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경부상피내종양

Case ReviewCervical Intraepithelial Neoplasia (CIN)Cervical Anatomy▪ 자궁경부상피의 구성 columnar epithelium squamous epithelium자궁경부암의 발생Site: squamocolumnar junction (SCJ) Metaplasia ► 사춘기, 임신, 호르몬에 의해 자궁경부 세포 성 장- SCJ가 자궁경부 바깥쪽으로 위치 변화 ► 질 상피 세포의 산성화와 체내의 생리적 변화 = columnar epithelium의 squamous epithelium 으로 change (transformation zone: metaplasia가 일어나는 부위) 호발시기 : menarche , after pregnancy (metaplasia 도 가장 활성화 되는시기)Human Papilloma virusHPV Infection이 주요 유발 물질 expression of E6 and E7 oncoproteins - Malignant transformation 30 of these HPV types: primarily infecting the squamous epithelium percentage of intraepithelial neoplasia : HPV infection approaches 90% 자궁경부암 위험도에 따른 HPV분류위험도HPV종류고위험16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82중위험26, 53, 66저위험6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81Human Papilloma virusType 16 : invasive cancer, CIN2, CIN3에서 가장 흔히 발견되는 type (but, the most common type in normal cytology). 한국여성 자궁경부 병변에서 발견되는 HPY typeDiagnosisPap test endocervix와 exocervix cell을 채취하여 슬 라이드에 도포, 95% ethanol에 고정 Sensitivity: 51%, specificity : 60~95%Diagnosis2. Colposcopy 1) Ix pap test에서 비정상 소견을 보일경우 육안적으로도 의심스러운 자궁경부의 병변 접촉성 혹은 성교 후 질 출혈 질이나 외음부의 의심스러운 병변 2) abnormal finding ① acetowhite epithelium : white epi. after acetic acid ② leukoplakia : white epi. before acetic acid ③ punctuation : dilated capillaries terminating on surface ④ mosaic : terminal capillaries surrounding acetowhite epi ⑤ atypical vascular pattern : esp. invasive cervical ca. looped vessels, branching vessels, and reticular vesselsleukoplakiaMosaic punctuation3. Biopsy Punch biopsy Colposcopically directed biopsy # Ix 세포진검사에서 이상 소견 발견시 질확대경 하에서 실시 자궁 경부에 육안적으로 의심스러운 병변이 있을 때3) Cone biopsy : both a diagnostic and therapeutic procedure # Ix Colposcopy로 lesion이 보이지 않음 SCJ 가 colposcopy에서 보이지 않음 ECC : CIN 2 or CIN 3. cytology, biopsy, colposcopy 의 결과가 다를 때 Microinvasion 의심될 때 Colposcopy로 invasive cancer를 R/O할 수 없을 때Cytology classificationDiagram of CINLower one third of epithelium:Lower two third of epitheliumAll epitheliumextent of the mitotic activity, immature cellular proliferationTreatmentAblative therapy # Ix cytology, colposcopy, endocervical curettage, or biopsy에서 microinvasive or invasive cancer 의 증거가 없음 lesion이 ectocervix에 위치하고 전부보여야함 colposcopy and endocervical curettage로 검사했을 때 endocervix의 high-grade dysplasia 가 없음 = 조건을 만족하지 못할 경우 conization이나 hysterectomyCryotherapycrystallizing the intracellular water - destroys the surface epithelium of the cervix Ix : CIN1~2 작은 병변 병변이 자궁경관외에 국한 자궁경관내 소파술 음성 조직검사상 자궁경관내선 침범 없음Laser AblationUsed effectively for the treatment of CIN But, Expensive, special trainingLoop Electrosurgical Excisional Procedure(LEEP)Wire loop electrode를 사용해서 모든 transformation zone을 제거하고 제거된 조직을 이용해서 진단과 치료 장점 -시술시간이 짧다 -배우기 쉽다 -레이저 노출에 의한 눈의 손상이 없다. -만족도는 증가하고 시술 중의 동통이 적다 -절제된 조직이 더 우수 하다 -장비의 고장이 덜하다.2. Conizationthe standard method of evaluating an abnormal Pap test result Dx and Tx procedure 절제시에는 모든 병변과 변형대 전부 포함3. Hysterectomy가장 재발률이 낮은 방법 Ix -invasive cancer -원추절제면 가장자리에 CIN3 -추적관찰이 어려운 환자 -다른 부인과적 문제 (fibroids, prolapse, endometriosis, PID)Reference대한산부인과학회 부인과학 4th Berek Novak's Gynecology, 14th{nameOfApplication=Show}

