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하부 위장관 출혈, Lower GI Bleeding

Lower GI bleedingIntroduction Definition: Lower GI bleeding  bleeding from a source distal to the ligaments of Treitz In some cases : includes small bowel bleedingIntroduction Lower gastrointestinal bleeding(LGIB) ~20% of all cases of GI bleeding Stop spontaneously Favorable outcomes, morbidity Symptoms: Sudden onset of hematochezia(maroon or red bleed passed per rectum) In rare cases : melena(black, tarry stools) from cecum/right colon If, passage time delayed About 60cc bleeding  melena 60cc bleeding  7d~ melenaUGI bleeding - incidenceIncidence of lower GI bleeding Anorectal(Hemorrhoids, anal fissure, rectal ulcers) : 6~16% Diverticulosis : 5~42% Angiodysplasia : 0~3% Postpolypectomy : 0~13% Ischemia : 6~18% Neoplasia(polyps and cancers) : 3~11% Inflammatory bowel disease : 2~4% Radiation colitis : 1~3% Other colitis (infectious, antibiotic associated, ischemic, colitis of unclear etiology) – 3 to 29 percent Small bowel/upper GI bleed – 3 to 13 percent Other causes – 1 to 9 percense – 6 to 23 percent Strate LL, Lower GI bleeding: epidemiology and diagnosis , Gastroenterol Clin North Am. 2005;34(4):643 .Colonic source of bleeding Hemorrhoids Anal fissures  minor bleeding and pain External hemorrhoids Internal hemorrhoids Harrison’s principles of Internal Medicine, 19 th editionColonic source of bleeding Diverticula bleeding Especially in the proximal colon of patients 70 years Neoplasms Primarily adenocarcinomaColonic source of bleeding Colitis Ischemic, infectious, idiopathic inflammatory bowel disease)Colonic source of bleeding Post polypectomy bleedingColonic source of bleeding Less common causes : NSAID-induced ulcers or colitis, radiation proctopathy, solitary rectal ulcer syndrome, trauma, varices (most commonly rectal), lymphoid nodular hyperplasia, vasculitis, and aortocolic fistulas. Harrison’s principles of Internal Medicine, 19 th editionSmall intestine bleeding Bleeding from sites beyond the reach of the standard upper endoscope Melena, hematocheziaiciency anemia Difficult to diagnose and are responsible for the majority of cases of obscure The most common causes in adults : Vascular ectasias, tumors (e.g., GI stromal tumor, carcinoid, adenocarcinoma, lymphoma, metastasis), and NSAID-induced erosions and ulcers Other less common causes in adults : Crohn’s disease, infection, ischemia, vasculitis, small-bowel varices, diverticula, Meckel’s diverticulum, duplication cysts, and intussusception. Harrison’s principles of Internal Medicine, 19 th editionManagement of LGIB Hemorrhoids Low grade  conservative care Rubber band ligation Sclerotherapy Infrared coagulation High grade  SurgeryManagement of LGIB Diverticular bleeding Abrupt onset, painless, arterial, typically presents as painless hematochezia or melena, sometimes massive Often from the right colonManagement of LGIB Diverticular bleeding Stop bleeding spontaneously in ~80% of patients and, on long-term follow-up, rebleed in ~15–25% of patients Endoscopic treatments : Include dilute epinephrine(1:20,000 admixture with saline, in 1 or 2ml aliquots per injection in four quadrants) Bipolar thermal coagulation Endoscopic clips  on the bleeding stigmata or by closure of the diverticular orifice in a “zipper-like” manner Angiography : ongoing bleeding or high-risk clinical featuresManagement of LGIB Diverticular bleedingManagement of LGIB Angioectasia Right colon and in the elderly, overt hematochezia Noncontact thermal therapy Argon plasma coagulationRisk factors for poor outcome Hemodynamically instability on presentation Tachycardia, hypotension, syncope Ongoing bleeding Comorbid illnesses Age 60yrs Initial Hct 35% Elevated creatinine History of diverticulosis or angioectasiaLGIB representing as melenaLGIB representing as melena 65 years old woman Symptom : diffuse abdominal pain, nausea, vomiting, diarrhea, painful joints and rectal tenesmusLGI representing as melena 65 years old woman: Diarrheic stools  melena EGD findings : Hiatal hernia, superficial erocopic findings : terminal ileum  redness, edema, swelling, ulcer Bx : Non-specific inflammation Duodenum 2nd portion Terminal ileumLGI representing as melena CT findings : moderate ascites, small pleural effusion, mesenteric lymphadenopathy and small bowel wall thickening at the level of the second duodenum, proximal jejunum and segments of ileumLGIB representing as melena 65 years old woman UA findings : microscopic hematuria with nephrotic range hematuria  Conclusion : Henoch–Schönlein purpura (HSP)LGIB representing as melenaLGIB representing as melena 72 years old woman Symptoms : abdominal pain Progress : hypovolemic shock with massive melena Emergent CT  sigmoid colon wall thickness, and leakage of dye Laparotomy findings  conglomerulated mass of terminal ileum, ileal mesenterium and sigmoid colon in the pelvis Diagnosis : Infiltration of the tumor to the ileal mesenterium with breaking down of the mesenteric arteryQuestions and comments Thank you for your attention{nameOfAppl

