GI conference 경희대학교 의과대학 소화기내과

Case 1 Chief Complaint Present Illness 이O현 (F/51) 12307235 Admission date : 2012.10.25 Chief Complaint melena o/s) 내원 전날 Present Illness F/51. 특이병력 없는 자로 약 3개월 전에 GI bleeding으로 보훈병원 입원하여 치료받았으며 당시 검사상 (EGD, CFS) 이상소견은 없다고 얘기 들음. 내원 전날 부터 melena, vomiting, nausea 호소 있어 소화기내과 외래 경유하여 입원함.

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/-/-/-) Operation Hx (+) : 2007년 hysterectomy Family history None Personal history Smoking (-) Alcohol (+) : 와인 2잔/2회/주

Review of system Physical examination Fever(-) Chilling(-) dizziness(+) General weakness(+) Itching(-) Jaundice(-) Epigastric discomfort(+) A/N/V/D/C(-/+/-/-/-) Abdominal distension(-) Abdominal pain(-) Melena(+) Hematochezia(-) Hematemesis(-) Physical examination V/S: 120/80 mmHg – 77/min – 18/min – 36.0 Alert mentality acute-ill looking Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen :Td(-) & rTd(-)

Initial Lab Findings CBC/DC 8,390/mm3 (66.7%) – 8.9g/dL – 31.1% - 418,000 /mm3 PT(INR) 12.6 sec (0.96) aPTT 28.2 sec Chemistry TB/DB 0.6/0.1 mg/dL Prot/Alb 6.8/4.1 g/dL AST/ALT 33/16U/L BUN/Cr 23/0.6 mg/dL ALP/GGT 72/26 U/L Na/K/Cl 136/4.4/102 mmol/L LD/CK 572/48 U/L Ca/P/Mg 8.4/3.6/2.0 mg/dL CRP <0.3 mg/dL

Work Up 2012.10.25 Abdominal CT, EGD, sigmoidoscopy 2012.10.26 Small bowel enteroscopy

Operation 2012.10.29 Laparoscopic segmental resection

Gastrointestinal stromal tumor Diagnosis : Small intestine, segmental resection: Gastrointestinal stromal tumor

GI bleeding d/t small bowel GIST Final Diagnosis GI bleeding d/t small bowel GIST

Case 2 Chief Complaint Present Illness 김O열 (M/27) 11903193 Admission date : 2012.10.23 Chief Complaint abdominal pain o/s) 내원 당일 Present Illness M/27, 2007년 intestinal tuberculosis 진단받고 Tb medication후 완치 판정 받은 과거력 있는 자로 09년에 crohn’s disease 진단받아 본원 소화기내과에서 면역 억제제 복용하며 외래 추적 관찰 중임. 내원 당일 오전 햄버거 먹은 후 오후부터 발생한 abdominal pain, nausea, vomiting으로 응급실 통해 입원함.

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/-/+/-) Operation Hx (+) : 1999년 hemorrhoidectomy (Local GS) Medication Hx (+) 본원 IG p.o med Mesalazine 1.5g-1g-1.5g Azathioprine 50mg-75mg Adalimumab -2012.9.10 부터 투여 Family history None Personal history Smoking (+) : 1갑/일 X 10년 = 10갑년 Alcohol (+) : 소주 1병/3~4회/주

Review of system Physical examination Fever(-) Chilling(-) General weakness(-) Itching(-) Jaundice(-) Epigastric discomfort(-) A/N/V/D/C(-/+/+/-/-) Abdominal distension(+) Abdominal pain(+) : whole-abdomen Melena(-) Hematochezia(-) Hematemesis(-) Physical examination V/S: 110/70 mmHg – 78/min – 20/min – 36.2 Alert mentality acutely-ill looking Clear breathing sound without rale Regular heart beat without murmur Rigid & flat abdomen :Td(+) & rTd(+), hyperactive BS

Initial Lab Findings CBC/DC 12,360 /mm3 (81.9%) – 12.0 g/dL – 39.1 % - 637,000 /mm3 PT(INR) 13.0 sec (0.99) aPTT 43.1 sec ESR 98 mm/hr Chemistry TB/DB 0.39/0.15 mg/dL Prot/Alb 7.6/4.1 g/dL AST/ALT 22/14 U/L BUN/Cr 13/1.0 mg/dL ALP/GGT 75/21 U/L Na/K/Cl 139/3.9/100 mmol/L LD/CK 513/91 U/L Ca/P/Mg 8.8/3.5/2.1 mg/dL CRP 5.82 mg/dL

Work Up 2012.10.23 Abdomen CT 2012.10.24 Chest CT 2012.10.26 PET CT

Operation 2012.10.31 Laparoscopic small bowel segmental resection c strictureplasty 2012.10.31 Wedge resection & LN bx via VATS, Rt.

Hodgkin’s lymphoma, nodular sclerosis type (S-2012-18417, S-2012-18299) Diagnosis : Small intestine, segmental resection: Crohn’s disease Lung biopsy: Hodgkin’s lymphoma, nodular sclerosis type

Small bowel obstruction d/t Crohn’s disease Final Diagnosis Small bowel obstruction d/t Crohn’s disease Hodgkin’s lymphoma

Case 3 Chief Complaint Present Illness 이O영 (F/54) 12306607 Admission date : 2012.11.05 Chief Complaint RUQ pain o/s) 내원 1달 전 Present Illness F/54, 특이 병력 없는 자로 약1달 전부터 RLQ pain으로 local에서 내시경 시행 받고 (당시 건강검진으로 chest CT, 복부초음파 시행: 이상소견 없다고 했다고 함) 이후에도 pain지속되어 본원 소화기내과 방문, 시행한 abd. CT상에서 Suggestive of peritoneal seeded metastases 소견으로 further evaluation위해 입원함.

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/-/-/-) Operation Hx (-) : none 28년전 IUD insertion Family history None Personal history Smoking (-) Alcohol (-)

Review of system Physical examination Fever(-) Chilling(-) Weight loss(+) : -7kg/1mo Fatigue(+) Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-) Abdominal distension(-) Abdominal pain(+) :RLQ pain Melena(-) Hematochezia(-) Hematemesis(-) Physical examination V/S: 120/90 mmHg – 98/min – 20/min – 36.2 Alert mentality acutely-ill looking Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen :Td(+) & rTd(-)

Initial Lab Findings CBC/DC 9,340 /mm3 (76.3%) – 10.2g/dL – 30.1% - 447,000 /mm3 PT(INR) 13.9 sec (1.08) aPTT 40.9 sec ESR 76 mm/hr Chemistry TB/DB 0.47/0.17 mg/dL Prot/Alb 7.2/3.5 g/dL AST/ALT 14/14 U/L BUN/Cr 13/0.4 mg/dL ALP/GGT 107/24 U/L Na/K/Cl 139/4.2/99 mmol/L LD/CK 249/20 U/L Ca/P/Mg 8.7/3.4/2.0 mg/dL CRP 7.50 mg/dL CA125/CA19-9/CEA 19.5/2.0/1.18

Work Up 2012.11.05 Chest CT 2012.11.06 AP sono 2012.11.07 PET CT 2012.11.08 Pelvis MRI

Biopsy 2012.11.09 Sono-guided biopsy

Actinomycosis, most likely Final Diagnosis Actinomycosis, most likely