Chief Complaint Diarrhea onset : 2015 년 4 월 Present Illness 17/F, 2015 년 4 월부터 fever (up to 38 ℃ ), diarrhea 증상 발생하며 1 달 반 동안 oral intake 절반으로 감소되고 약 10kg 의 weight loss (53kg → 43kg) 동반되어 본원 소화기내과 2015 년 6 월과 7 월 2 차례 입원하여 amebic colitis 로 치료하였으 나 abdominal pain 과 diarrhea 지속되어 재입원함. Case 송 O 영 (F/17) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Op Hx : none NP consultation d/t anxiety & depressive mood on previous admission Personal history Alcohol(-) Smoking(-)

Work Up Endoscopy EGD & CFS Sigmoidoscopy CFS EGD Image study Abdomen & pelvis CT small bowel (Entero) CT

S Gross Description : Submitted for EXPRESS is 4 discs of gray white mucosal tissue. Totally embedded in 1. (CH) Diagnosis : Stomach, antrum, endoscopic biopsy: Chronic granulomatous inflammation S Gross Description : Submitted for EXPRESS is 9 discs of gray white mucosal tissue. Totally embedded in 1. (CH) Micro : Section from the colon shows patchy infiltration of acute and chronic inflammatory cells. Mild to moderate cryptal distortion present with cryptitis. Multifocal patchy ulceration with granuloma present. Diagnosis : Colon, colonoscopic biopsy: Chronic granulomatous inflammation Special stain finding: A.F.B (-)

Diagnosis 1.Crohn’s disease 2. Anxiety disorder

Chief Complaint Known rectal cancer Present Illness 50/M, HTN 으로 외부병원에서 po medication 하고 있는 자로 2015 년 3 월 건강검진으로 시행한 내시경 검사에서 직장암 진단되어 본원 GS 에서 7 월 14 일 laparoscopic LAR with ileostomy 수술 받음. Case 김 O 호 (M/60) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) Malignancy Hx (-) Op Hx : 3 년전 백내장 수술 ( 타병원 ) Personal history Alcohol (-) Smoking : ex-smoker, 25 pack-years

Work Up Endoscopy EUS Sigmoidoscopy Image study Rectum & sigmoid MR Rectum CT Rectum & sigmoid MR, Rectum CT

S Gross Description : Specimen received fresh consists of 2 parts. The first part is a product of low anterior resection of the rectum, measuring 15.0 cm in length and 6.0 cm in circumference. Mucosal surface shows a polypoid mass, measuring 1.9x1.5x0.7cm in size, which locates 13.0cm and 0.4cm from the proximal and distal resection margins. This specimen is prepared whole mount section. Anterior and posterior margins inked yellow and green, respectively. Partially embedded in 1 to 9. The second part is a piece of yellow/brown tissue labelled with “IMA lymph node”, measuring 4.0x4.0x2.0cm in size. Partially embedded in 10 to 12. (MJW) Main lesion in 1 to 4. Pericolic lymph node in 5 to 9. Inferior mesenteric artery lymph node in 10 to 12. Diagnosis : Adenocarcinoma, moderately differentiated, rectum 1) Tumor size: 1.9 cm x 1.5 cm x 0.7 cm 2) Tumor gross type: Polypoid 3) Depth of invasion: Tumor invades submucosa (pT1) 4) Margins of resection: No tumor identified at proximal, distal, and circumferential resection margins (safety margin: proximal 13.0 cm, distal 0.4 cm, circumferential 1.6cm) 5) Lymphatic invasion: Not identified 6) Vascular invasion: Not identified 7) Perineural invasion: Not identified 8) Regional lymph nodes: No metastasis in 21 regional lymph nodes (0/21, pN0) 9) Tumor budding: Insignificant 10) Tissue submitted for special investigation IHC for hMLH1, hMSH2, Cytokeratin, D2-40 and EGFR Immunohistochemical finding (S , 2): hMLH1 (+), hMSH2 (+), EGFR (+), Cytokeratin (+), D2-40 (+, for lymphatics without tumor emboli)