의/약학| 2018.08.01| 26페이지| 5,000원| 조회(373)

하부 위장관 출혈, Lower GI Bleeding, 하부 위장관 출혈 PP..

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상피하 종양, SET, SMT, 위장관 상피하 종양

상피하 종양Introduction Subepithelial mass lesions (SEML) are frequently encountered at upper endoscopy appearing as a mass, bulge, or impression covered with normal appearing mucosa . The term subepithelial is favored over submucosal as the masses can arise from outside the gastrointestinal wall or from layers other than the submucosa (lamina propria to muscularis propria). J Gastroenterol Hepatol. 2008 Apr;23(4):556-66Prevalence Among 11,712 health examinees, 194 (1.7%) had gastric SET. Korean J Gastroenterol. 2015 Nov;66(5):274-6Prevalence Korean J Gastroenterol. 2015 Nov;66(5):274-6A retrospective review of 375 surgically resected gastric hypoechoic SETs ≥2 cm J Gastrointest Surg. 2015 Apr;19(4):631-8 PrevalenceSET 의 내시경 관찰 모양 크기 위치 이동성 (mobility) 견고함 (firm, cystic) 색조 박동성 표면점막의 형태 Rolling sign Pillow sign Cushion signNormal fiver layers of gastric wall on EUSSubepithelial Lesion of Esophagus Leiomyoma Granular cell tumor GIST Extrinsic compression Esophageal phlebectasia vs VarixLeiomyarks: 1) size: 3.5x2.5x2.3cm 2) histologic type: spindle 3) mitotic figures (/50HPF): more than10 4) resection margin: abutting 5) MIB proliferating index: 20~25% 6) Immunoexpression of tumor cells C-Kit(+), CD34(+), Actin(+), S-100 protein(-), DOG-1(+)Granular cell tumor of Esophagus Schwann 세포에서 기원 8% 가 소화관에서 관찰되며 , 소화관 과립세포종의 1/3 은 식도에서 발생 65% 원위부식도 , 20% 중부식도 , 15% 근위부식도 악성시사 소견 크기가 4 cm 이상 급격한 크기 증가 절제 후 재발 소견 내시경 소견은 약간 융기되고 하얗거나 노란색의 부드러운 종양으로 관찰 내시경초음파 소견에서 2 층 또는 3 층에 위치하고 주변과 경계가 잘 지워지는 균일한 저에코성병변으로 관찰 병변이 1 cm 이하이고 악성화 소견이 관찰되지 않는 경우 1 년마다 추적 관찰 증상이 있거나 , 크기가 2cm 이상인 경우 , 악성화가 의심될 경우 수술을 권유 크기가 2 cm 이하이고 고유근층을 침범하지 않은 경우에는 내시경절제40/M45/FExstrinsic Compression of Esophagus 대동맥궁 25cm, 9 시 좌측 주기관지 27cm, 1 시 -10 시 우심방 35cm, 10 시 -12 시J Gastrointest Surg. 2015 Apr;19(4):631-8 A retrospective review of 375 surgically resected gastric hypoechoic SETs ≥2 cm Subepithelial lesion of StomachGIST of Stomach 위 상피하종양 중 가장 흔함 진단 당시 10~30% 악성 대부분 50~60 대에 발견 기원 : Interstital cell of Cajal Imnal stromal tumor with low risk of aggressive biologic behavior Remarks: 1) size: 3.2x2.5x2.0cm 2) histologic type: spindle 3) mitotic figures (/50HPF): up to 3-4 4) prognostic group: 2 5) clear resection margin 6) Immunoexpression of tumor cells C-Kit(+), CD34(+), Actin(-), DOG-1(+), PHH(+ in mitotic figures)67/M 2014.01.0267/M 2017.03.2867/M Stomach, wedge resection: Gastrointestinal stromal tumor with low risk of aggressive biologic