GI conference 경희대학교 의과대학 소화기내과

Case 1 Chief Complaint Present Illness 이O경 (F/54) 12322252 Admission date : 2013.02.01 Chief Complaint Lower abdominal pain o/s) 내원 2주일전 Present Illness F/54. Hyperlipidemia로 local에서 약물 복용중인 자로, 2013년 1월부터 상복부 통증 있어왔고 약 한달 반 동안 6kg가량의 체중 감소 있었으며 내원 2주일전부터는 하복부 통증 발생하여 local에서 검사 및 치료 받았으나 호전 없어 본원 소화기내과 입원하여 산부인과적 평가를 포함한 일련의 검사 진행 후 말단부 회장염 진단하에 퇴원하였으나 이후에도 증상 호전 보이지 않아 응급실 통해 입원함. .

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/-/-/-) Hyperlipidemia (+) Operation Hx (+) : 13년 전 자궁물혹제거 수술 Family history None Personal history Smoking (-) Alcohol (-)

Review of system Physical examination Fever(-) Chilling(-) Dizziness(-) General weakness(-) Itching(-) Jaundice(-) Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-) Abdominal pain(+) : Lower abdomen, cramping 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 8,760/mm3 (78.6%) – 12.5g/dL – 38.5% - 374,000 /mm3 PT(INR) 14.3 sec (1.12) aPTT 39.9 sec Chemistry TB/DB 0.7/0.2 mg/dL Prot/Alb 6.9/4.1 g/dL AST/ALT 16/9U/L BUN/Cr 6/0.6 mg/dL ALP/GGT 83/17 U/L Na/K/Cl 140/4.1/103 mmol/L Ca/P/Mg 8.6/4.2/2.0 mg/dL CRP <0.3 mg/dL

Work Up 2013.01.19 외부 Abdominal CT 2013.01.28 A-P US 2013.01.29 EGD, Colonoscopy 2013.02.02 Abdomen CT

Operation 2013.02.25 Laparoscopic small bowelsegmental resection

Diffuse large B cell lymphoma (DLBL) Diagnosis : Ileum, segmental resection: Diffuse large B cell lymphoma (DLBL)

Small bowel obstruction d/t DLBL Final Diagnosis Small bowel obstruction d/t DLBL

Pathology

CD20

CD3

BCL-2

CD10

MUM-1

Ki-67

Diagnosis Diffuse large B cell lymphoma Ileum, segmental resection: 1) Tumor size: 5.0 x 4.0 cm 2) Depth of invasion: Serosal penentration is not identiifed 3) Margins of resection: No tumor identified at proximal and distal resection margins (safety margin: proximal 23.0 distal 14.0cm) 4) Lymphatic invasion: Not identified 5) Vascular invasion: Not identified 6) Regional lymph nodes: Lymph nodes involvement in 1 out of 8 mesenteric lymph nodes (1/8)

IHC pannel CD20 B cell marker CD3 T cell marker CD10, BCL-6 Germinal center (GCB-DLBCL) Mum-1 Postgerminal center (ABC-DLBCL)

IHC pannel BCL-2 DDx. Burkitt lymphoma Ki67 Proliferating activity (eg. Bukitt lymphoma)

Case 2 Chief Complaint Present Illness 김O태 (F/54) 12322401 Admission date : 2013.02.01 Chief Complaint Rectal mass o/s) unknown Present Illness HTN , horse shoe kidney 있는 자로, colonoscopy 상 rectal mass 발견되어 치료 위해 본원 방문

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (-/+/-/-) Horseshoe kideny Operation Hx (+) : Rt 2nd finger OP (7~8 yr ago) Family history None Personal history Smoking (-) Alcohol (-)

Review of system Physical examination Fever(-) Chilling(-) Dizziness(-) General weakness(-) Itching(-) Jaundice(-) Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-) 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 7110/mm3 (58.5%) – 15.1g/dL – 43.1% - 296,000 /mm3 Chemistry TB / DB : 0.59 / - AST / ALT : 21 / 25 ALP / GGT : 77 / - BUN / Cr : 12 / 1.0 Na / K / Cl : 140 / 4.3 / 104

