1. 제 79 회 대한 소화기 내시경 월례집담회 예수병원 소화기 내과 이영재

2. 64/F Chief Complaint : Hematemesis Onset : 3 월 15 일 새벽 2:00( 내원 1 시간전 ) Nature : 붉은색 선혈 Amout : 한 모금씩 2 회 → 병원 도착 직후 100~200cc 2 회 Vector : spontaneous ass. Sx : nausea/vomiting (-)

3. Present illness(1) 2008.3.4( 내원 11 일전 ) 1 st OPD visit 내원 3 일전부터 시작된 epigastric discomfort (lower sternum, 먹거나 움직일 때, 찌르는 것처럼, 뒷가슴까지 같이 아프다 ) 를 주소로 외래 방문하여 복부 CT, 상부 내시경 검사, 심장 검사 (echo & TMT) 에 대해 권유 받음 Past History : n/s P/E : n/s 2008.3.13( 내원 2 일전 ) 2 nd OPD visit 외래 방문하여 시행한 검사 결과 확인, 증상 변화 없음 (?) * EGD : n/s * 복부 CT : n/s * 심전도 : normal sinus rhythm * 심장 초음파 : EF=76%, mild AoV calcification(TMT : refuse) 2008.3.15 Hematemesis 를 주소로 AM 03:00 ER visit

4. Present illness(2) 2007. 봄 검진 EGD : n/s 2007.8 목이 찌져지게 아팠다 : ENT 진료 2008.3.13 EGD : n/s

5. Physical Examination Vital Sign : BP 100/60mmHg, HR 72 회 /min, BT 36.5 (BP 90/60, HR 88) G.A acute ill appearance HEENT mild anemic conjunctiva anicteric sclera Chest relatively clearly breathing sound regular heart beat without murmur Abdomen soft usual bowel sound Ext. No pitting edema L-tube irrigation : fresh blood color DRE : n/s

6. Initial laboratory data AM 03:31(3/5) CBC Hg 9.1g/dL(12.4) WBC 23.3X10 3 /uL(seg 93%,12.0X10 3 ) PLT 387X10 3/ uL aPTT 26.6s PT 12.2s(89.1%) INR 1.05 LFT & BUN/Cr : W.N.L AM 05:40 ♣Central line insertion 후 Emergency Endoscopy 시행함

7. Chest PA

8. EGD

9. IC 25cm, esophageal Dieulafoy’s ulcer

10. Progression(1) AM 06:05 내시경검사 종료하여 약 5 분 경과후 massive re-hematemesis 1)Mental change 와 동반하여 많은 양의 fresh blood hematemesis 2)ER 로 transfer 3)Intubation 하여 기도확보, fluid loading & transfusion 4)BP 80/- mmHg HR 120~130 회 /min AM 07:05 2 nd Emergency Endoscopy 1) 많은 양의 출혈로 내시경적 시야 불량 2)SB tube insertion try → Failure 3)Embolization & surgical management recommend

11. Progression(2) Hg 추적 검사 결과, 계속해서 출혈, 총 10 pints 의 PRBC transfusion 1)06:21 6.7 g/dL 2)07:04 8.0 g/dL 3)BP 60/- mmHg, HR 140 회 /min 4)08:39 4.2 g/dL 5)Cardiac arrest → CPR AM 09:20 transfer to 전북대학교병원 응급실 1)BP 40/- mmHg 2)SB tube insertion 3)AM 11:00, 혈관촬영실로 이송중 다시 arrest 발생하여 CPR 후 사망 4)Hg 2.0 g/dL

12. Diagnosis Esophageal ulcer bleeding d/t Dieulafoy’s ulcer d/t s/o aortoesophageal fistula

14. Aortoesophageal Fistula ; A comprehensive Review of the literature JUDDE, MD et al. September 1991 The American Journal of Medicine Volume 91 Review literature of 500case of AEF : for discuss diagnostic and therapeutic modality avalilable for slow the hemorrhage so as to allow time to correct the anatomic defect Chiari triad 1)Mild thoracic cheset pain 2)Sentinel bleeding 3)Massive hemorrhage after asymptomatic period