behavior Remarks: 1) size: 2.5x2.2x1.7cm 2) histologic type: spindle 3) mitotic figures (/50HPF): ≤5 4) clear resection margin 5) Immunoexpression of tumor cells C-Kit(+), Actin(focal +), S-100 protein(-), DOG-1(+)Carcinoid tumor of Stomach Body 나 fundus 의 oxyntic mucosa 에서 기원하는 비기능성 enterochromaffin like cell 로 구성된 신경내분비 종양 점막층에서 발생하여 점막하층으로 침범 유병률 : 약 0.5% 미만 대부분 무증상 내시경 소견 얕은 함몰이나 미란이 관찰 되는 경우가 많음 약간의 황색조를 띄는 견고한 상피하종양 일반적인 조직검사에서도 진단이 가능한 경우가 많음 내시경 초음파 2 nd or 3 rd layer 에서 기원하는 저에코성 종양Carcinoid tumor of Stomach53/M52/F52/F Stomach, posterior wall o/10 high power field 7. Nonneoplastic mucosa showing multifocal atrophic gastritis with intestinal metaplasia.64/FGlomus tumor of Stomach 변형된 혈관평활근 세포에서 기원 EUS - 3 rd or 4 th layer 에 경계가 분명한 저에코 Immunohistochemical stain Smooth muscle actin (+), vimentin(+), CD117(c-kit) (-)50/F Stomach, wedge resection: Glomus tumor 1) size: 3x2.4x2.4cm 2) clear resection margin 3) Immunohistochemistry: SMA(+), S-100(-), C-Kit(-), PHH3(-)Ectopic Pancreas of Stomach 위 상피하종양의 약 16% 호발부위 : antrum ( 유문부 6cm 이내 전정부 대만 ) 내시경소견 대부분 2cm 이내 비교적 작고 편평한 낮은 융기 중앙부에 배꼽모양 또는 화산모양의 함몰 EUS 2 nd , 3 rd or 4 th Hypoechoic or mixed echoic42/M42/M Stomach, posterior wall of proximal antrum, endoscopic biopsy: 1) Consistent with Helicobacter pylori gastritis with moderate inflammatory activity, multifocal atrophy, intestinal metaplasia and lymphoid follicular hyperplasia. 2) Ectopic pancreas.26/FLeiomyoma of Stomach 고유근층 점막근층 EUS 2 nd or 4 th layer 균질한 저에코성의 경계가 명확한 병변 2cm 이상일 경우 GIST 와 감별필요38/M51/FLipoma of Stomach 위의 양성D117(-), S-100(-) EGD 피막이 없는 황백색의 고형성 종괴 대부분 목이 없거나 짧고 , 기저부가 넒은 용종 모양 외 다양 EUS 3 rd or 4 th layer Hyperechoic, indistinct margin, homogenous65/F55/MDuplication cyst Benign lesion that result from invagination and fusion of the longitudinal folds during embryonic development Ileum esophagus colon stomach EUS Any or extralumina Anechoic 3-5 layer wall Round or oval73/F73/F Stomach, wedge resection: Consistent with foregut duplication cyst with respiratory-type epithelium.54/M 08.05.2254/M54/M Duodenum, wedge resection: Suspicious of duplication cystExtrinsic compression Liver Pancreas Spleen Gastric bodyExtrinsic compression GB Pancreas Spleen Liver ColonExtrinsic compression 47/FExtrinsic compression 47/FSubepithelial Tumor of DuodenumBrunner’s gland hyperplasia Brunner’s gland : 주로 점막하층에 위치하는 분지화된 관상의 알칼리성 점액 분비선 , 주로 duodenal bulb 에 위치 Brunner’s gland hyperplasia : 조직학적으로 도관 및 산재된 간질성분을 동반한 정상적인 Brunner’s gland 의 결절성 증식을 특징으로 하는 양성 상피성 종양 EGD 정상 점막 또는 약간 붉은 빛을 띠는 점막으로 덮여 있는 상피하 종양의 형how}

의/약학| 2018.08.01| 64페이지| 5,000원| 조회(146)

