Asan Medical Center Choi Ji Young ESD complication 38534779 박상훈 Asan Medical Center Choi Ji Young

Present Illness 1st case 57/M 건강 검진 EGD상 EGC 진단받고 본원으로 전원됨. Endoscopic resection 위해서 입원. Past Medical History DM HTN Social History Alcohol : social drinker (매주 소주 1잔) Smoking : 10 pyrs, ex-smoker Family History N/S

Review of System Physical Examination General weight loss(-) Respiratory cough/sputum/rhinorrhea(-) dyspena(-) Gastrointestinal dyspepsia(-) anorexia/nausea/vomiting(-/-/-) General healthy-looking appearance alert mental status Respiratory clear breathing sound without crackle and wheezing Gastrointestinal soft and flat tenderness/RT (-/-)

Initial Lab Data CBC 7800 /mm3 - 14.1 g/dL - 335 K /mm3 AST/ALT 23/30 IU/L ALP 63 IU/L TB/DB 0.7/0.2 mg/dL Protein 7.3 g/dL Albumin 4.4 g/dL Electrolyte 141 – 4.0 – 102 mEq/L BUN 11 mg/dL Cr 1.0 mg/dL PT 115.8 % (0.95 INR) aPTT 27.5 sec

Initial CXR

EGD

Post ESD S) Fever with chills, cough, rhinorrhea (POD#0) O) BP 126/82 HR 100 RR 24 BT 38.6℃

A) Post-ESD aspiration pneumonia P) Conservative management including antibiotics

Post ESD POD #4 POD #12

Present Illness 2nd case 73/M Dyspepsia로 외부 병원에서 EGD 시행 후 gastric adenoma 진단받고 본원으로 전원됨. Endoscopic resection 위해서 입원. Past Medical History HTN Social History Alcohol : heavy drinker (매일 소주 1병) Smoking : 50 pyrs Family History Mother – pancreatic cancer

Review of System Physical Examination General weight loss(-) Respiratory cough/sputum/rhinorrhea(-/-/-) dyspnea(-) Gastrointestinal dyspepsia(+) anorexia/nausea/vomiting(-/-/-) General not so ill-looking appearance alert mental status Respiratory clear breathing sound without crackle and wheezing Gastrointestinal soft and flat tenderness/RT (-/-)

Initial Lab Data CBC 8100 /mm3 - 14.5 g/dL - 145K /mm3 AST/ALT 27/30 IU/L ALP 48 IU/L TB/DB 0.9/- mg/dL Protein 6.5 g/dL Albumin 3.9 g/dL Electrolyte 141 – 4.5 – 103 mEq/L BUN 15 mg/dL Cr 1.2 mg/dL PT 83.4 % (1.17 INR) aPTT 28.9 sec

Initial CXR

Initial EGD Bx : tubular adenoma

Post ESD S) dyspnea, chest pain O) BP 120/70 HR 79 RR 22 BT 38.9℃ SpO2 90% POD #0 POD #1

r/o Post-ESD aspiration pneumonia r/o Community-acquired pneumonia P) Conservative management including antibiotics

Post ESD Pneumococci-urine Ag test : positive

POD #2 POD #4 POD #6 POD #8 POD #17 POD #24

Brief review Post ESD - pneumonia

ESD complication - pneumonia Possibly because of aspiration Relatively rare complication 0.8 ~ 4% More frequently in the elderly patients (0% vs 2.2%) All patients recoverd well with antibiotic treatment. Isomoto et al. Eur J Gastroenterol Hepatol 2010; 22: 311-317 Lee et al. J Clin Gastroenterol 2008; 42: 42-47

ESD complication - pneumonia Aspiration is another problem because ESD is a time-consuming procedure. The risk of aspiration may increase if it is a long-term endoscopic procedure. No clear whether the use of prophylactic antibiotics therapy is beneficial in such settings. A low frequency of bacteremia has been reported after EMR-c. Lee et al. J Clin Gastroenterol 2008; 42: 42-47 Lee et al. Gastrointes Endosc 2002; 52: 223-225