2. Chief Complaint for evaluation of esophageal lesion onset > 2012.02.01 Present Illness 매일 소주 1~1.5 병 마시던 자로 2012.2.1 건강검진에서 시행한 EGD 에서 esophageal cancer 의심되는 병변 보여 이에 대한 정밀검사 위하여 입원함 Case 1 박 O 윤 (F/69) 10920069 Admission date : 2012.02.14

3. Past-medical history DM / HTN / Tbc / Hepatitis (-/-/-/-) Operation Hx (+): 1990. Appendectomy 1991.9. OR/IF d/t cottons Fx, ankle Lt. Medication Hx : none Family history None S Personal history S moking : (-) Alcohol : (+) : 매일 소주 1~1.5 병

4. Review of system Weight loss (-) A/N/V/D/C(-/-/-/-/-) Melena(-) Hematochezia(-) Hematemesis(-) Physical examination No palpable LN Soft and flat abdomen Normoactive bowel sound Td/RTd(-/-)

5. Initial Lab Findings CBC/DC 3500/mm 3 (57.6%) – 12.0 g/dL - 37.7 % - 305,000/mm 3 PT(INR) 12.5 sec (0.93) aPTT 35.6 sec Chemistry TB/DB 0.92/0.29 mg/dL Prot/Alb 7.0/4.3g/dL AST/ALT 25/10 U/LBUN/Cr 16/0.3 mg/dL ALP/GGT 33/30 U/LNa/K/Cl 141/4.0/103 mmol/L LD/CK 405/138U/LCa/P/Mg 9.0/3.9/2.2 mg/dL CRP < 0.3 CA 125/CEA 7.1/3.08

6. Work Up 2012.02.01 EGD

7. Endoscopic biospy (S-2012-01579) Diagnosis : Squamous cell carcinoma

8. Work Up 2012.02.14 EGD

9. Work Up 2012.02.14 EGD

10. Esophagectomy (2012.3.6)

11. Work Up 2012.02.01 EGD 2012.02.14 EGD & EUS 2012.02.14 chest CT & abdomen CT 2012.02.14 abdomen CT 2012.02.15 PET CT

12. Work Up 2012.02.01 EGD 2012.02.14 EGD & EUS 2012.02.14 chest CT & abdomen CT 2012.02.14 abdomen CT 2012.02.15 PET CT

13. Final Diagnosis Esophageal squamous cell carcinoma

14. Chief Complaint abd. distension onset > 내원 1 달 전, 2012.02.08 Present Illness F/83. 10 여 년전 DM 및 cervical cancer 진단받아 외부병원 ( 원자력병원 ) 에서 chemoradiotherapy 시행한 후 장천공 발생하여 수술한 과거력 있는 자로 내원 1 달전 부터 abd. Distension, nausea, vomiting 증상으로 외부병원 ( 동해 동인병원 ) 에서 입원 치료하였으나 증상 호전 없어 본원으로 전원됨. Case 2 신 O 임 (F/83) 11711294 Admission date : 2012.03.05

15. Past-medical history DM / HTN / Tbc / Hepatitis (+/-/-/-) cervical cancer s/p chemoradiotherapy : 10 년전 Operation Hx (+): abdominal surgery d/t intestinal perforation, 10YA Medication Hx : none Family history None Personal history S S moking : (-) Alcohol : (-)

16. Review of system Weight loss (-) A/N/V/D/C(-/+/+/-/-) Abdominal distension (+) Melena(-) Hematochezia(-) Hematemesis(-) Physical examination No palpable LN Soft and distended abdomen hypoactive bowel sound Td/RTd(+/-)

17. Initial Lab Findings CBC/DC 13,020/mm 3 (88.9%) – 9.4 g/dL – 29.6 % - 204,000/mm 3 PT(INR) 15.1 sec (1.19) aPTT 38.5 sec Chemistry TB/DB 0.35/0.18 mg/dL Prot/Alb 5.2/2.7g/dL AST/ALT 24/15 U/LBUN/Cr 48/1.1 mg/dL ALP/GGT 79/7 U/LNa/K/Cl 136/4.4/103 mmol/L LD/CK 518/23 U/LCa/P/Mg 7.8/3.5/2.0 mg/dL CRP 18.59 CA 19-9/CEA 8.96/2.17

18. Work Up 2012.03.06 colon CT 2012.03.12 colon CT

19. Final Diagnosis Small bowel obstruction at distal ileum

20. Review Acute intestinal obstruction

21. Etiology & classification Extrinsic lesion (75%) adhesive bands or internal hernias secondary to previous abd. surgery external hernias Intrinsic lesion diverticulitis, carcinoma, and regional enteritis Obstruction of normal bowel lumen gallstone obstruction, intussusception Adynamic ileus Primary intestinal pseudo-obstruction 1. any abdominal operation 2. Retroperitoneal hematoma ; vertebral fracture 3. other retroperitoneal conditions; ureteral calculus, severe pyelonephritis. 4. Thoracic diseases ; lower-lobe pneumonia, fracture d ribs, and myocardial infarction 5. electrolyte disturbances ; potassium depletion

22. Pathophysiology Distention of the intestine : gas and fluid proximal to and within the obstructed seg. Between 70 ~ 80% of intestinal gas consists of swallowed air; mainly of nitrogen, which is poorly absorbed from the intestinal lumen fluid : ingested fluid, swallowed saliva, gastric juice, and biliary and pancreatic se cretions + interference with normal sodium and water transport During the first 12–24 h of obstruction : flux from lumen to blood of sodiu m and water After 24 h : sodium and water move into the lumen, contributing further to the distention and fluid losses. Intraluminal pressure : from a normal of 2–4 cmH 2 O to 8–10 cmH 2 O

23. Pathophysiology A "closed loop" is the most feared complication During peristalsis, pressures 30–60 cmH 2 O Strangulation of the closed loop is common Once impairment of blood supply to the GI tract occurs, bac terial invasion supervenes, and peritonitis The systemic effects of extreme distention elevation of the diaphragm with restricted ventilation and a telectasis Venous return via the inferior vena cava

24. Treatment The overall mortality rate for obstruction : 10% nonstrangulating obstruction : 5–8% strangulating obstruction : 20 - 75% strangulating small-bowel obstruction : surgical intervent ions fluid and electrolyte balance decompression : by a nasogastric tube Adynamic Ileus Correction of electrolyte abnormalities (potassium, magnes ium) decompression of a colonic ileus : repetitive colonoscopy