ERCP 집담회 단국대 김홍자, 문성훈

Chief Complaint epigastric pain for 1day CASE 1 : M/67 Chief Complaint epigastric pain for 1day 콕콕 찌르는듯한 통증

Present Illness 내원 2년 전 본원에서 AGC로 total gastrectomy & splenectomy, papillary thyroid cancer with L/N invasion으로 total thyroidectomy with both MRDN 시행받고 요양원에서 지내는 분으로 내원일 아침 식사 이후 mild epigastric discomfort발생하였으나 지켜보다가 점심 이후에 쿡쿡 찌르는 듯한 통증으로 악화되어 local clinic 통해 본원 ER에 내원함.

Social History & Family History Past Medical History DM/HTN/Hepa/Allergy/Tb(-/-/-/-/-) 2009.6.25. total gastrectomy with esophagojejunostomy Roux- en-Y anastomosis and splenectomy d/t AGC 2009.6.25. total thyroidectomy with Both MRDN d/t thyroid papillary carcinoma, Lt Social History & Family History smoking(+) : 1pack/day * 40years alcohol(-) non-sepecific family history AGC Bx 소견 : with 1) tumor size: 9.2x7.4 cm 2) extension to perigastric adipose tissue 3) lymphovascular tumor emboli 4) negative proximal and distal resection margins 5) metastasis in regional lymph nodes (14/44) LN-1 (0/5), LN-2(0/0), LN-4S (0/2), LN-5 (0/0), LN-6 (3/4), LN-7 (0/1), LN-8A (0/6), LN-8P (0/3), LN-9 (1/2), LN-10 (0/1), LN-11P (0/4), LN-11D (0/0) LN-12A (0/0), LN-14V (0/3) Thyroid cancer Bx 소견 : with 1) the size: 6.2 cm in greatest dimension 2) extension to perithyroidal skeletal muscle 3) very close to soft tissue resection margin ( safety margin: about 1 mm ) 4) metastasis to 7 out of about 34 perithyroidal lymph nodes

Review Of System Gneral weakness/poor oral intake(-/-) fatigue(-), headache/dizziness(-/-) body weight change(-) fever/chill(-/-) cough/sputum/rhinorrhea/congestion(-/-/-/-), sore throat(-) chest pain/discomfort(-/-), palpitation(-) abdominal pain/discomfort(+/+) : epigastric area dysphagia/odynophagia(-/-), dyspepsia/heartburn(-/-) hematemesis/hematochezia/melena(-/-/-) anorexia/nausea/vomiting/diarrhea/constipation(-/-/-/-/-)

Physical Examination V/S : 137/80mmHg - 104/min - 20/min - 36.6℃ G/A : not so ill looking appearance HEENT : not anemic, anicteric sclera, dehydrated tongue/lips(-/-) Abdomen : soft and flat, normoactive bowel sound tenderness/reboound tenderness(+/-) : epigastric area Murphy’s sign(-) Corstovertevral angle tenderness(-/-) Pretebial pitting edema(-/-)

Initial Laboratory Findings CBC 16360/㎕(neutrophil 87.7%), Hb 12.3g/㎕, Hct 37.5%, plt 380k Na 137mEq/ ℓ, K 3.7mEq/ ℓ, Cl 102 mEq/ ℓ BUN 10.1mg/ ㎗, Cr 0.77 mg/ ㎗ AST 110 U/ ℓ, ALT 88 U/ ℓ, total bilirubin 2.64mg/㎕ CRP 0.73mg/ ㎗ PT 9.7sec, INR 0.82, aPTT 25.4sec

