복부불편감과 구역을 주소로 내원한 65세 여자 환자 82회 소화기 내시경 학회 월례 집담회 복부불편감과 구역을 주소로 내원한 65세 여자 환자 을지의과 대학 노원 을지병원 소화기 내과 전임의 최정호 / 교수 박영숙

Chief Complaint Abdominal distension, nausea & vomiting (onset: 2 weeks ago) Present illness 강직성 척추염으로 약물 치료 중 이던 65세 여자 환자가 2주 전부터 abdominal distension, nausea, vomiting 있었으며 1주 전 부터는 abdominal pain 동반되어 외래 통해 입원함. Past History Ankylosing spondylitis: 1년 전 진단 후 celecoxib 투여 받음. Family history Non specific

Review of system General ache/general weakness (+/+) headache/dizziness (-/-) Nausea/vomiting/diarrhea/constipation (+/+/-/-) Abd. Discomfort/ Abd. Pain (+/-) dyspnea/ chest pain/ chest discomfort (-/-/-) Physical examination HEENT: Non specific Chest: Regular Heart Beat without murmur, Clear breath sound without rale Abdomen: No direct and rebound tenderness decreased bowel sound Back and Extremity: Nuchal pain other non specific

Laboratory finding WBC 7,470 /uL PLT 312000 / uL Hb 8.8 g/dL corrected reti count: 0.1 Iron/TIBC: 30/168 ㎕/dL ( 17%<20%) ferritin 202.2 ng/ uL ESR 79 mm/hr CRP 2.8 mg/dL AST/ALT 21/12 IU/L ALP/LD H 203/414 IU/L T.Protein/Albumin 6.1/3.1 g/dL BUN/Cr 16.6/1.4 mg/dL U protein 105.9 mg/dL Na/K/Cl 142/3.9/105 mMol/L Ca/P 8.4/2.9 mg/dL β2 microglobulin 7.4 g/m (< 2.7 g/ml)

Stomach antrum biopsy report: 2007년 11월 Stomach antrum biopsy report: Chronic ulcer (H. P. negative)

2007년 12월

shows food material stasis and Diffuse wall thickening of stomach antrum with gastric distension

Stomach H & E stain x 100 H & E stain x 200 H & E stain x 400 It shows deposition of eosinophilic amorphous materials in lamina propria and submucosa , consistent with amyloidosis .

Duodenum H & E stain x 50 H & E stain x 200 H & E stain x 400

Stomach Congo red stain x 200 B is congo-red staining picture viewed to polarization microscope. It shows kappa , lamda, AA amyloid positive

Stomach shows subepithelial layers (X2500). B shows fibrils attached amyloids

Bone marrow biopsy Serum Immunoelectrophoresis Urine Electophoresis : M/E ratio 3.8:1 : Erythroid series – normal : Myeloid series – normal : No malignant cell : No evidence of plasma cell myeloma Serum Immunoelectrophoresis : Monoclonal gammopathy, Lamda type Urine Electophoresis :Tubular proteinuria with Bence jones proteinuria

Secondary amyloidosis Gastric and duodenal involvement(AA) Final diagnosis Secondary amyloidosis Gastric and duodenal involvement(AA) in anklyosing spondylitis (A.S.) progress: 대증적 전정부 절제술 및 chemotherapy 를 권유하였으나 전원 후 수술 없이 Chemotheapy 시행 받음 ..