의/약학| 2012.01.13| 19페이지| 2,500원| 조회(131)

cin, HPV, cervical intraepithe, Human Papil..

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chronic pancreatitis

Chronic PancreatitisReview Of DiseaseDefinitionChronic inflammation, fibrosis, and progressive destruction of both exocrine and eventually endocrine tissue. Irreversible damageCause (TIGAR-O classification)1. Toxic-metabolic Alcoholic , Tobacco smoking, Hypercalcemia, Hyperlipidemia, Chronic renal failure Medications(phenacetin abuse) 2. Idiopathic Early onset, Late onset, Tropical 3. Genetic Hereditary pancreatitis, Cationic trypsinogen, PRSS1, PRSS2, CFTR mutations, SPINK1 mutations 4. Autoimmune Isolated autoimmune chronic pancreatitis, Autoimmune chronic pancreatitis associated with Sjögren's syndrome, Inflammatory bowel disease, Primary biliary cirrhosisCause (TIGAR-O classification)5. Recurrent and Severe Acute Pancreatitis Postnecrotic (severe acute pancreatitis), Recurrent acute pancreatitis, Vascular diseases/ischemia , Postirradiation 6. Obstructive Pancreas divisum, Sphincter of Oddi disorders , Duct obstruction, Preampullary duodenal wall cysts, Posttraumatic pancreatic ducea, weight loss, fatigue deficiencies of fat-soluble vitamins are uncommonDiagnosisImage finding Plain abdominal film : diffuse calcification= significant damage Abdominal US Abdominal CT : calcification, dilated duct, atrophic pancreas MRCP : diagnostic procedure of choiceDiagnosisEUS not sensitive test Endosonographic feature (≥5) -parenchyma- echogenic strand/foci, calcification, lobular contour, cyst -duct-stone,echogenic or irregular ductal wall,stricture,visible side br.,ductular dilatationDiagnosis2. Blood test Serum amylase lipase : not strikingly elevated Serum bilirubin alkaline phosphatase ↑ : 2ndary cholestasis d/t CBD stricture Impaired glucose tolerance 3. Exocrine function test Secretin test IV secretin - duodenal contents bicarbonate level Maximal bicarbonate ↓ 60% of the pancreatic exocrine function has been lost Correlates with onset of chronic abdominal pain Combined secretin-CCK stimulation test Sensitive, invasive Bicarbonate, Pancreatic ez↓4. ETC. Cobalamin malabsretinopathy Effusions with high amylase content Gastrointestinal bleeding Jaundice Cholangitis and/or biliary cirrhosis Subcutaneous fat necrosis Bone pain Pancreatic cancerTreatment1.Medication Stop drinking Pancreatic Ez : pain relief, correct maldigestion, decrease steatorrhea Antioxidatnt : pain relief Prokinetic agent : impaired gastric emptying2. Endoscopic treatment sphincterotomy, stenting, stone extraction, drainage of a pancreatic pseudocyst significant complications can occur (i.e., bleeding, cholangitis, stent migration, and stent clogging).3. Surgical therapy Ductal decompression alcoholoc induced chronic pancreatitis- large duct Ds :therapy of choice 80% immediate pain relief, 3yr 50% pain recurrence Pancreatic resection : localization, no ductal dilatation Whipple's operation, total pancreatectomy autologous islet cell transplantation : refractory to conventional therapyHereditary Pancreatitissimilar to chronic pancreatitis Onset : childhood 7q35 mutation of the cationiced incidence of pancreatic carcinoma (40% by age 70 years) Pain relief Tx : surgical ductal decompressionAutoimmune Pancreatitisprimary pancreatic disorder associated with autoimmune disorders (primary sclerosing cholangitis, primary biliary sclerosis, rheumatoid arthritis, Sjögren's syndrome, ulcerative colitis, mediastinal adenopathy, autoimmune thyroiditis, tubulointerstitial nephritis, and retroperitoneal fibrosis)Autoimmune Pancreatitis1. Manifestation Mild Sx. obstructive jaundice. Weight loss and new onset of diabetesAutoimmune Pancreatitis2. Diagnosis An obstructive pattern on liver tests (serum ALP ↑↑, AST,ALT ↑) Serum IgG4↑ CT: pancreatic heat enlargement ERCP or MRCP : strictures in the bile duct Mayo Clinic criteria(≥1) diagnostic histology characteristic findings on CT and pancreatography IgG4↑ response to glucocorticoid therapy, with improvement in manifestations.Autoimmune Pancreatitis3. Treatment glucocorticoid alleviating symptoms, decreasing the size of the pancreas, ms of chronic pancreatitisAutoimmune Pancreatitis4. Clinical feature Mild symptoms usually abdominal pain, but without frequent attacks of pancreatitis, which are unusual Presentation with obstructive jaundice Diffuse swelling and enlargement of the pancreas, especially the head, the latter mimicking carcinoma of the pancreas Diffuse irregular narrowing of the pancreatic duct in ERCP Increased levels of serum gamma globulins especially IgG4Autoimmune PancreatitisPresence of other autoantibodies (ANA), rheumatoid factor (RF) Extra pancreatic bile duct changes such as stricture of the common bile duct and intrahepatic ducts Can occur with other autoimmune diseases: Sjögren's syndrome, primary sclerosing cholangitis, ulcerative colitis, rheumatoid arthritis Absence of pancreatic calcifications or cystsAutoimmune PancreatitisPancreatic biopsies reveal extensive fibrosis and lymphoplasmacytic infiltration Glucocorticoids are effective in alleviating symptoms, decreasing size of the pancreashow}

