2. Chief Complaint known hepatic cyst o/s) 2012 년 12 월 Present Illness F/64. HTN 으로 약물치료 중인 자로 2012 년 12 월 건강검진으로 타병원에서 시행한 복부 초음파 소견에서 간낭종 ( 약 10cm) 소견 있어 본원 소화기내과 및 외과 외래 진료 후 수술 권유 받아 외과로 입원함. Case 1 박 O 선 (F/64) 12322685 Admission date : 2013.03.06

3. Past-medical history DM / HTN / Tbc / Hepatitis (-/+/-/-) Operation Hx (-) Family history None Personal history Smoking (-) Alcohol (-)

4. Review of system Fever(-)chilling(-) Weight loss(-)Itching(-)Jaundice(-) Epigastric pain(-) A/N/V/D/C(-/-/-/-/-) Abdominal distension(-)abdominal pain(-) Melena(-)Hematochezia(-)Hematemesis(-) Physical examination V/S: 150/80 mmHg – 64/min – 20/min – 36.4 Alert mentalityacute-ill looking Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen :Td(-) & rTd(-)

5. Initial Lab Findings CBC/DC 5,950/mm 3 (49.4%) – 12.4 g/dL – 38.0 % - 270,000 /mm 3 PT(INR) 12.2 sec (0.92)aPTT 27.0 sec Chemistry TB/DB 0.83/0.22 mg/dL Prot/Alb 7.7/4.3 g/dL AST/ALT 26/15 U/LBUN/Cr 17/0.5 mg/dL ALP/GGT 111/26 U/LNa/K/Cl 139/3.4/100 mmol/L Ca/P 9.1/4.3 mg/dL

6. Work Up 2013.01.30 GB & biliary CT 2013.02.14 Liver MR

7. Operation 2013.03.07 Lap. Excision

8. (S-2013-03764) Diagnosis : : Biliary cystadenoma

9. Final Diagnosis Biliary cystadenoma

17. Liver, excision: Biliary cystadenoma

18. Biliary cystadenoma Less than 5% of all hepatic solitary cysts 95% occur in women, range 2-87 years 84% are intrahepatic, also in common bile duct (6%), hepatic ducts (4%), cystic duct (4%), gallbladder (2%) 25% have coexisting malignancy

19. GI Conference Case 1

20. C.C > 대변량 감소 o/s) 2 wks P. I >1998 년 crohn`s disease 진단받은 자로, rectal stricture 있어 2012 두차례 balloon dilatation 하였으며, 약 2 주 전부터 대변량 줄고 복부 불편감 있어 stricture 의심되어 입원. PMHx > DM / HTN / Tb / Hepatitis ( - / - / - / - ) Remicade #1 ~ #12 Ballon dilatation (2012 년 8 월, 9 월 ) OPHx > Anal fistula OP (2005, 2008) 12295021 이 ○ (M/36)

21. 1. General Fever ( - ), Chill ( - ), Fatigue ( - ), Wt. loss ( - ) 2. Cardiopulmonary Dyspnea ( - ), Cough ( - ), Sputum ( - ), Hemoptysis ( - ) PND ( - ), Chest Pain ( - ), Palpitation ( - ) 3. Abdomen A / N / V / D / C ( - / - / - / - / + ) Abd. discomfort ( + ) Hematemesis ( - ) Melena ( - ) Hematochezia ( - ) Stool Caliber Change ( - ) Review of systems

22. 1. General Alert mentality 2. Chest Symmetric expansion RHB without murmur, CBS without rale 3. Abdomen Abdomen : soft NABS Abd Td / rTd ( - / - ) Palpable mass ( - ) Muscle Guarding ( - ) CVA Td ( - / - ) Physical examination

23. WBC : 3390 (seg. 71 %) Hb : 9.0 Hct : 29.9 Plt : 255000 TB / DB: 0.75 / 0.19 AST / ALT : 20 / 5 ALP / GGT: 110 / 17 BUN / Cr: 12 / 0.8 Na / K / Cl : 140 / 4.0 / 105 Initial lab finding

24. 1. Image study - 2013. 5. 20 Small bowel series 2. Pathology Work up

25. Rectal stenosis Impression

26. 2013. 5. 22 Laparoscopic colonic segmental resection & transanal dilatation Operation