SET, SMT, 상피하 종양, 위장관 상피하 종양

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궤양성 대장염, UC, Ulcerative colitis

궤양성 대장염 - Ulcerative colitisIntroduction Recurring episodes of inflammation limited to the mucosal layer of the colon Commonly involves the rectum and may extend in a proximal and continuous fashion to involve other parts of the colonClinical manifestation Present with diarrhea, which may be associated with blood; frequent and small volume as a result of rectal inflammation Colicky abdominal pain, urgency, tenesmus, and incontinence The onset of symptoms is usually gradual, and symptoms are progressive over several weeks.Clinical manifestation Systemic symptoms Fever, fatigue, and weight loss Also have dyspnea and palpitations due to anemia (secondary to iron deficiency from blood loss, anemia of chronic disease, or autoimmune hemolytic anemia)Physical examination Often normal, especially in patients with mild disease Patients with moderate to severe ulcerative colitis may have abdominal tenderness to palpation, fever, hypotension, tachycardia, and pallorDisease severity Mild 4 stools/resentation, 25% of patients have an EIM in their lifetimeLab findings Severe ulcerative colitis may have anemia, an elevated ESR(≥30 mm/hour), low albumin, and electrolyte abnormalities due to diarrhea and dehydration UC+ PSC  may have an elevation in serum alkaline phosphatase concentrationImaging Usually normal in mild to moderate disease proximal constipation, mucosal thickening or thumbprinting secondary to edema, and colonic dilation in patients with severe or fulminant ulcerative colitisImaging CT and MRI have lower sensitivity than barium enema for the detection of subtle early mucosal disease, but are equivalent in patients with established and severe diseaseDiagnosis Presence of chronic diarrhea for more than 4wks and evidence of active inflammation on endoscopy and chronic changes on biopsy Since these features are not specific for ulcerative colitis, establishing the diagnosis also requires the exclusion of other causes of colitis by history, laboratory studies, and by biobleeding, and copious exudates Nonneoplastic pseudopolyps may be present in areas of disease involvement due to prior inflammationEndoscopic findingsEndoscopic findings The initial episode of ulcerative colitis Limited to the rectum or sigmoid colon in 30~50 % Lt-sided colitis in 20~30% 20% of patients have pancolitis with disease extending proximal to the splenic flexureEndoscopic findings Occasionally a subset of patients with ulcerative