의/약학| 2012.01.13| 22페이지| 2,500원| 조회(128)

췌장염, pancreatitis, cause, 만성췌장염, Chronic pan..

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소아 천식

-Asthma-Allergic disorder Asthma is a chronic inflammatory condition of the lung airways resulting in episodic airflow obstructionDefinitionEtiologyGenetic - asthma와 관련있는 gene locus가 15 autosomal chromosomes 에 있음 -기도과민성과 기도 염증 반응에 관여하는 IL–4 gene이 chromosome 5에 가까이 있음Environment. respiratory virus - Recurrent wheezing (RSV, rhinovirus, influenza virus, parainfluenza virus, human metapneumovirus) allergen- Indoor and home allergen exposures air environment- tobacco smoke and air pollutants (ozone, sulfur dioxide) Cold dry air, strong odors - bronchoconstriction (but, do not worsen airways inflammation or Hyper- responsiveness)PathogenesisHyperresponsiveness 가장 특징적인 소견 유전적 소인과 기도염증- 기도 벽 비후, 기도상피세포 손상, 기도 내 신경계통 이상, 기도근육 이상 - 기도 과민성 Airway obstruction 기도벽의 부종 : 미세혈관 투과성 증가 - 액체의 기도점막으로 저류 - edema - 기도내경 감소, 기침 유발 급성 기도 수축 : cytokine에 의해 기관지 평활근 수축 Mucus plug의 형성 : goblet cell, submucosal gl.에서 secretion+염증세포, 호산구 단백, 상피세포 - viscosity 증가 기도 remodeling : 천식발작의 반복 - 기도 탄력성과 주변 폐조직의 변성, 기도 벽이 유발Epidemiology소아 응급실 내원의 m/c cause(in US) 223명 소아 death (2000년 US) 전세계적으로 10년마다 50%씩 증가 우리나라에서 1980년 5%- 2000년 13% 80%이상이 6세 이전에 처음나타남Risk factorParental asthma Allergy Atopic dermatitis Allergic rhinitis Food allergy Inhalant allergen sensitization Food allergen sensitization Severe lower respiratory tract infection Pneumonia Bronchiolitis requiring hospitalization Wheezing apart from colds Male gender Low birthweight Environmental tobacco smoke exposureAsthma predictive IndexMAJOR CRITERIAMINOR CRITERIAParent asthmaAllergic rhinitisEczemaWheezing apart from coldsInhalant allergen sensitizationEosinophils ≥ 4%Food allergen sensitizationpre–school-age children with frequent wheezing in the past year, 1major criterion OR 2minor criteria = high specificity (97%) and positive predictive value (77%) for persistent asthma into later childhoodClinical Manifestationm/c chronic Sx : cough, expiratory wheezing sputum, dyspnea General fatigue (due to sleep disturbance), chest pain, nasal flarinnctivitis, atopic dermatitis, food allergiesDiagnosisHx taking – 재발성, 알레르겐 및 유발인자와 증상발현 관계, 다른 알레르기 질환의 동반 유무, 가족력 확인 P/E – wheezing, rale, tachypnea, chest retraction, cyanosis CBC, WBC differntial count – eosinophil 증가 CAPS, MAST, RAST – total Ig E, specific Ig E 증가 Prick test – 알레르겐과의 연관성 찾기 PFT ImagingPulmonary Function TestSpirometry - 6세 이상 이어야 유효한 결과를 얻을 수 있음 - 3회시도 - 예측정상 값에 비해 낮은 FEV1 - FEV1/FVC≤0.8 - bronchodilator - FEV1 12%이상 증가 Bronchial challenge test - 기도 과민성 측정 - allergen, inhaled methacholine, histamine(bronchoconstrictor), - cold or dry air(비특이적 자극) - methacholine provocation test : PC20≤25mg/mL - exercive challenge test : 운동- FEV1 이 기저치의 15% 이상 감소Pulmonary Function TestPeak Expiratory Flow - simple and inexpensive home-use tool to measure airflow - 진단보다는 지속적 측정으로 천식발작 조기 발견 - 4세 이상 사용 - 3회 측정 - 일중변동; 아침에 낮고, 오후에 높음 - 최대값의 80% 이하 or 일중변동률≥ 20Image findingDifferential DiagnosisUPPER RESPIRATORY TRACT CONDITIONS Allergic rhinitis, Chronic rhinitis, Sinusitis, Adenoidal , Vocal cord dysfunction,, Vocal cord paralysis, Tracheoesophageal fistula, Vascular ring, sling, or external mass compressing on the airway, Foreign body aspiration,,Chronic bronchitis from environmental tobacco smoke exposure, Toxic inhalationsDifferential DiagnosisLOWER RESPIRATORY TRACT CONDITIONS Bronchopulmonary dysplasia, Viral bronchiolitis, GERD, Cystic fibrosis, Allergic bronchopulmonary mycoses, Chronic aspiration, Immotile cilia SD, Bronchiolitis obliterans , Interstitial lung diseases, Hypersensitivity pneumonitis, Pulmonary eosinophilia, Churg-Strauss vasculitis , Pulmonary hemosiderosis, TB, Pneumonia, Pulmonary edema, Medications associated with chronic cough, Acetylcholinesterase inhibitors β-adrenergic antagonistsTreatment - Asthma ExacerbationHome management 기침, 호흡곤란 등의 증상과 PEFR로 진단 Inhaled β2 agonist Inhaled β2 agonist 20분 간격 3회 이상에도 호전이 없으면 내원 PEFR, 증상, 호전정도 파악 Inhaled β2 agonist, inhald anti-cholinergics, steroid, short acting theophillin Severe asthma and/or a hihaled β2 agonist Inhaled β2 agonist 반복 or anti- cholinergics, ICS. PEFR, 증상, 산소포화도 확인 Inhaled β2 agonist, inhald anti-cholinergics, steroid, short acting theophillin, intubationLongterm management환경관리 -집, 자동차, 학교에서 allergen 노출 줄이기 - common allergen: 동물의 털, 깃털(특히 애완동물, 쥐), 집먼지 진드기, 바퀴벌레, 곰팡이, 담배, 나무와 석탄 연기, 먼지, 강한 냄새 - influenza vaccination recommend = asthmatic Sx, medication requirement, asthma exacerbations 감소 약물치료Long term management for young childrendLongterm management환경관리 약물치료 감시 및 평가 병원에 정기적 방문 frequency of asthma symptoms during the day, at night, and with physical exercise frequency of “rescue” SABA medication use and refills number and severity of asthma exacerbation since the last visit participation in school, sports, and other preferred activities. PFT는 적어도 일년에 한 번 PEF monitoring at homeAsthma controlPrognosisRecurrent coughing and wheezing : 35% of pre–school-age children. (⅓ : persistent asthma into later childhood) Moderate to severe asthma lower lung function - persis}