27. GI Conference Case 2

28. C.C > fevero/s) 2 wks P. I > 2005 부터 recurrent pancreatitis, CBD obstruction, liver abscess 로 수차례 stent insertion, 2009 hepaticojejunostomy 한 자로, 이후에도 상기 증상 악화, 호전 반복하며 f/u 중임. 내원 2 주 전부터 fever 있으며 CT 상 liver abscess 있어 입원하였으며, PCD insertion 하였으나 호전되지 않아 수술 계획함. PMHx > DM / HTN / Tb / Hepatitis ( - / - / - / - ) OPHx > 2009 Lap. hepaticojejunostomy c cholecystectomy 11812901 곽 ○ 윤 (M/53)

29. 1. General Fever ( + ), Chill ( + ), Fatigue ( - ), Wt. loss ( - ) 2. Cardiopulmonary Dyspnea ( - ), Cough ( - ), Sputum ( - ), Hemoptysis ( - ) PND ( - ), Chest Pain ( - ), Palpitation ( - ) 3. Abdomen A / N / V / D / C ( - / - / - / - / - ) Abd. discomfort ( - ) Hematemesis ( - ) Melena ( - ) Hematochezia ( - ) Stool Caliber Change ( - ) Review of systems

30. 1. General Alert mentality 2. Chest Symmetric expansion RHB without murmur, CBS without rale 3. Abdomen Abdomen : soft NABS Abd Td / rTd ( - / - ) Palpable mass ( - ) Muscle Guarding ( - ) CVA Td ( - / - ) Physical examination

31. WBC : 8420 Hb : 12.7 Hct : 40.4 Plt : 297000 TB / DB: 1.32 AST / ALT : 18 / 24 ALP / GGT: 523 / 468 BUN / Cr: 12 / 1.0 Na / K / Cl : 139 / 5.1 / 99 Initial lab finding

32. 1. Image study - 2013. 4. 11 Abdominal CT - 2013. 4. 20 GB, billiary CT 2. Endoscopy - 2013. 4. 19 Gastroscopy 3. Pathology - S-2013-06900 Work up

33. Liver abscess Impression

34. 2013. 4. 23 Lt lobectomy Operation

42. Diagnosis Liver, left, lobectomy: Chronic granulomatous inflammation

44. Chief Complaint Abdominal pain (RLQ) onset) 내원 1 일전 오전 10 시경 Present Illness F/82, 2003 년 8 월 진단받은 C-viral LC c ascites, esophageal varix s/p EVL #3, DM, aortic stenosis, Parkinson disease 로 IG(Prof. 김병호 ), NR(Prof. 윤성상 ) f/u 중인 자로 내원 1 일전부터 시작된 복통으로 응급실 통해 acute appendicitis, perforated 진단 하 보존적 치료 위해 GS(Prof. 박선진 ) 입원함. Case 1 안 O 숙 (F/82) 11675199 Admission date : 2013.4.26

45. Past-medical history HTN / DM / Hepatitis / Tbc (-/+/+/-) : chronic hepatitis C C-viral LC (Child B(8), MELD 9.94) c ascites, esophageal varix s/p EVL #3 Aortic stenosis Parkinson disease Drug Hx (+) Operation Hx (-) Family history None Personal history Smoking (-) Alcohol (-) IG : Legalon 1C qd NR : Amitriptyline 10mg qd Propranolol 10mg tid Propranolol 10mg tid Perkin 0.75T tid Perkin 0.75T tid Ropinirole 0.25mg tid Ropinirole 0.25mg tid Stillen 1T tid Stillen 1T tid 삼육병원 IC : Aspirin 100mg qd Varsartan 80mg qd Varsartan 80mg qd Furosemide 40mg qd Furosemide 40mg qd Metolazone 5mg qd Metolazone 5mg qd Local clinic : Janumet 50/1000 1T qd

46. Review of system Fever (+) : 37.7 ℃ Chilling (-) Dizziness (-) General weakness (-)Itching (-) Jaundice (-) Epigastric discomfort (-) A/N/V/D/C (-/-/-/-/-) Abdominal pain (+) : RLQ, on-going Melena/Hematochezia/Hematemesis (-/-/-) Physical examination V/S: 110/70 mmHg – 80/min – 20/min – 37.7 ℃ Alert mentalityAcute-ill looking appearance Clear breathing sound without rale Regular heart beat without murmur Soft & flat abdomen : Abdomen Td/rTd(+/+), nomoactive bowel sound