Image study 5/10 AP-CT 1. Distal CBD stone with mild bile duct dilatation, suggesting calculous cholangitis in EHD. -- Periportal lymphedema in liver. 2. No interval change of stone in GB. (0.6 cm) 3. Post status of total gastrectomy and splenectomy with esophagojejunostomy. L-tube insertion in efferent loop of jejunum in epigastric area. 4. Localized mild paralytic ileus in epigastric area and left upper quadrant of abdomen. : R/O postop adhesion. 5. Short segmental thrombotic obliteration of right superficial femoral artery with reconstitution in distal portion. Mild cardiomegaly and atherosclerosis of abdominal aorta and bilateral common, internal, external, and common femoral arteries. 6. Multiple small diverticula in cecum and proximal ascending colon. 7. No interval change of a few tiny non-calcified subpleural nodules on right lower lobe lateral basal segment. 2011.01.13. stomach CT 1. No evidence of newly appeared focal lesion or distant metastasis in liver, retroperitoneum, both basal lungs and scanned bone. 2. Post status of total gastrectomy with esophagoduodenostomy and splenectomy due to advanced gastric cancer. 3. Increased extent of soft tissue density lesion in GB (1.5 cm extent). : R/O GB polyp. 4. No significant interval change of mild cardionmegaly, thrombocalcific atherosclerosis along abominal aorta and both iliac arteries.

Single balloon small bowel enteroscope assisted gastroscopic CBD stone removal

CASE 2 : M/66 Chief Complaint RUQ abdominal pain, onset : 3 days ago

Present Illness 10년전 AGC로 subtotal gastrectomy (Biloth-II) 시행 받은 분으로 9년전 CBD stone 으로 입원하여 ERCP 시도하였으나 실패하여conservative care 후 퇴원한 병력 있음. 내원 3일전부터 식후에 지속적으로 발생한 RUQ pain 을 주소로 ER 경유 입원함.

Past Medical History Social History & Family History DM/HTN/Tb/hepatitis(-/+/-/-) 1994년 subtotal gastrectomy, Biloth-II with brown anastomosis d/t AGC 2001년 CBD stone으로 conservative management후 퇴원 drug Hx(+) : caduet (amlodipin/atrovastatin 5/10mg) qd Social History & Family History smoking(-), alcohol(-) non-sepecific family history AGC : in lower body along lesser curvature with L/N metastasis 1(+)/20 => T2N1M0, stage II 1994년 12월부터 1997년 1월까지 2년동안 항암제 po mededication받음(DDT1 2년, 1996년 1월부터 3월까지 mitomycin 400mg + 5FU 700mg주사 총 3회 받음)

Review Of System Gneral weakness/poor oral intake(-/+) fatigue(-), headache/dizziness(-/-) body weight change(-) fever/chill(-/-) cough/sputum/rhinorrhea/congestion(-/-/-/-), sore throat(-) chest pain/discomfort(-/-), palpitation(-) abdominal pain/discomfort(+/+) : RUQ area dysphagia/odynophagia(-/-), dyspepsia/heartburn(-/-) hematemesis/hematochezia/melena(-/-/-) anorexia/nausea/vomiting/diarrhea/constipation(-/-/-/-/-)

Physical Examination V/S : 127/84mmHg - 78/min - 20/min - 38.6℃ G/A : acute ill looking appearance HEENT : Not anemic, anicteric sclera, dehydrated tongue/lips(-/-) Chest : N-S Abdomen : soft and flat, normoactive bowel sound tenderness/rebound tenderness(+/-) : RUQ Murphy sign(+) Corstovertevral angle tenderness(-/-) Pretebial pitting edema(-/-)

Initial Laboratory WBC 11940/㎕(neutrophil 93.3%), Hb 13.1g/㎗, Hct 39.4%, plt 234k Na 143mEq/ℓ, K 4.6mEq/ℓ, Cl 106 mEq/ℓ BUN 14.8mg/㎗, Cr 0.82 mg/㎗ AST 653 U/ℓ, ALT 485 U/ℓ, total bilirubin 2.02mg/㎗ alkaline phosphatate 173 IU/L amyalse 41U/ℓ, lipase 33U/ℓ, cholesterol 145 mg/㎗ CRP 0.39 mg/㎗ PT 10.3sec, INR 0.86, aPTT 25.0sec urine protein(-), RBC <1, WBC <1

Image study :Several GB stones with distension, wall thickening, and pericholecystic fat stranding : Acute calculous cholecystitis. A far distal CBD stone & mild dilatation of EHD and central IHD. S/P STG & G-J)

Single balloon enteroscope guided duodenoscopic stone removal