의/약학| 2012.01.13| 24페이지| 3,000원| 조회(144)

천식, asthma, allergy, GINA, Allergic disorder, Recurrent wheezing

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adenomyosis

Presence of endometrial tissue within the myometrium, at least 1 high-power field from the basis of the endometrium Adeno(gland)+myo(muscle)+oasis(a condition) = a condition of glandular tissue in the muscleDefinitionCauseThe cause of adenomyosis isn't known. Expert theories : Invasive tissue growth : direct invasion of endomertial cell into uterine wall Developmental origins Uterine inflammation related to childbirth. : break in the normal boundary of the uterus lining cellRisk factorPrior uterine surgery, such as a C-section or tubal ligation childbirthSymptomsAsymptomatic Menorrhagia(40~50%) : related with increased endometrium, PG, hyperestrogenemia Dysmenorrhea(15~30%) Metrorrhagia(10~12%) Dyspareunia Uterine cramping DyscheziaDiagnosisHistory taking, Physical exam - tender uterus Abdominal X-ray (after ingestion of contrast )DiagnosisEnchanced resolution of Transvaginal ultrasound - ill defines hypoechoic areas - heterogeneous myometrial echotexture - small anechoic area - asymmetrical uterine enlargement - indistinct endometrial-myometrial borderDiagnosisMRI with contrast medium - T2 weigted image: the contrast between the low signal inner myometrium and the intermediate signal outer myometrium is maximal Serum CA-125 - pregnancy, PID, adenomyosis, endometriosis, metastatic endometrial cancer, ovarian cancer Pathologic examination after removal of the uterusU/S MRIMicroscopy자궁근층 주변 안에서 내막선과 기질이 보임Differential diagnosisadenomyosisendometriosismyomaage4025~4530~45Dysmenorrhea+++++Menorrhagia++-++Dispareunia+/-+++Infertility20%75%5~10%frequently coexist!Differential diagnosisadenomyosisendometriosismyomaUterusDiffuse enlargement Soft and TenderNormal size Retroversion NodularEnlargementRadiating painLower back, upper thigh, umbilical areaUpper leg belly button rareComplicationStrain relationships Depression, irritability, anxiety, anger Chronic anemiaTreatmentSymtomatic treatment - pain - NSAID, birth control pills - heavy bleeding - birth control pills, progesterone-containing IUD - Decreased in Uterine size - Gonadotropin releasing agent The mainstay of Dx and Tx : hysterectomy (more effective)Reference제4판 부인과학 ; 대한산부인과학회 Berek Novak's Gynecology, 14th ed. Textbook of gynecology ; John I.Brewer Edwin J. DeCosta St.Charles Medical center endometriosis newsletter summer 2002:adenomyosis:a common cause of uterine symptoms after age 30 understanding the basics, distinguishing from endometriosis ; David B. Redwine, MD mayoclinic.com www.ultrasound-images.com{nameOfApplication=Show}

의/약학| 2012.01.13| 15페이지| 2,000원| 조회(100)

adenomyosis, 선근증, Microscopy, 샘근증, 자궁근층, meno..