colitis have focal inflammation around the appendiceal orifice that is not contiguous with disease elsewhere in the colon (a cecal patch) Ileal inflammation (backwash ileitis) may occasionally be seen in patients with ulcerative colitis with active right-sided colitis. Unlike the ileitis associated with Crohn disease which is patchy, backwash ileitis associated with ulcerative colitis is diffuse.Cecal patch Korean J Gastroenterol. 2010 Sep;56(3):201-204. Korean.Cecal patch Gastroenterology Research • 2011;4(2):58-631240783 M/22Ileitis of IBD Multipletemic therapy and have a higher risk of colectomyFactors affecting disease course Extension of colonic disease is seen in up to 20 percent of patients within five years 67% of patients have at least one relapse 10 years following the diagnosis The risk of relapse depends on the age at initial diagnosis . Mucosal healing in response to treatment is an important predictor of long-term clinical outcomeChronic complications Stricture d/t repeated episodes of inflammation and muscle hypertrophy in approximately 10 percent of cases, most frequently seen in the RS colon and may cause symptoms of obstruction Dysplasia or colorectal cancer Increased risk for CRC. Extent of colitis and duration of disease are the two most important risk factors1687307 M/332246046 M/510045821 M/690539194 M/461233989 F/492141377 F/62Management치료 목표 증상과 점막의 염증을 호전시켜 관해를 유도하고 가능하면 오랜 기간 동안 관해를 유지 하여 환자의 삶의 질을 높이는 것 환자의 약 15% 가 위약만으로도 관해 상태에 도달한다고 하지만 대부분 환자들에서는 치료를 받지 않으면 혈변과 설사 등의 증상이 지속치료 접근 중요 요인 : 질병의 범위 , 중증도 ,된 경우 경구 스테로이드 (prednisolone 30-40 mg/day, 또는 0.5-1.0mg/kg) 사용을 권장한다 .활동기 궤양성 대장염의 치료 * 좌측 및 광범위 대장염 - 경도 - 중등도의 좌측 및 광범위 대장염의 초치료로 2.4 g/day 이상의 경구 5-ASA 투여를 권장한다 - 경구 5-ASA 단독치료보다 국소 5-ASA (0.25-1.0g/day) 와의 병합치료가 더 효과 적이다 - 관해 유도를 위하여 경구 5-ASA 를 하루에 한번 복용하는 방법은 나누어 복용하는 것과 효과가 비슷하므로 환자 선호도와 약제 순응도를 고려하여 투여 횟수를 결정 한다 - 5-ASA 를 충분히 사용해도 효과가 없거나 전신 증상이 동반된 경우 , 경구 스테로이 드 (prednisolone 30-40 mg/day, 또는 0.5-1.0 mg/kg) 사용을 권장한다 .활동기 궤양성 대장염의 치료 중등도 - 중증 궤양성 대장염의 치료 - 관해 유도의 초치료로 경구 스테로이드 투여를 권장한다 - 전신 독성 증상을 동반한 중증 궤양성 대장염의 경우 입원 치료가 필요 하며 스테로이드 정주 치료를 권장한다 (methylprednisolone 40- 60mg/day 또는 hydrocortisone 300-400 mg/day) - 중증 궤양성 대장염에서 스테로이드 정주 치료에 대한 반응 확인을 위 해 치료 3-7 일째 배변 횟수 , C-reactive protein 단순 복부 촬영 등을 통해 평가를 시행하고 , 7-14 일 후에도 호전이 없으면 수술 , cyclosporine 정주 , 항 TNF 치료 등을 포함한 향후 치료 방침에 대해 논의한다활동기 궤양성 대장염의 치료 * 스테로이드 치료에 반응하지 않는 중등도 - 중증 궤양성 대장염의 치료 - 스테로이드 치료에 반응하지 않는 중등도 - 중증 궤양성 대장염은 항 TNF 치료를 권장한다 - 스테로이드 정주에 반응하지 않는 중증 궤양성 대장염의 경우에 CMV 감염 여부를 확인하고 , 감염이 확인되면 항바이러스 치료를 권장한다 - 스테로ow}

