1. GI conference
경희대학교 의과대학 소화기내과

2. Case 1 Chief Complaint Present Illness 이O경 (F/54) 12322252
Admission date :
Chief Complaint
Lower abdominal pain o/s) 내원 2주일전
Present Illness
F/54. Hyperlipidemia로 local에서 약물 복용중인 자로, 2013년 1월부터 상복부 통증 있어왔고 약 한달 반 동안 6kg가량의 체중 감소 있었으며 내원 2주일전부터는 하복부 통증 발생하여 local에서 검사 및 치료 받았으나 호전 없어 본원 소화기내과 입원하여 산부인과적 평가를 포함한 일련의 검사 진행 후 말단부 회장염 진단하에 퇴원하였으나 이후에도 증상 호전 보이지 않아 응급실 통해 입원함. .

3. Past-medical history Family history None Personal history
DM / HTN / Tbc / Hepatitis (-/-/-/-)
Hyperlipidemia (+)
Operation Hx (+) : 13년 전 자궁물혹제거 수술
Family history
None
Personal history
Smoking (-) Alcohol (-)

4. Review of system Physical examination
Fever(-) Chilling(-) Dizziness(-)
General weakness(-) Itching(-) Jaundice(-)
Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-)
Abdominal pain(+) : Lower abdomen, cramping pain
Melena(-) Hematochezia(-) Hematemesis(-)
Physical examination
V/S: 120/80 mmHg – 77/min – 18/min – 36.0
Alert mentality acute-ill looking
Clear breathing sound without rale
Regular heart beat without murmur
Soft & flat abdomen :Td(-) & rTd(-)

5. Initial Lab Findings CBC/DC
8,760/mm3 (78.6%) – 12.5g/dL – 38.5% - 374,000 /mm3
PT(INR) sec (1.12) aPTT sec
Chemistry
TB/DB /0.2 mg/dL Prot/Alb 6.9/4.1 g/dL
AST/ALT 16/9U/L BUN/Cr 6/0.6 mg/dL
ALP/GGT 83/17 U/L Na/K/Cl 140/4.1/103 mmol/L
Ca/P/Mg 8.6/4.2/2.0 mg/dL CRP <0.3 mg/dL

6. Work Up 2013.01.19 외부 Abdominal CT 2013.01.28 A-P US
EGD, Colonoscopy
Abdomen CT

7. Operation
Laparoscopic small bowelsegmental resection

8. Diffuse large B cell lymphoma (DLBL)
Diagnosis :
Ileum, segmental resection:
Diffuse large B cell lymphoma (DLBL)

9. Small bowel obstruction d/t DLBL
Final Diagnosis
Small bowel obstruction d/t DLBL

10. Pathology

18. CD20

19. CD3

20. BCL-2

21. CD10

22. MUM-1

23. Ki-67

24. Diagnosis Diffuse large B cell lymphoma Ileum, segmental resection:
1) Tumor size: 5.0 x 4.0 cm
2) Depth of invasion: Serosal penentration is not identiifed
3) Margins of resection: No tumor identified at proximal and distal resection margins
(safety margin: proximal 23.0 distal 14.0cm)
4) Lymphatic invasion: Not identified
5) Vascular invasion: Not identified
6) Regional lymph nodes: Lymph nodes involvement in 1 out of 8 mesenteric lymph nodes (1/8)

25. IHC pannel CD20 B cell marker CD3 T cell marker
CD10, BCL Germinal center
(GCB-DLBCL)
Mum Postgerminal center
(ABC-DLBCL)

26. IHC pannel BCL-2 DDx. Burkitt lymphoma Ki67 Proliferating activity
(eg. Bukitt lymphoma)

27. Case 2 Chief Complaint Present Illness 김O태 (F/54) 12322401
Admission date :
Chief Complaint
Rectal mass o/s) unknown
Present Illness
HTN , horse shoe kidney 있는 자로, colonoscopy 상 rectal mass 발견되어 치료
위해 본원 방문

28. Past-medical history Family history None Personal history
DM / HTN / Tbc / Hepatitis (-/+/-/-)
Horseshoe kideny
Operation Hx (+) : Rt 2nd finger OP (7~8 yr ago)
Family history
None
Personal history
Smoking (-) Alcohol (-)

29. Review of system Physical examination
Fever(-) Chilling(-) Dizziness(-)
General weakness(-) Itching(-) Jaundice(-)
Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-)
Abdominal pain(-)
Melena(-) Hematochezia(-) Hematemesis(-)
Physical examination
V/S: 120/80 mmHg – 77/min – 18/min – 36.0
Alert mentality acute-ill looking
Clear breathing sound without rale
Regular heart beat without murmur
Soft & flat abdomen :Td(-) & rTd(-)