Work Up 1. Image study - 2013. 1. 30 Rectum MR 2. Endoscopy - 2013. 1. 28 Sigmoidoscopy 3. Pathology - S-2013-01590 - S-2013-01760 - S-2013-01761

Operation 2013. 1. 31 : Robotic partial ISR

Final Diagnosis Rectal GIST

Pathology

C-Kit

CD34

Desmin

S100

Diagnosis Rectum, lower anterior resection: Gastrointestinal stromal tumor, low risk 1) Size: 4.9x3.0x2.5 cm 2) Mitotic activity: not identified

Primary site of GIST Stomach (60%) Small intestine(jejunum and ileum, 30%) Duodenum (5%) Rectum (3%) Colon (1-2%) Esophagus (less than 1%) AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 175-80. 

Risk stratification of GIST

Case 3 Chief Complaint Present Illness 우O자 (F/76) 10964875 Admission date : 2013.02.01 Chief Complaint Gastric polyp o/s) unknown Present Illness DM, HTN, old CVA Hx 있는 환자로, local 에서 시행한 gastroscopy 상 multiple polyp 발견됨. 본원에서 biopsy, CT 시행하여 EGC, type I 및 pancreas IPMN 발견되어 수술 위해 입원

Past-medical history Family history None Personal history DM / HTN / Tbc / Hepatitis (+/+/-/-) Old CVA (‘04) Operation Hx (-) : Family history None Personal history Smoking (-) Alcohol (-)

Review of system Physical examination Fever(-) Chilling(-) Dizziness(-) General weakness(-) Itching(-) Jaundice(-) Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-) 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 3290/mm3 (53.2%) – 12.2g/dL – 37.3% - 340,000 /mm3 Chemistry TB / DB : 0.65 / 0.21 AST / ALT : 16 / 16 ALP / GGT : 77 / 20 BUN / Cr : 14 / 0.6 Na / K / Cl : 138 / 3.7 / 102

Work Up 1. Image study - 2012. 10. 30 Abdomen US - 2012. 10. 31 Abdomen CT - 2012. 11. 2 PET CT 2. Endoscopy - 2012. 10. 31 Gastroscopy 3. Pathology - S-2012-18368 - I-2012-01298 - S-2012-19074 - S-2012-19075

Operation 2012. 11. 13 : Open distal gastrectomy c distal pancreatectomy c splenectomy

Early gastric cancer c IPMN Final Diagnosis Early gastric cancer c IPMN

Pathology

Diagnosis Stomach, distal gastrectomy: Tubular adenocarcinoma, well differentiated 1) Location: Body, lesser curvature 2) Tumor gross type: Early gastric carcinoma, type I 3) Histologic type by Lauren classification: Intestinal 4) Tumor size: 3.0 x 2.3 x 1.5 cm 5) Depth of invasion: Tumor invades lamina propria/muscularis mucosae (pT1a) 6) Margins of resection: No tumor identified at proximal and distal resection margins 7) Lymphatic invasion: Not identified 8) Vascular invasion: Not identified 9) Regional lymph nodes: No metastasis in 11 regional lymph nodes ( 0/11 , pN0) 10) Additional pathologic findings: Hyperplastic polyp (x5)

Diagnosis Pancreas, distal pancreatectomy: I. Ductal adenocarcinoma, moderately differentiated 1) Size: 2.5 x 2.5 cm 2) Location: pacreatic tail 3) Extent of tumor: Tumor invades peripancreatic soft tissue (pT3) 4) Negative proximal and peripancreatic (circumferential) resection margins 5) No matastasis in 18 peripancreatic lymph nodes (0/18, pN0) 6) Lymphovascular invasion: not identified II. Intraductal papillary mucinous neoplasm with low-grade dysplasia III. Chronic pancreatitis Spleen, splenectomy: Chronic congestion (History of idiopathic thrombocytopenic purpura)

IPMN 1) Differential diagnosis Mucinous cystadenoma Serous cystadenoma Pancreatic intraepithelial neoplasia 2) Degree of dysplasia Two grade or three grade system 3) The presence of invasive carcinoma (30%)