종례 : 궤양성 대장염 환자에서 발생한 하대정맥 혈전증과 급성 췌장염 1예

신도현 ( Do Hyun Shin ),이광혁 ( Kwang Hyuk Lee ),김치훈 ( Chi Hoon Kim ),김갑현 ( Kap Hyun Kim ),박성현 ( Sung Hyun Park ),장동경 ( Dong Kyung Chang ),이종균 ( Jong Kun Lee ),이규택 ( Kyu Taek Lee ) 대한소화기학회 2010 대한소화기학회지 Vol.56 No.4

A 21-year-old man admitted complaining of sudden severe epigastric pain for 1 day. He had been diagnosed as ulcerative colitis (UC) and taking mesalazine for two months. UC was in nearly complete remission at admission. He never drank an alcohol, and serum amylase was 377 IU/L. CT scan showed inferior vena cava (IVC) thrombosis in addition to mild acute pancreatitis. To evaluate the cause of acute pancreatitis and IVC thrombosis, magnetic resonance cholangiopancreatogram (MRCP), endoscopic ultrasonogram (EUS), lower extremity Doppler ultrasonogram (US) and blood test of hypercoagulability including factor V, cardiolipin Ab, protein C, protein S1, antithrombin III, and anti phospholipids antibody were performed. There was no abnormality except mild acute pancreatitis and IVC thrombosis in all the tests. He was recommended to stop taking mesalazine and start having anticoagulation therapy. After all symptoms disappeared and amylase returned normal, rechallenge test with mesalazine was done. Flare-up of abdominal pain occurred and the elevation of serum amylase was observed. Ulcerative colitis came to complete remission with short-term steroid monotherapy. Acute pancreatitis and IVC thrombosis were completely resolved after 3-month anticoagulation therapy with no more mesalazine. We postulated that IVC thrombosis occurred due to hypercoagulable status of UC and intra-abdominal inflammation caused by mesalazine-induced pancreatitis. (Korean J Gastroenterol 2010;56:255-259)

고립성 직장 궤양 증후군의 진단과 치료에 대한 문제점에 관한 검토

이종균,임석원,김현식,이광렬,유정준,김건욱,박원갑 대한소화기내시경학회 1999 Clinical Endoscopy Vol.19 No.2

Background/Aim: Solitary rectal ulcer syndrome (SRUS) is a rare disease, but it is encountered in the colorectal field. SRUS is usually associated with defecation disorders such as puborectalis dysfunction, rectal occult or overt prolapse, descending perineum syndrome, and so forth. Without knowledge about SRUS, the lesion could be easily overlooked or misdiagnosed. The histologic characteristics of SRUS are fibromuscular obliteration in the lamina propria and/or misplaced mucinfilled cysts below the muscularis mucosae, this latter condition being commonly referred to as colitis cystica profunda. However, these characteristics, even though they exist, are often missed in the initial biopsy specimens from SRUS patients, leading to misdiagnoses which cause delayed diag-nosis and treatment. In spite of the incomplete histologic indications, a careful and conscientious clinician, using clinical features and characteristic endoscopic findings, would not misdiagnose SRUS lesions. In other words, the clinical features and endoscopic find-ings are as important as, if not more important than, the histologic findings in the diag-nosis of SURS lesions. Methods: The authors reviewed and analyzed 18 recently experienced, biopsy-proven cases of SRUS with emphasis on gross classification and initial pathologic misdiagnoses. Results: The most common age groups were the 5th and the 6th decades with a mean age of 46.5. The male-to-female ratio was 1.6 :1. The most common symptoms were mucous discharge and defecation difficulty. All lesions involvedthe rectum, and the lower rectum was the most common site. Four diffuse-type lesions showed an extensive involvement up to the sigmoid colon. The most common form of SRUS was the elevated type (44.4%). The ulcerated type accounted for 27.8% of the cases and the flat type, 22.2%. Circumferential involvement of the SRUS was noticed in 3 cases. In 9 cases (50%), pathologic findings missed the characteristics of SRUS and indicated one or a combination of chronic nonspecific inflammation,a chronic ulcer, an inflammatory polyp, an adenomatous polyp, pseudomembranous colitis, and adenocarcinoma. In three of these cases, a second biopsy was taken with the same results. Based on the clinician's belief that SRUS was the cause of the lesions, all nine cases were reviewed by the pathologist and a final diagnosis of SRUS was reached. Associated disorders were hemorrhoids, rectoceles, rectal prolapse, perianal fistulas, descending perineum syndrome, and anal fissures. Among them, hemorrhoids and rectoceles were the most common disorders. Four SRUS cases were managed surgically with good results. The surgical treatment was an excision of the lesion itself and/or the correction of the associated disorders. Conclusions: The histologic characteristics of SRUS are the key to diagnosis, but sufficiently large biopsy specimens are necessary in order to obtain the correct diagnosis. However, the clinical features, including symptoms and associated disorders, plus the characteristic endoscopic findings can produce the correct diagnosis even in cases of insufficiently large biopsy samples or incomplete histologic reports.

