갑작스런 상복부 통증을 주소로 내원한 23 세 여자 건국대학교병원 소화기내과 이경훈, 이선영, 홍성노, 김정환, 성인경, 박형석, 진춘조, 민영일

Case presentation 지 O (F/23) 주호소 숨을 못 쉴 정도로 배가 아프다 ( 하루 전부터 ) 현병력 평소 건강하게 지내던 아마추어 운동선수로서 내원 전날 단거리 달리기 연습 후에 갑자기 심한 상복부 통증이 유발됨. 하루 동안 쉬었으나 복통이 호전되 지 않고 구역감이 함께 동반되어 내원함.

Past history DM(-), HTN(-), Tbc(-) 6 개월 전부터 여드름 약을 복용함. 마지막 생리 시작일 - 2 일 전 Family history 특이소견 없음 Social history 술 - 거의 마시지 않음 담배 - 금연 History

Review of system General general weakness (+), fatigue (+) HEENT headache (-), dizziness (-) Chest cough (-), sputum (-), dyspnea (-), chest pain (-), palpitation (-) Abdomen anorexia (+), nausea (+), vomiting (+), diarrhea (-), constipation (-)

Physical examination Vital sign BP 108/68 mmHg, HR 58/min, RR 20/min, BT 36.5 C Height 165 cm, Weight 54 kg General Alert mentality, acute ill looking HEENT Not anemic conjunctivae, anicteric sclerae Chest Clear breath sound, regular heart beat without murmur Abdomen Tenderness on mid-abdomen, above umbilicus

Laboratory finding CBC WBC 6,600/ul Hb 13.7 g/dL PLT 181,000/ul Chemistry BUN/Cr 10.4/0.9 mg/dL Protein/Albumin 6.7/4.5 AST/ALT/ALP/GGT 21/ 14/ 68/ 11 IU/L T.bilirubin 0.4 mg/dl Amylase 84 U/L CRP 0.06 mg/dl

Laboratory finding Electrolytes Na/K/Cl 140/3.6/105 mmol/L U/A WBC (-) Nitrite (-) hCG (-)

Chest X-ray

Abdomen CT

Endoscopy: Antrum

Endoscopy: Bulb, Body

Impression Acute Gastric Mucosal Lesion R/O Acute Phlegmonous Gastritis

Pathology Report (1) Stomach, "antrum", endoscopic biopsy: 1. Acute and chronic gastritis with 1) moderate inflammation 2) moderate activity 3) atrophy (not applicable) 4) no intestinal metaplasia 5) extensive erosion 6) moderate density of Helicobacter pylori-like microorganism, consistent with Helicobacter pylori associated gastritis and acute gastric mucosal lesion 2. Peptic detritus

Hospital Course 3 일간 입원치료 후 퇴원 1 주 PPI + mucosal coating agent 사용 후 외래 방문시 symptom-free state. H. pylori eradication (3 제요법, 1 주 ) 시행 후 EGD f/u

Endoscopy, 16 days later

Pathology (2) Stomach, "antrum", endoscopic biopsy: Chronic gastritis with 1) moderate inflammation 2) no activity 3) mild atrophy 4) no intestinal metaplasia 5) edema and granulation tissue formation in lamina propria 6) no Helicobacter pylori-like microorganism [SPECIAL & IMMUNOHISTOCHEMICAL STAIN] Giemsa stain [A01] : negative (JWK)

Exercise-associated Gastrointestinal Ischemia 건국대학교병원 소화기내과 이경훈

Exercise-associated GI ischemia Colonic ischemia > Gastric ischemia Cause: dehydration, hyperthermia, exhaustion Mechanisms: decreased splanchnic blood flow, acid hypersecretion Treatment: hydration, transfusion, acid blockade Complication (rare): intestinal infarction Prognosis: Good (resume activities without restrictions) Moses F. Cur Sports Med Rep 2005;4:91-5.

Exercise-associated ischemic hemorrhagic gastritis Diagnosis: by history taking and EGD finding EGD finding: Acute gastric mucosal lesion (from mild erosion to severe necrotizing ulcer) Symptom: severe epigastric pain, nausea, vomiting Treatment: effective acid blockade Prognosis: quickly recovering symptoms and gastric lesions on EGD finding

Previous reports on exercise-related gastric ischemia Exercise induces gastric ischemia in healthy volunteers: a tonometry study Otte J et al. J Appl Physiol 2001;91: Effects of ranitidine for exercise induced gastric mucosal changes and bleeding Choi SJ et al. World J Gastroenterol 2006;12: Erosive gastritis and gastrointestinal bleeding in a female runner Cooper BT et al. Gastroenterology 1987;92: Submaximal exercise in healthy volunteers: the relationship between gastric mucosal and systemic energy status. Rokyta R et al. Eur J Physiol 2002;443:852-7.

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