Final Diagnosis Rectal cancer s/p LAR with ileostomy

Chief Complaint Palpable mass on rectal exam Present Illness 68/F, 2015 년 7 월초부터 대변보기가 힘들어서 외부병원에서 시행한 rectal exam 에서 mass 촉지되어 본원에서 내시경 시행 후 rectal cancer 로 진단하였 으며 7 월 28 일 laparoscopic LAR 수술 받음. Case 김 O 희 (F/68) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( - / - / +/ - ) Tuberculous pleurisy (35 년전 ) Bronchiolitis (r/o diffuse panbronchiolitis) 로 성바오로 병원에서 2015 년 6 월 입원치료 받음 Op Hx (-) Personal history Alcohol (-) smoking(-)

Work Up Endoscopy EGD & CFS Image study Abdomen CT, Rectum & sigmoid MR

S Gross Description : Specimen received fresh is a product of low anterior resection of the rectum ring 17.0 cm in length and 6.0 cm in circumference. Mucosal surface shows an ulceroinfiltrative mass, measuring 2.5x2.0cm in size, which locates 10.0cm and 2.5cm from the proximal and distal resection margins. There is a polypoid mass also seen, measuring 0.8x0.5cm in size, which locates 7.5cm and 9.0cm from the proximal and distal resection margin. This specimen is prepared whole mount section. Anterior and posterior margins are inked with yellow and green, respectively. Partially embedded in 1 to 9. (MJW) Main mass in 1 to 5. Polypoid lesion in 6. Pericolic lymph node in 7 to 9. Diagnosis : Rectum, lower anterior resection Adenocarcinoma, moderately differentiated Immunohistochemical finding (S , 4): hMLH1 (+), hMSH2 (+), EGFR (+, score 1), Cytokeratin (+), D2-40 (+, for lymphatics with tumor emboli)

Final Diagnosis #1. Rectal cancer s/p LAR

Chief Complaint Abdominal pain onset: 2015 년 5 월 Present Illness 65/M, HTN,DM,stable angina 의 병력 있는 자로 2015 년 5 월부터 배변을 잘 하지 못하며 복통 발생하여 관장받았으나 증상 호전 보이지 않아 5 월 성빈센트 병원 입원치료 후 증상 다소 호전되었다고 함. 하지만 퇴원 후 다시 대변 계속 보지 못하며 복통 발생하 여 본원 소화기내과 외래 통해 입원하였으며 megacolon 으로 6 월 17 일 laparoscopic AR 수술 받음. Case 김 O 진 (M/65) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( + / + / - / - ) Op Hx (+) Rt. ESS d/t paranasal sinusitis at 본원 ENT (2006) Personal history Alcohol (+) smoking(+) current smoker 20PY

Work Up Endoscopy Sigmoidoscopy Image study Abdomen & pelvis CT

S Gross Description : Specimen received fresh is a product of anterior resection of the sigmoid colon, measuring 32.0 cm in length and 11.0 cm in circumference. Serosal surface is unremarkable. Mucosal surface shows an edematous change, measuring 16.0cm in length x 10.0cm in circumference. Remaining mucosal surface shows an ulcerative lesion, measuring 1.0x0.5cm in size, which locates 21.0cm and 8.0cm from the proximal and distal resection margins. Partially embedded in 1 to 7. (MJW) Mucosal edematous change lesion in 1 to 3. Ulcerative lesion in 4 and 5. Pericolic lymph node in 6 and 7. More gross in A(normal), B(transitional area), C and D (dilated area). Diagnosis : Sigmoid colon, anterior resection: 1. Ganglion cells present 2. Chronic ulcer (1.0x0.5 cm) 3. Submucosal edema (History of volvulus) Special stain finding (S , A to C): Masson's Trichrome (was done) Normal (A) Transitional (B) Dilated (C) Masson's Trichrome + + +