47. Initial Lab Findings CBC/DC 7,890/mm 3 (Seg 87.7%) – 10.7g/dL – 30.4% - 78,000 /mm 3 PT(INR) 15.6 sec (1.25) aPTT 40.0 sec Chemistry TB/DB 3.22/1.25 mg/dL Prot/Alb 6.3/3.1 g/dL AST/ALT 22/18 U/LBUN/Cr 21/0.7 mg/dL ALP/GGT 71/23 U/LNa/K/Cl 135/4.3/96 mmol/L Ca/P/Mg 9.0/2.0/1.4 mg/dL CRP 7.97 mg/dL pH 1.015 U/A pH 1.015 Nitrite (-) RBC 5~9/HPF WBC 0~1/HPF

48. Initial Chest X-ray

49. Initial assessment #1. Abdominal pain r/o Acute appendicitis r/o Spontaneous bacterial peritonitis #2. C-viral LC (Child B(8), MELD 9.94) c ascites, esophageal varix s/p EVL #3 (‘06.10.24) #3. DM #4. Aortic stenosis #5. Parkinson disease

50. 4/26 4/28 4/30 5/1 5/2 5/3 5/4 5/5 5/6 Liver CT Adm Adm Urine Cx : no growth Urine Cx : no growth 4/26 4/295/25/45/6 WBC (seg) 7890(87.7)10780(78.0)5910(74.1)11950(79.6)27070(87.8) CRP 7.976.99 0.98 Blood Cx 미시행 No growth TB/DB 3.22/1.252.32/1.15 4.84/3.027.11/5.16 BUN/Cr 21/0.717/0.6 33/1.055/1.756/1.6 Na/K 135/4.3129/4.3 125/4.2117/4.4123/4.0 Blood Cx : no growth Blood Cx : no growth Clinical course before transfer 1. Comparison to 2012-08-16 abdomen CT scan. 2. Acute appendicitis : diffuse swelling of the appendix. 3. Increased right pleural effusion. 4. Scanty pelvic ascites. 5. No change, others : Cirrhosis of liver with splenomegaly and moderate splenorenal collaterals with aneurysmal dilatation. Probably a small splenic hemangioma or cyst, GB stones, and a tiny left renal cyst. Urine Cx : Bacillus spp Urine Cx : Bacillus spp Urine Cx : Pseudomonas Urine Cx : Pseudomonas Cefotiam + Metronidazole Cefaclor + Metronidazole po (4/29 ~ 5/5) Decreased urine output Decreased urine output FEna 0.16% FEurea 11.46% Cefotiam + Metronidazole Transfer to IG FNS hydration Lasix 1~2@ &continuous infusion FNS hydration Lasix 1~2@ &continuous infusion Inotropics : norepinephrine Inotropics : norepinephrine TTE ECG : Atrial fibrillation with RVR (HR 120-160) Enlarged LA (45mm, vol index 34.40ml/m*) Normal LV systolic function No regional wall motion abnormality SEPTIC SHOCK

51. 2012 Surviving sepsis campaign Table 1

52. 5/6 5/7 5/8 5/9 5/10 5/11 5/12 5/13 Paracentesis : WBC(seg) 760(58%) Paracentesis : WBC(seg) 760(58%) 5/65/8 5/105/12 WBC (seg) 27070(87.8)10690(87.4)9560(78.5)15320(79.4) CRP 0.771.081.02 Blood Cx No growth TB/DB 7.11/5.168.24/5.6811.61/7.9012.39/8.93 BUN/Cr 56/1.646/0.972/1.5104/2.5 Na/K 123/4.0131/3.4129/5.0124/5.5 Lasix fluid stop Abdomen CT Clinical course after transfer Urine Cx : Yeast Urine Cx : Yeast Inotropics stop Meropenem Vancomycin Expired Consistent with peritonitis with generalized edema. Short appendicitis cannot be excluded. Liver cirrhosis with collateral vessels. Multiple gallstones. Both pleural effusion. FEna 0.23% FEurea 13.94% Urine Cx : Pseudomonas Urine Cx : Pseudomonas Blood Cx : no growth Blood Cx : no growth Paracentesis : WBC(seg) 310(24%) Paracentesis : WBC(seg) 310(24%) Transfer to IG Morphine fluid CVP 10cmH 2 O

53. Final diagnosis #1. Septic shock a/w peritonitis with multi-organ failure #2. C-viral LC (Child B(8), MELD 9.94) c ascites, esophageal varix s/p EVL #3 (‘06.10.24) #3. DM #4. Aortic stenosis #5. Parkinson disease

54. WJH 2013 Jan 27;5 16~25 Hepatology 2012;56:2305~2315