30. Initial Lab Findings CBC/DC
7110/mm3 (58.5%) – 15.1g/dL – 43.1% - 296,000 /mm3
Chemistry
TB / DB : / -
AST / ALT : 21 / 25
ALP / GGT : 77 / -
BUN / Cr : 12 / 1.0
Na / K / Cl : 140 / 4.3 / 104

31. Work Up 1. Image study - 2013. 1. 30 Rectum MR 2. Endoscopy
Sigmoidoscopy
3. Pathology
- S
- S
- S

32. Operation
: Robotic partial ISR

33. Final Diagnosis
Rectal GIST

34. Pathology

41. C-Kit

42. CD34

43. Desmin

44. S100

45. Diagnosis
Rectum, lower anterior resection: Gastrointestinal stromal tumor, low risk 1) Size: 4.9x3.0x2.5 cm 2) Mitotic activity: not identified

46. Primary site of GIST Stomach (60%)
Small intestine(jejunum and ileum, 30%)
Duodenum (5%)
Rectum (3%)
Colon (1-2%)
Esophagus (less than 1%)
AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp  

47. Risk stratification of GIST

48. Case 3 Chief Complaint Present Illness 우O자 (F/76) 10964875
Admission date :
Chief Complaint
Gastric polyp o/s) unknown
Present Illness
DM, HTN, old CVA Hx 있는 환자로, local 에서 시행한 gastroscopy 상
multiple polyp 발견됨. 본원에서 biopsy, CT 시행하여 EGC, type I 및 pancreas
IPMN 발견되어 수술 위해 입원

49. Past-medical history Family history None Personal history
DM / HTN / Tbc / Hepatitis (+/+/-/-)
Old CVA (‘04)
Operation Hx (-) :
Family history
None
Personal history
Smoking (-) Alcohol (-)

50. Review of system Physical examination
Fever(-) Chilling(-) Dizziness(-)
General weakness(-) Itching(-) Jaundice(-)
Epigastric discomfort(-) A/N/V/D/C(-/-/-/-/-)
Abdominal pain(-)
Melena(-) Hematochezia(-) Hematemesis(-)
Physical examination
V/S: 120/80 mmHg – 77/min – 18/min – 36.0
Alert mentality acute-ill looking
Clear breathing sound without rale
Regular heart beat without murmur
Soft & flat abdomen :Td(-) & rTd(-)

51. Initial Lab Findings CBC/DC
3290/mm3 (53.2%) – 12.2g/dL – 37.3% - 340,000 /mm3
Chemistry
TB / DB : / 0.21
AST / ALT : 16 / 16
ALP / GGT : 77 / 20
BUN / Cr : 14 / 0.6
Na / K / Cl : 138 / 3.7 / 102

52. Work Up 1. Image study - 2012. 10. 30 Abdomen US
Abdomen CT
PET CT
2. Endoscopy
Gastroscopy
3. Pathology
- S
- I
- S
- S

53. Operation 2012. 11. 13 : Open distal gastrectomy c distal
pancreatectomy c splenectomy

54. Early gastric cancer c IPMN
Final Diagnosis
Early gastric cancer c IPMN

55. Pathology

61. Diagnosis
Stomach, distal gastrectomy: Tubular adenocarcinoma, well differentiated 1) Location: Body, lesser curvature 2) Tumor gross type: Early gastric carcinoma, type I 3) Histologic type by Lauren classification: Intestinal 4) Tumor size: 3.0 x 2.3 x 1.5 cm 5) Depth of invasion: Tumor invades lamina propria/muscularis mucosae (pT1a) 6) Margins of resection: No tumor identified at proximal and distal resection margins 7) Lymphatic invasion: Not identified 8) Vascular invasion: Not identified 9) Regional lymph nodes: No metastasis in 11 regional lymph nodes ( 0/11 , pN0) 10) Additional pathologic findings: Hyperplastic polyp (x5)

69. Diagnosis
Pancreas, distal pancreatectomy: I. Ductal adenocarcinoma, moderately differentiated 1) Size: 2.5 x 2.5 cm 2) Location: pacreatic tail 3) Extent of tumor: Tumor invades peripancreatic soft tissue (pT3) 4) Negative proximal and peripancreatic (circumferential) resection margins 5) No matastasis in 18 peripancreatic lymph nodes (0/18, pN0) 6) Lymphovascular invasion: not identified II. Intraductal papillary mucinous neoplasm with low-grade dysplasia III. Chronic pancreatitis Spleen, splenectomy: Chronic congestion (History of idiopathic thrombocytopenic purpura)

70. IPMN
1) Differential diagnosis Mucinous cystadenoma Serous cystadenoma Pancreatic intraepithelial neoplasia 2) Degree of dysplasia Two grade or three grade system 3) The presence of invasive carcinoma (30%)