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궤양성 대장염, ulcerative colitis, uc

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크론병, Crohn's disease

Crohn’s diseaseInflammatory Bowel Diseases Idiopathic IBD Other than Idiopathic IBD UC Infectious enterocolitis -TB -Amebic -Bacterial infection ; Yersinia, Salmonella, Shigella -viral infection ; CMV CD Ischemic colitis Indeterminate Colitis Drug-induced colitis Antibiotics NSAIDs Intestinal Behcet’s disease Radiation colitis정의 구강에서 항문까지 위장관 전체를 침범할 수 있는 원인 불명의 만성 염증성 장질환이다크론병은 만성 , 진행성 질환우리나라 크론병 환자활동도 분류 및 관해 Crohn’s disease activity index(CDAI) 150 미만 - 관해 150~220 미만 – 경증활동성 220~450 미만 - 증등도활동성 450~ - 중증활동성 Harvey-Bradshaw index(HBI)Montreal Classification of Crohn’s ds. ; age, location, behavior진단임상양상임상양상 , 크론병 진단 가이드라인 (2009) 대한소화기학회지 (1) 연령 10 대 중반 ~ 20 대 후반 (2) 주증상 6 주이상 설사 및 복통 (+- 체중감소 ) 전신쇠약감 , 식욕부진 , 발열 , - M/C ) 복통 , 체중감소 , 설사 DDx, IBS 수면중에 복통 드물다 , 야간설사 드물고 설사 , 변비 반복 , 단기간의 급격한 체중감소 없음 .임상양상 , 크론병 진단 가이드라인 (2009) 대한소화기학회지 (3) 장관외 증상 M/C 근골격계 이상 말초관절염 ; 5 개 미만 6%, 5 개 이상 4%, 관절통이 관절염보다 흔하고 , 비대칭적으로 큰 관절 침범 피부병변 안구병변 구강병변과거병력 폐 혹은 기타 부위 결핵병력 흡연력 가족력 치열 , 치루 , 항문 주위 농양 수술 및 치료력 , 기타 부위누공 국내 단일기관연구 , The incidence and natural history of perianal fistulas in Korean patients with Crohn's disease. Intest Res 2006;4:22-31. - 크론병 환자의 48.5% 치루호소 - 15% 환자가 다른 증상없이 첫 증상으로 치루 호소Europe Crohn’s and Colitis Organisation(ECCO)2016검사실 소견 빈혈 ; 철결핍성 , 만성질환 , 비타민 B12 또는 엽산결핍성 CRP; 질병 활동도를 잘 반영 Calprotectin( 분변염증표지자 ) ASCA - 35~50% 에서 양성 -ASCA(+) and pANCA(-) - 민감도 55%, 특이도 93% - 진단이 어려울 때 보조적으로 도움될수있음Colonoscope . Observation point for Differential Dagnosis Character Description Hyperemia Edema Granularity Mucosla friability Erosion Aphthous ulcer Ulcer Inflammatory sequelae Location of lesions Continuity of lesions Features of ulcers Morphology Direction Mucosal change adjacent to ulcers Inflammatory sequelae Scar(pseudopolyps, pseudodiverticulum, patulous ICV) Stricture FistulaCD, 대장내시경 소견CD, 대장내시경 소견CD, 대장내시경 소견 아프타 궤양 ; 종주형으로 보일때 더 특이적국내 단일기관 처음 진단환자중 Park JB, Yang SK, Myung SJ, et al. Clinical characteristics at diagnosis and course of Korean patients with Crohn's disease. Korean J Gastroenterol 2004;43:8-17. CD 아프타 궤양 59.3% 종주 궤양 37.2% 조약돌 점막모양 23.9%상부위장관내시경 상부위장관 증상이 있는 경우에만 추천 - 발적 , 미란 , 궤양 등 비특이적일수 있음 Bamboo joint-like(BJL) appearance BJL 크론병 43~65.2% 47.6%( 국내연구 ) 크론병이 아닌환자 1.1~10% UC 3.6%( 국내연구 ) 비염증성 장질환 환자 0.1%( 국내연구 )조직검사 궤양변연 , 궤양저부도 함께 생검 생검 부위당 최소 2 개 이상 추천 1) 만성염증과 국소 음와구조 변형 , 음와 손상과 인접하지 않은 육아종 2) 비건락성 육아종 ( 질병특유적이지 않고 , 민감한 소견아님 ) 수술 검체의 40~60% 내시경 검체의 15~36%감별진단 IBS Acute infectious colitis UC Tb colitis Behcet’s colitisMorphology Direction Common IBDs Longitudinal ulcer CD Ischemic colitis Circular ulcer Tuberculosis Severe ischemic colitis CD Deep steep ulcer Behcet’s colitisMorphology Common IBDs Pseudopolyps, pseudodiverticulum Tb, CD, UC Patulous IC valve Tb Stricture CD, Tb, ischemic Fistula CD, Severe radiation, Behcet’s, simple ulcerDDx. 크론병과 장결핵DDx. 크론병과 장결핵DDx. 크론병과 장결핵UC불량한 예후 인자들Meta-Analytic Bayesian Model For Differentiating Intestinal Tuberculosis from Crohn's Disease. Am J Gastroenterol 2017; 112:415–42766 세 남자 0193639 2009 년 R/O TBc colitis, R/O crohn - 5 개월간 Tbc med.2009, IC valve, A(2),T(1), D(1),S(1)201618 세 M 현재 28 세 , 0202516 2008 년 , S-colon(G)2010, A-colon(G) 2013, S-colon (nonspecific colitis)21 남 0725570 2015 년 fistular 수술 2015 년 타병원 복통 , 혈변 등 의뢰 Azathioprine 으로 변경으로 유지중 . 2016 년 9 월 혈변 , 복통심해 내시경{nameOfApplication=Show}

의/약학| 2018.08.01| 49페이지| 5,000원| 조회(275)

