 진행함.

Past-medical history Personal history Op Hx (+): Cataract,Rt op (12') DM / HTN / Tb / Hepatitis ( - / -/ - / - ) Op Hx (+): Cataract,Rt op (12') Traumatic Cb contusion c subdural hygroma(91’) Organic personality disorder Personal history Alcohol (-): 1년 전 부터 금주 Smoking (-): 1년 전 부터 금연, past 30PYs

Work Up Endoscopy - 2015.07.31 colonoscopy - 2015.12.18 sigmoidoscopy Image study - 2015.07.31 Colon CT - 2015.12.29 Embolization - 2015.12.31 AP-CT - 2016.01.11 AP-CT - 2016.02.03 AP-CT

Diagnosis # Ischemic colitis with perforation # S-colon cancer c lung, liver metastasis (Adenocarcinoma, moderately differentiated, stage IV, EGFR(+1), K-ras(-)) 향후 치료 계획 논의

Case 3 Chief Complaint Present Illness OPD date : 2015.12.30. Chief Complaint Lower abdominal pain recent onset>3 months ago Present Illness 72/M, Ulcerative colitis s/p remicade#2(20151113)<#1:20150821> 인 자로 최근 복부 통증 악화되고, 외래에서 시행한 대장내시경 상 Ulcerative colitis 악화소견 보여 외래 통해 입원함. 병변의 병리학적 검토에 대해 토의 후 향후 치료 계획 논의

Past-medical history Personal history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Ulcerative colitis s/p remicade#2(20151113)<#1:20150821> Grave's disease 본원 IG 입원 - 2015.11 Pseudomembranous colitis - 2015.10 CMV colitis - 2015.08 remicade #1 시행 후 PCP pneumonia Op Hx (-) Personal history Alcohol (-) Smoking (-)

Work Up Endoscopy - 2015.07.17 Sigmoidoscopy Image study - 2015.07.17 AP-CT - 2016.01.20AP-CT - 2016.02.05 AP-CT

2016.01.19 Lap.proctocolectomy c end ileostomy Operation 2016.01.19 Lap.proctocolectomy c end ileostomy

Pathologic finding S-2016-01398 Diagnosis : Colon and appendix, from ascending to rectum, proctocolectomy: 1. Ulcerative colitis 2. Reactive hyperplasia, lymph nodes (0/18) 3. No specific change, appendix Micro : Section from colon shows continuous diffuse distorted cryptal architecture, cryptitis, cryptal microabscess, basal plasmacytosis, and ulceration with acute and chronic inflammation of the mucosa. This lesion is mainly limited to the submucosa. Colonic loop formation due to fibrous adhesion and focal subserosal inflammation, and inflammatory pseudopolyps are noted. Definite evidence of granuloma is not identified. Correlating with clinical findings, the diagnosis of this case is consistent with ulcerative colitis.

Severe ulcerative colitis s/p Lap.proctocolectomy c end ileostomy Diagnosis Severe ulcerative colitis s/p Lap.proctocolectomy c end ileostomy 병변의영상학적, 병리학적 검토 후 추후 치료 계획 논의