Inflammatory Bowel Disease 14ÆÇ
(Ulcerative colitis & Crohn's disease)
1. Á¤ÀÇ
unknown cause¿¡ ÀÇÇØ GIT¸¦ ħ¹üÇÏ´Â chronic inflammatory disorder.
pathognomonicÇÑ Æ¯Â¡µµ, specificÇÑ Áø´ÜÀû °Ë»çµµ ¾øÀ¸¹Ç·Î ÀÌ ÁúȯµéÀº ´Ù¸¥ º´µéÀÌ
¹èÁ¦µÈ ÈÄ¿¡ Áø´ÜµÈ´Ù(diagnosis of exclusion)
* chronic IBD´Â 2 major groups
chronic nonsepcific ulcerative colitis¿Í Crohn's disease·Î ³ª´µ¾îÁø´Ù.
cf. small bowel¿¡ »ý±ä Crohn's disease´Â "regional enteritis"·Î ¾Ë·ÁÁ®ÀÖ´Ù.
2.¿ªÇÐ
ÈæÀΰú µ¿¾çÀκ¸´Ù ¹éÀο¡°Ô ´õ ÈçÇÏ°í ºñÀ¯ÅÂÀο¡ ºñÇØ À¯ÅÂÀο¡¼ 3-6¹è(14ÆÇ: 2-4¹è)
´õ ³ôÀº ºóµµ¸¦ º¸ÀδÙ.
³²³àºñ´Â °°´Ù(15ÆÇ: UC = 1:1, CD=1.1-1.8:1)
peak incidence : 15-30¼¼(¸ðµç ¿¬·É¿¡¼ º¸°íµÇ°í ÀÖ´Ù), 2nd peak age: 60-80¼¼
°¡Á·Àû ¹ß»ý : CD or UC ȯÀÚÀÇ 2-5% -> À¯ÀüÀû ¿ä¼Ò + ȯ°æÀû ¿ä¼Ò°¡ °ü¿©ÇÔÀ» ¾Ï½Ã
* UC incidence : 6-8/100,000¸í(15ÆÇ: 11¸í)
prevalence : 70-150/100,000¸í
* CD incidence : 2/100,000(15ÆÇ: 7¸í)
prevalence : 20-40/100,000
* CD ¹ß»ýÀÌ Áõ°¡Çϰí ÀÖ´Ù(UCº¸´Ù ¹ß»ý·ü°ú À¯º´·üÀÌ 5¹è Áõ°¡).
3.¿øÀΰú º´ÀÎ : unknown
familial or genetics, infection, immunologic, psychological factorµîÀÇ °¡´É¼ºÀÌ Á¦½ÃµÇ°í
ÀÖ´Ù.
1) genetic predisposition
¹éÀΠƯÈ÷ À¯ÅÂÀο¡ ÈçÇÏ°í °¡Á·¼ºÀ» º¸ÀδÙ.
À̰ÍÀº ÀÌ ÁúȯÀÇ ¹ßº´¿¡ À¯ÀüÀû °æÇâÀÌ ÀÖÀ½À» ½Ã»çÇÑ´Ù.
monozygotic twinÀÇ crohn's ds¿¡¼ genetic componentÀÇ °ÇÑ Áõ°Å¸¦ º¸¿©ÁØ´Ù.
2) infectious cause
known bacterial, fungal, viral agent¸¦ ¹ß°ßÇÏ·Á°í ½ÃµµÇÏ¿´À¸³ª isolationµÇÁö´Â ¾Ê¾Ò´Ù.
acute colitis³ª ileitis¸¦ ÀÏÀ¸Å°´Â ¸¹Àº infectious agent°¡ chronic inflammatory bowel ds
¿¡ °ü¿©ÇÑ´Ù´Â Áõ°Å´Â ¾ø´Ù.
3) immune Mx
ÀÌ º´¿¡¼ µ¿¹ÝµÇ´Â extraintestinal manifestation(arthritis and pericholangitis)°¡
autoimmune phenomenonÀ» º¸À̰í glucocorticoid, azathioprine, cyclosporine°°Àº Ä¡·á
Á¦°¡ ¸é¿ª¾ïÁ¦ ±âÀüÀ¸·Î ÀÛ¿ëÇÑ´Ù´Â Á¡¿¡ ±Ù°ÅÇÑ´Ù.