N함몰형 대장 종양에 대한 인식과 대책

이종균,임석원,김현식,이광렬,박원갑,유정준,황도연,김건욱 대한소화기내시경학회 1999 Clinical Endoscopy Vol.19 No.3

Background/Aim: While detection and removal of polyps on the basis of the adenoma- carcinoma sequence has been a principal procedure for endoscopists, a new type of early colorectal cancer has been recognized and has become a hot issue. This new ailment is a depressed-type early colorectal cancer, which has the characteristics of rapid growth and early invasion of the submucosa. Though once considered to be mere conjecture, many researchers claim that this cancer is a de novo carcinoma despite of its rare occurrence. Recently, 4 depressed-type neoplastic lesions were presented, which signifies the importance of recognizing that this type of cancer exists and is characterized by rapid growth and early invasion of the submucosa. Methods: The 4 recently experienced depressed neoplastic lesions were reviewed and analyzed with respect to their endoscopic and clinicopathologic characteristics. The sizes of the lesions were measured in the fully inflated state of the bowel by using an endoscopic ruler. Results: The sites of predilection were the descending and sigmoid colon. All of the lesions were under 10 mm, with 75% being below 5 mm. The largest lesion was an 8-mm, well-differentiated mucosal carcinoma. The overall malignancy rate was 25%. Light redness was observed in all patients. Distortion with air transformation of the mucosal fold was also recognized in all the patients. The main treatment was endoscopic mucosal resection, which amounted to 50%. Conclusions: Depressed colorectal neoplasms are real. They can be determined by their characteristic endoscopic features, such as light redness and distortion with air transformation of the mucosal fold. Because of their characteristics of rapid growth and early invasion of the submucosa, it is important to detect and manage them in an early stage, when their sizes are below 10 mm.

대장 편평융기형 병변의 분석과 의의

이종균,임석원,김현식,이광렬,박원갑,유정준,황도연,김건욱 대한소화기내시경학회 1999 Clinical Endoscopy Vol.19 No.2

Background/Aims: There are two main routes in the growth and development of colo-rectal carcinomas, that is to say, the adenoma-carcinoma sequence and the route described by the de novo theory. The adenoma-carcinoma sequence has been considered a principal route for colorectal carcinomas for a long time, but recently the de novo cancer theory has become a controversial issue, and many authors have claimed that their cases were de novo carcinomas. Since Muto described small “flat elevations ”and emphasized their significance as precursors of colorectal carcinomas, especially of flat colorectal carci-nomas, many flat elevations have been reported. He cautioned that the reported de novo carcinomas could also be carcinomas that developed from small flat adenomas. In addition, no data are available in Korea on the subject of flat elevations. Accordingly, we attempted to analyze flat elevations in the colon and to obtain correlations between their endoscopic and histologic features and their clinical implicationsMethods: The authors performed colonoscopic removal of 146 flat elevations from January 1997 to December 1997 at Song-Do Colorectal Hospital in Seoul, Korea. We reviewed and analyzed all those lesions. During colonoscopy, the sizes of the lesions were measured by an endoscopic ruler. Results: The most common age group was the sixth decade. Only one case involved a patient under 30 years old. The male-to-female ratio was 3.2 :1. The numbers of flat adenomas and flat adenocarcinomas were 68 and 1, respectively. These 69 cases amounted to 47.3% of the flat elevations. The malignancy rate for flat adenomas was 1.4% (1/69). There were no malignancies in flat elevations with diameters below 10 mm. Hyperplasticpolyps and chronic nonspecific inflammation showed 34.9% and 15.8%, respectively. Most of the flat elevations were smaller than 10 mm (98.6%). Recognizable endoscopic features of the flat elevations were redness (47.3%) and depression (15.8%), but 50 cases (34.2%) of the flat elevations had no specific featurs. Flat elevations smaller than 5 mm had discolorations in 15 cases (14%). The sigmoid colon was the most common site of the flat elevations. The percentage of flat elevations found in the sigmoid colon and the rectum was 70.5%. Hot biopsy was the main treatment for lesions smaller than 5 mm (75.7%), and snare polypectomy was the main treament for lesions from 5 mm to 9 mm. Conclu-sions: Flat elevations were detected without difficulty through careful examination. Nearly half of the flat elevations were flat adenomas. Accordingly, flat elevations may have some clinical significance on the basis of the adenoma-carcinoma sequence, but flat elevations greater than 10 mm should be managed cautiously because of possible malignancy.

분변 오염 환자에서 항문압 검사의 소견과 치료

이광렬,황도연,김건욱,박원갑,유정준,임석원,김현식,이종균 대한대장항문학회 1998 Annals of Coloproctolgy Vol.14 No.3