소화기, 내시경, 크론병, Crohn`s Disease

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항생제 연관 설사, 위막성 대장염, PMC

Clostridium difficile PMCClostridium difficile Gram-positive, anaerobic, spore-forming bacillus Vegetative cells die quickly in an aerobic environment Spores are a survival form and live for a very long time in the environmentClostridium difficile Infection (CDI) CDI rates of diarrhea and colitis have continued to increase in the United States since 2000. More severe CDI with higher mortality and higher rates of colectomy, especially in the elderly, continues to be reported. Currently, non-absorbed oral agents that are locally active such as vancomycin and new investigational drugs are the most effective treatments available for severe CDI.Inflammatory Response to C. difficile Toxins alters GI Tract Physiology Toxin A is a potent enterotoxin (causes fluid loss) and a very active white blood cell attractant. Toxin B is a potent cell cytotoxin (kills cells) Cyclooxygenase (Cox)-2 expression and prostaglandins are elevated in the presence of Toxin A.Risk Factors for Infection Hospitalizatrated colon  sepsis  deathMarkers of Severe Disease Leukocytosis Prominent feature of severe disease Rapidly elevating WBC Up to 100 K 10 BM/day Albumin 2.5 Creatinine 2x baseline Hypertension Pseudomembranous colitis Toxic megacolon Severe distension and abdominal painDiagnosis The diagnosis of C. difficile infection should be suspected in patients with clinically significant diarrhea (≥3 loose stools in 24 hours) or ileus in the setting of relevant risk factors (including recent antibiotic use, hospitalization, and advanced age). The diagnosis is established via a positive laboratory stool test for C. difficile toxins or C. difficile toxin gene . Laboratory testing does not distinguish between C. difficile –associated diarrhea (CDAD) and asymptomatic carriage (which does not warrant treatment) - diagnostic laboratory testing should be pursued only in patients with clinically significant diarrheaDiagnosis Findings of pseudomembranous colitis on radiographic or endoscopic examination) if medically reasonable Metronidazole Oral or IV, 500 mg TID for 10-14 days is standard therapy 5 – 20% failure rate 20% relapse rate Can use a full 2 nd course for failure/relapse but beyond 2 courses, switch to vancomycin Failures not due to metronidazole resistanceInitial Treatment Options for CDI Historical response (96%) and relapse rates (20%) similar between metronidazole and vancomycin More recently, efficacy of metronidazole for severe disease called into question Recent prospective trials report vancomycin to be superior to metronidazole in severe CDIInitial Treatment Options for CDI Metronidazole 250 mg QID or 500 mg TID May be administered PO or IV Development of resistance rare Historical first-line agent Vancomycin 125 mg QID effective in enteral (oral or rectal) form only Typically reserved for severe disease, those failing to respond to metronidazole, or cases in which metronidazole is contraindicatedManagement of Severe CDI Early recognition is critical Initiate thersult There were numerous discrete yellow plaques present at S colon and rectum (x6). A few polyps were noted at S colon. Biopsy result Colon, sigmoid and rectum, endoscopic biopsy: Consistent with infectious colitis, see note. Note: No pathognomonic histologic finding to suggest pseudomembranous colitis is present. CD toxin A and B : positive오세분 1868926Endoscopic result After washing with water, rectum and sigmoid colon mucosa was covered with multiple small whitish plagues. biopsy was done three times Biopsy result Consistent with infectious proctitis, see note. Note There is no pathognomic histologic finding to suggest pseudomembranous colitis. CD toxin A and B : positive김연순 2115188Endoscopic result Advanced to S-colon 이전 검사와 비교하여 more edematous, more friable 한 mucosa 에 fecal material 을 포함한 dirty exudate 가 뒤덮여있는 양상이 관찰됨 . S-colon 상방의 mucosa 는 touch bleeding 이 동반되어 검사를 더 진행하지 않았음 . Biopsy result Rectum, 10cm from anal verge, endoscopic biopsy: Suspicious of pseudomembranous colitis. CEndoscopic result Advanced to S-colon Whitish patches were noted on rectum and S-colon. Bx was done at(#Ax2: 30cm from AV, #Bx2: 15cm from AV) Biopsy result A. Colon, 30cm from anal verge, endoscopic biopsy: Consistent with infectious colitis. B. Colon, 15cm from anal verge, endoscopic biopsy: Consistent with infectious colitis. CD toxin A and B : negative이순애 2065894Endoscopic result Advanced to S-colon Incomplete study due to poor bowel preparation. There were multiple variable sized round shaped lesions with yellowish plaque until S-colon (AV 50cm). Bx was done randomly (#AX1, #BX1, #C X1) Biopsy result A. Colon, sigmoid, 50cm from anal verge, endoscopic biopsy: Consistent with infectious colitis. B. Colon, sigmoid, 50cm from anal verge, endoscopic biopsy: Low grade mucosal damage. C. Colon, sigmoid, 50cm from anal verge, endoscopic biopsy: Inflammatory exudate. CD toxin A and B : equivocal강막교 1842478Endoscopic result Multiple whitish patches were noted on D-colon ~ rectum. Bx was dohow}

의/약학| 2018.08.01| 47페이지| 5,000원| 조회(298)

PMC, 위막성 대장염, 항생제 연관 설사

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