¨ç IBDȯÀÚ¿¡¼ colon cell, bacterial Ag(E.coli), lipopolysaccharide, foreign protein(cow's
milk protein)¿¡ ´ëÇÑ humoral antibody¸¦ °¡Áú¼ö ÀÖ´Ù.
ÀÌ·± Ab titer¿Í disease activity»çÀÌÀÇ °ü·Ã¼ºÀº ¾ø´Ù.
±×¿Ü IBD´Â IgA deficiency»Ó¸¸ ¾Æ´Ï¶ó agammaglobulinemia¿Í °ü°èÀÖÀ¸¸ç
extraintestinal manifestationÀ» ¼³¸íÇϴµ¥ immune complex·Î ¼³¸íÇÑ´Ù.
¨è cell-mediated immunityÀ̻󿡴 cutaneous anergy, mitogenic stimuli¿¡ ´ëÇÑ ¹ÝÀÀ¼ºÀÇ
ÀúÇÏ, peripheral T cell¼öÀÇ °¨¼Ò °°Àº°ÍµéÀÌ ÀÖ´Ù.
mucosal IgG cell ¼ö°¡ Áõ°¡Çϸç T cell subsetÀÇ º¯È·Î antigenic stimulationµÈ´Ù..
¨é non-cytokine inflammatory mediators(PG or thromboxane°°Àº)
: IBDȯÀÚÀÇ mucosa¿¡ Áõ°¡µÇ¾î ¸é¿ª¹ÝÀÀÀ» Áõ°¡½ÃŲ´Ù.
* ±×·¯³ª UC or CD¿¡ ƯÀÌÀûÀÎ ¸é¿ªÇÐÀû º¯È´Â ¾ø´Ù.
4) psychological features
emotional stress°¡ ÀÌ º´ÀÇ Áõ»óÀ» ¾ÇȽÃŲ´Ù.
5) smoking : CD¿¡¼ mucus productionÀÌ Áõ°¡µÇ°í, colonic mucosal blood flowº¯È,
mucosal permeability°¨¼Ò°¡ º´Àο¡ ¿¬°üÀÌ ÀÖÀ»°Í(Sleisenger¿¡)
<15ÆÇ Á¤¸®>
1) defective immune regulation
Á¤»óÀο¡¼´Â °æ±¸·Î Åõ¿©µÈ ³»¿ë¹°¿¡ ´ëÇØ oral tolerance¿¡ ÀÇÇØ immune response°¡
¾ïÁ¦µÈ´Ù. soluble AgÀÌ °æ±¸·Î Åõ¿©µÉ ¶§ Ag-specific nonresponsiveness°¡ À¯µµµÈ´Ù.
oral tolerance induction¿¡´Â multiple mechanismÀÌ °ü¿©ÇÑ´Ù.
i) Ag-reactive T cell anergy or depletion
ii) CD4+ T cell activation : inhibitory cytokines(IL-10, TGF-¥â)ºÐºñ¸¦ ÅëÇÑ
gut inflammation¾ïÁ¦
¾î¶»°Ô immune suppressionÀÌ À¯ÁöµÇ´ÂÁö´Â Àß ¸ð¸¥´Ù.
UC, CD µÑ´Ù lamina propria & PB¿¡ CD4+ T cell(+) : inflammatory cytokinesºÐºñ
-> macrophage, B cell°°Àº ´Ù¸¥ inflammatory cell activation
* CD4+ T cellÀÇ 2 major groups
i) TH1 cells(IFN-¥ã, TNF): transmural granulomatous inflammation(CD)
ii) TH2 cells(IL-4, IL-5, IL-13) : superficial mucosal inflammationÀÌ ´õ Ư¡Àû(UC)
TH1 cytokine pathway´Â IL-12¿¡ ÀÇÇØ initiationµÇ´Âµ¥ ½ÇÇè¿¡¼ mucosal inflammation
pathogenesisÀÇ key cytokineÀÌ IL-12ÀÌ´Ù.