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조기진통 조기양막파수

Preterm BirthDelivery before 37 completed weeks Mortality rate : approximately two thirds of these death (in the United States in 2005, 28,384 infants died )Cause of Preterm DeliveryMedical and obstetrical indications 1) common : preeclampsia, fetal distress, SGA, placantal abruption 2) spontaneous preterm labor Threatened abortion Lifestyle : smoking, inadequate maternal weight gain, drug use, psychological factorsCause of Preterm DeliveryRace : black, African-American, and Afro-Caribbean Genetic factor : recurrent, familial Prior preterm birth Periodontal diseaseCause of Preterm DeliveryBirth defect Infection – 25-40% of preterm birth Bacterial vaginosisPredictorPrior preterm birth Cervical change cervical dilatation cervical length shortening cervical incompetence : recurrent, painless cervical dilatation and spontaneous midtrimester birthPredictorFetal fibronectin role in intercellular adhesion detected in cervicovaginal secretions stromal remodeling of the cervix 50 ng/mL : marker for impending preterm laborPreterm Laborlabor before 37 completed weeks Sx painful or painless uterine contractions pelvic pressure menstrual-like cramps watery vaginal discharge lower back painDiagnosisContractions of four /20 minutes or eight / 60 minutes + progressive change in the cervix Cervical dilatation 1 cm Cervical effacement ≥ 80%TreatmentBefore 34weeks : Ix for delivery - delivery Not Ix - close observation - corticosteroid - group B streptococcal prophylaxis - tocolytics After 34weeks : monitored for labor progression and fetal well-being antimicrobialPrevention of preterm birthBed rest, Hydration, Sedation Tocolytics - β-Adrenergic Receptor Agonists : Ritodrine, Terbutaline, Fenoterol, Salbutamol (side effect: hyperglycemia, hypotension, Pulmonary edema, acute respiratory distress, arrhythmia, myocardial ischemia, maternal death, newborn with myocardial necrosis) - Magnesium Sulfate - Prostaglandin Inhibitors - Calcium-Channel Blockers - Atosiban : oxytocin analog - Nitric Oxide Donors (side effect: hypotension)Premature Rupture of Membrane (PROM)rupture of the membranes before labor begins (PPROM: prior to 37 weeks)Diagnosissterile speculum examination : vaginal leakage, cervical effacement, dilatation (avoid digital exams) Nitrazine test - vaginal fluid pH 4.5~5.5 blue - amniotic fluid pH 7.0~7.5 yellow - ROM pH 6.5 blue (false positive: blood, semen, antiseptics, or bacterial vaginosis)DiagnosisFern test : ferning of vaginal fluid USG : amniotic fluid volume, presenting part, gestational age Instillation of indigo carmine dye : passage of blue fluid from the vaginaIndication of DeliveryActive labor is present Signs of infection chorioamnionitis ① Fever : only reliable indicator for this diagnosis ≥ 38°C (100.4°F) with ROM ② Maternal leukocytosis ③ Maternal or Fetal Tachycardia ④ Uterine tenderness ⑤ Malodorous vaginal discharge2 or more + feverIndication of DeliveryFetal distress Appears pulmonary maturation Fetal malformationTreatment34 weeks or more - labor X - IV oxytocin induced delivery - group B streptococcal prophylaxis Before 34 weeks : Ix for delivery - delivery Not Ix - close observation - corticosteroid - group B streptococcal prophylaxis -CompicationPreterm delivery Infection Chorioamnionitis - mortality, morbidity ↑ Fetal distress Fetal development problem Increased in frequency of C-sec Placental abruptionReferenceWilliams Obstetrics, 23rd ed{nameOfApplication=Show}

의/약학| 2012.01.13| 19페이지| 2,000원| 조회(108)

조기진통, 조기양막파수, 양막파수, PROM, predictor, Preterm ..

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