15. Etiology Etiology of AEFNumber of cases Thoracic aortic aneurysm Foreign body ingestion Esophageal malignancy Postsurgical Esophageal ulcer and reflux Tuberculosis Traumatic false aneurysm Lye ingestion Bronchoesophageal-aortic fistula Atheromatous aortic ulcer Congenital aortic arch anomaly Instrumentation Obscure etiology 256 93 85 24 10 9 6 3 2 1. 500

16. Clinical characteristics Etiology Cases since No Chiari’s Triad PainDysphagia Sentinel bleed Thoracic aortic aneurysm Foreign bodies Esophageal malignancy Peptic disease Tuberculosis Grafts Total 1962 1965 1963 1964 1965 1978 31 9 10 6 4 64 15(48%) 7(78%) 0(0%) 3(50%) 2(50%) 29(45%) 18(58%) 8(89%) 3(30%) 4(67%) 3(75%) 2(50%) 38(59%) 13(42%) 6(67%) 5(50%) 2(33%) 2(50%) 1(25%) 29(45%) 20/32(63%) 12/13(92%) 4/11(36%) 5/7(71%) 2(50%) 3(75%) 46/71(65%)

17. Treatment No survivors of non surgically managed AEF Supportive care 1)Volume replacement and transfusion 2)Broad spectrum IV antibiotics 3)Correction of electrolyte and coagulopathy Radiographic embolization 1)role as a temporizing control measure in the management of an AEF 2)report of delayed bleeding and pt’s rapid expire 3)embolization shoud be considered only temporary method 4)surgical definitive correction will need to be performed soon SB Tube insertion 1)demonstrated benefit(several reports) 2)adequat temporary control of the exsanguinating hemorrhage Surgical repair is the only cure method

18. Selected Studies of AEF InvestigatorS/AetiologyInitial Sx initial evaluation Endoscopi c finding Initial Tx Confirm evaluaiton Definitive TxResult Roderik Metz et al., 2006, Netherlands M/31 Chicken bone Mild chest pain, dysphagia, malaise, coughing Endoscopy Mid esophagus dee defect Endoscopic injection CT Endovascular aortic stent insertion, esophagectomy 8month f/u D,H, Park et al., 2006, Korea F/35Fish bone Anterior chest pain, melena CT IC 22cm active spurting Covered metal stent Surgery Li-Jung Tseng et al., 2001, Taiwan F70? Progressive dysphagia Endoscopy IC 20cm submucosal mass with ulcerated mucosa CTSurgeryDeath 김대진 et al., 2007, Korea F/68 닭뼈 ? 토혈 Endoscopy Exposured vessel with oozing 수술 CTDeath Kim L et al., 2002, Mayo clinic F/13 Nasogastric tube insertion Massive hematemesis Endoscopy Could not evaluation Fluid admDeath

19. Temporary placement of a covered metal stent for the management of a bleeding aortoesophageal fistula DH Park, Endoscopy. 2007 Feb;39 Suppl 1:E61-2 35/F, C.C : anterior chest pain and melena Past Hx : 12 days ago, after eaten fish, developed foreign body sensation → EGD : extracted V-shape fish bone in her cervical esophagus EGD : Active blood spurting was noted 22cm from the incisor Stent insertion and fully expanded !!! After procedure vital sign became stable and 6hr later definitive op was done Prompt endoscopic placement of a covered esophageal stent for the treatment of a bleeding AEF may play a role as “ salvage therapy”

20. Aortoesophageal fistula successfully treated by endovascular stent-graft Metz R, Ann Thorac Surg. 2006 Sep;82(3):1117-9 31/F, C.C : Severe hematemesis Past Hx : 8days earlier, Foreign body (chicken bone) Emergency EGD : r/o M-W syndrome (d/t distal eso. ulcer) Next day – hemodynamically unstable → Emergency CT : contrast leakage form aorta and mediastinal mass(hematoma)