2) inflammatory cascade
inflammatory cytokines(IL-1, IL-6, TNF)
: fibrogenesis, collagen production¡è
tissue metalloproteinase¡è
´Ù¸¥ inflammatory mediator »ý»ê¡è
5-ASA: ÀÌ·¯ÇÑ inflammatory mediatorÀÇ potent inhibitor
NF-kB¿Í °°Àº transcription factor inhibitionÀ» ÅëÇÏ¿© ÀÛ¿ë
3) exogenous factors: infectious etiology
¼¼°¡Áö°¡ ÁÖ¸ñ¹Þ°í ÀÖ´Ù.
Mycobacterium paratuberculosis, Paramyxovirus, Helicobacter species
4. º´¸®
1) Ulcerative colitis
* colon : ulcerated, hyperemic, hemorrhagic
inflammation˼ uniform & continuous
* retum: ÈçÈ÷ ħ¹ü( 95%¿¡¼ )
* Àüü colonÀ» ħ¹üÇÒ¶§ terminal ileum ¸î cm°¡ ħ¹üµÉ¼ö Àִµ¥ ÀÌ·²¶§ÀÇ ¿ë¾î¸¦
"backwash ileitis"(¿ª·ù¼º ȸÀå¿°)À̶ó ÇÑ´Ù.
* crypt epithelium°ú submucosa»Ó¸¸ ¾Æ´Ï¶ó surface mucosal cell¿¡ neutrophilic
infiltrationµÈ ¿°Áõ¹ÝÀÀÀÌ ÀϾÙ. surface epithelial cellÀÇ ¼Ò½Ç·Î multiple ulcerationÀÌ
»ý±ä´Ù.
crypt¿¡ neutrophilic infiltrationÀº ƯÀÌÀûÀÌÁö´Â ¸øÇÏÁö¸¸ Ư¡ÀûÀÎ small crypt abscess
¸¦ Çü¼ºÇÏ°í °á±¹ ÆÄ±«µÈ´Ù.
* ¿°ÁõÀÇ ¹Ýº¹À¸·Î mild submucosal fibrosis°¡ »ý±ä´Ù. Crohn's ds¿Í ´Þ¸® submucosa
¾Æ·¡ÀÇ bowelÀÇ deep layer´Â ħ¹üµÇÁö ¾Ê´Â°ÍÀÌ Áß¿äÇÏ´Ù.
* toxic megacolon°ú °°Àº ½ÉÇÑ U.C¿¡¼ bowel wallÀº ±ØÈ÷ ¾ã°í, mucosa´Â ¹þ°ÜÁö°í,
¿°ÁõÀº serosa¿¡±îÁö È®ÀåµÇ¾î dilatation°ú perforationÀ» ÃÊ·¡ÇÑ´Ù.
* ¹Ýº¹Àû ¿°ÁõÀº "chronicity"ÀÇ Æ¯Â¡Àû ¼Ò°ßÀ» ³ªÅ¸³½´Ù.
: fibrosis¿Í longitudinal retractionÀº colon shorteningÀ» ÃÊ·¡ÇÑ´Ù.
normal haustral patternÀÌ ¼Ò½ÇµÇ¾î ¹æ»ç¼±ÇÐÀûÀ¸·Î colonÀÇ smooth, "lead-pipe"
appearance¸¦ ³ªÅ¸³»°ÔµÈ´Ù.
* regenerating islands of mucosa´Â ulceration & denuded mucosa¿¡ ÀÇÇØ µÑ·¯½Î¿©
colonÀÇ lumen³»·Î µ¹ÃâÇÑ "polyps"ó·³ º¸ÀδÙ. ±×·¯³ª ÀÌ·± µ¹ÃâÀº ¿°Áõ¼ºÀÌÁö
½Å»ý¹°ÀÌ ¾Æ´Ï´Ù. ±×·¡¼ "pseudopolyps"À̶ó ºÎ¸¥´Ù.
* long-standing U.C¿¡¼ surface epitheliumÀº dysplasiaÀÇ Æ¯Â¡À» º¸¿©ÁØ´Ù.
long-standing U.C¿¡¼ nuclear & cellular atypiaÀÇ º¯È´Â premalignant change·Î »ý°¢
µÈ´Ù.