Final Diagnosis Megacolon s/p laparoscopic AR

Chief Complaint known rectal cancer Present Illness 69/M, HTN 으로 외부병원에서 po medication 하고 있는 자로 2015 년 5 월 건강검진으 로 시행한 대장내시경에서 대장암 진단받고 본원 입원함. 검사에서 간전이를 동반 한 직장암으로 진단되어 6 월 12 일 laparoscopic AR 수술 후 adjuvant chemotherapy 로 FOLFIRI with erbitux 진행하고 있음. Case 명 O 식 (M/69) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( - / + / - / - ) Op Hx (+) 왼쪽 무릎 수술 (2007) Personal history Alcohol (+) 소주 1 달에 1 회 0.5 병 smoking(-)

Work Up Endoscopy colonoscopy Image study colon CT Liver MR Abdomen CT Abdomen CT

S Gross Description : Specimen received fresh is a product of low anterior resection, measuring 23.0cm in length x 8.0cm in circumference. Mucosal surface shows an ulcerofungate mass, measuring 4.5x3.8cm in size, which locates 14.0cm and 6.0cm from the proximal and distal resection margins. Remaining mucosal surface shows a polypoid lesion, measuring 0.6x0.3x0.3cm in size. Partially embedded in 1 to 12. (NBJ) Whole mount in 1 to 8. A polypoid lesion in 9. Perirectal lymph node in 10 to 12. Diagnosis : Adenocarcinoma, moderately differentiated Immunohistochemical finding (S , 4): hMLH1 (+), hMSH2 (+), EGFR (+, score 1), Cytokeratin (+), D2-40 (+, for lymphatics with tumor emboli)

Final Diagnosis Rectal cacner with liver metastasis (pT3cN1cM1) s/p laparoscopic AR s/p FORFIRI with erbitux #2

Chief Complaint hematochezia o/s) 6 월 초 Present Illness 75/M, chronic alcoholics 로 2015 년 4 월부터 매일 hematochezia 있어 건강보험공단에서 대변검사 시행 후 상급병원 권유받고 입원함. 검사에서 S-colon cancer c multiple LNs meta, lung metastasis (T4aN2M1) 보여 S-colon 에 stent 삽입하였으며 palliative CTx 예정 임 Case 강 O 배 (M/76) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( - / - / - / - ) malignancy hx (-) Personal history Alcohol(+) : 막걸리 1 병 / 일주일 2~3 번, 20 년 Smoking(+) : 0.2 갑 X 30 년 = 6 갑년

Work Up Endoscopy EGD CFS Image study colon CT chest CT PET CT

S Gross Description : Submitted for EXPRESS are 2 parts labelled as A and B. There are 8 and 5 discs of gray white mucosal tissue. Totally embedded in 1 and 2, respectively. (CH) Diagnosis : A. Colon, proximal sigmoid, 40cm from anal verge, colonoscopic biopsy: Adenocarcinoma, moderately differentiated B. Colon, distal sigmoid, 15~18cm from anal verge colonoscopic biopsy: Adenocarcinoma, moderately differentiated

Final Diagnosis S-colon cancer c multiple LNs & lung metastasis (T4aN2M1)

Chief Complaint constipation Present Illness 70/M, DM,HTN 으로 po med 하는 자로 내원 8 일전부터 변이 나오지 않아 타병원 입원치료 하였으며 증세 호전되지 않아 본원 외래 진료 후 입원함. Case 장 O 웅 (M/70) Admission date :

Past-medical history DM / HTN / Tb / Hepatitis ( + / + / - / - ) malignancy hx (-) Personal history Alcohol (-) smoking (-)

Work Up Endoscopy sigmoidoscopy Image study colon CT

Final Diagnosis paralytic ileus hypercalcemia r/o parathyroid adenoma