* long-standing U.C¿¡¼ marked dysplasia´Â carcinoma°¡ µ¿¹ÝµÉ À§Ç輺ÀÌ ³ô¾Æ¼
colectomy¸¦ ±ÇÇÑ´Ù.
2) Crohn's disease
* intestinal wallÀüÃþ¿¡ ¿°ÁõÀÌ »ý±â¸ç mesentery, regional LN±îÁö ħ¹üÇÑ´Ù.
small bowel or colonÀÌ Ä§¹üµÇµç ¾ÈµÇµç°£¿¡ basic pathologic process´Â °°´Ù.
Ãʱ⠺´¸®Àû º¯È´Â Àß ¸ð¸£´Âµ¥ ±× ÀÌÀ¯´Â ÀÌ º´ÀÌ Ãʱ⿣ ¼ö¼úÀ» ÈçÈ÷ ÇÏÁö ¾Ê±â
¶§¹®À̸ç laparotomy»ó¿¡¼ terminal ileumÀº hyperemicÇϰí boggy(´ËÀ̸¹Àº,¼ö··ÀÇ)
Çϰí, mesentery¿Í mesenteric LN´Â ºÎÇ®¾îÀÖ°í, ¹ßÀûµÇ¾î ÀÖ´Ù. Ãʱâ´Ü°è¿¡¼ bowel
wallÀº ºñ·Ï edematousÇÏÁö¸¸ ÈçÈ÷ À¯¿¬ÇÏ´Ù.
¹ßÇö½Ã »ó´ç¼ö ȯÀÚ°¡ Yersinia enterocolitica¿¡ °¨¿°µÇ¾î ÀÖÀ¸¸ç ÀÌ ±ÕÀº self-limited,
acute inflammatory ileitis¸¦ À¯¹ßÇÒ¼ö ÀÖ´Ù.
* º´ÀÌ ÁøÇàÇÔ¿¡ µû¶ó À°¾ÈÀû ¸ð¾çÀº Ư¡Àû ¼Ò°ßÀ» º¸¿©ÁØ´Ù. ÀåÀº ¾ÆÁÖ µÎ²¨¿öÁö°í, °¡Á×
°°ÀÌ µÇ°í, lumenÀº Á¼¾ÆÁø´Ù. ÀÌ Æ¯Â¡Àû ÇùÂøÀº ÀåÀÇ ¾î¶² ºÎºÐ¿¡¼µµ ³ªÅ¸³¯¼ö ÀÖ°í
´Ù¾çÇÑ Á¤µµÀÇ ÀåÇùÂø°ú °ü·ÃÀÖ´Ù.
mesentery´Â ¾ÆÁÖ µÎ²®°í, Áö¹æ¼ºÀ̰í, ÀÚÁÖ ÀåÀÇ serosal surface·Î extendµÈ´Ù.
* º¸´Ù ÁøÇàµÈ °æ¿ì Á¡¸·Àº nodular, "cobblestone"ÀÇ ¸ð¾çÀ» °¡Áø´Ù. À̰ÍÀº Á¡¸·ÇϺñÈÄ¿Í
Á¡¸· ±Ë¾çÀÇ °á°úÀÌ´Ù. Á¡¸·±Ë¾çÀº mucosal foldÀÇ base¿¡¼ bowelÀÇ long axis·Î linear
ÇÏ°Ô »ý±ä´Ù. ÀÌ ±Ë¾çÀº submucosa¿Í muscularis¸¦ ¶ÕÀ»¼öµµ ÀÖ°í, ÇÕÃÄÁ®¼ intramural
channelÀ» Çü¼ºÇϸç fistula¿Í fissure·Î ³ªÅ¸³ª±âµµ ÇÑ´Ù.
- discontinuous : "skip area"¿¡ ÀÇÇØ bowel segment°¡ ¼·Î¼·Î ºÐ¸®µÇ¾î ÀÖ´Ù.
- colonÀÇ Crohn's diseaseÀÇ ¾à 50%¿¡¼ rectumÀÌ spareµÈ´Ù.
(cf. U.C´Â contiguous, rectumÀÌ °ÅÀÇ Ç×»ó involveµÈ´Ù.)
- intramural inflammatory process : serosa, mesentery involve
--> Ư¡ÀûÀÎ fistula¿Í abscess formation
serosal inflammationÀÇ °á°ú·Î ¼ÒÀåÀÇ ÁÖÀ§ loop°¡ fibrinous peritoneal reaction¿¡ ÀÇÇØ
¼·Î ÇùÂøµÈ´Ù. palpable mass¸¦ ÃÊ·¡Çϱ⵵ ÇÑ´Ù(´ëºÎºÐ RLQ).
fistulous tractÀº ¶ÇÇÑ skinÀ¸·Î ÅëÇϱ⵵ Çϰí, bowelÀÇ adherent loop¿Í inflammatory
tissue¿¡ µÑ·¯½ÎÀÎä peritoneumÀ̳ª retroperitoneum³»·Î ³¡³ª±âµµ ÇÑ´Ù.
( fistula formationÀº U.C¿¡¼± º¼¼ö ¾ø´Ù.)
* Çö¹Ì°æÀûÀ¸·Î granuloma°¡ crohn's disease¿Í ´Ù¸¥ IBD¸¦ ±¸ºÐÇϴµ¥ °¡Àå µµ¿òÀÌ µÈ´Ù.
À̰ÍÀº U.C¿¡¼± »ý±âÁö ¾Ê´Â´Ù.
* 30% : small intestine without colon disease (ÈçÈ÷ terminal ileum) involve
30% : only colon
40% : ileum, Rt colon
¼Ò¼ö´Â jejunum°ú ileum¿¡ diffuse & extensive ulcerationÀÌ »ý±â±âµµ ÇÑ´Ù.
(ÁÖ·Î ¾î¸°ÀÌ,»çÃá±â).
5. ÀÓ»óÀû Ư¡
1) Ulcerative colitis
ÁÖÁõ»ó : bloody diarrhea & abdominal pain
½ÉÇѰæ¿ì : fever, weight loss
liquid stool³» blood & pusÇÔÀ¯
severe crampÈ£¼Ò
dehydration, anemia, fever, wt lossÀÇ sx, sign
rectal involvementµµ ¼³»çº¸´Ù´Â º¯ºñ°¡ ÀÖÀ»¼ö ÀÖ´Ù.
tenesmusµµ ÁÖ¿äÇÑ È£¼ÒÀÌ´Ù.
°¡²û intestinal sxÀº fever, wt loss, extracolonic manifestationÀ¸·Î µ¤¿©Áú¼ö ÀÖ´Ù.
* ÁøÂû ¼Ò°ßÀº ºñƯÀÌÀûÀÌ´Ù : abdominal distension or tenderness
* extracolonic manifestation : arthritis, skin change, liver ds
* fever, tachycardia & postural hypotension : ÈçÈ÷ severe disease¿Í °ü·ÃÀÖ´Ù.
<Lab>
ºñƯÀÌÀûÀÌ´Ù.
- anemia : chronic blood loss·Î ÀÎÇÑ iron deficiency»Ó¸¸ ¾Æ´Ï¶ó chronic ds¹Ý¿µ
- leukocytosis with left shift
- ESR¡è
- electrolyte abnormality : ƯÈ÷ hypokalemia(diarrhea¶§¹®)
- hypoalbuminemia : ulcerated mucosa¸¦ ÅëÇÑ luminal protein loss¶§¹®
- ALP¡è: hepatobiliary dsµ¿¹Ý ¾Ï½Ã
ÀÓ»óÀû °æ°ú´Â ´Ù¾çÇÏ´Ù.
´ëºÎºÐ ȯÀÚ°¡ ù ¹ßº´ 1³â³» Àç¹ßÇÑ´Ù.
Áõ»óÀÇ ÁßÇÑ Á¤µµ´Â colon ħ¹üÁ¤µµ¿Í ¿°ÁõÀÇ Á¤µµ¸¦ ¹Ý¿µÇÑ´Ù.
Á¦ÇÑµÈ Ä§¹üÀ» º¸À̴ ȯÀÚµµ ÀÖ´Ù.
rectum : ulcerative proctitis
rectum & sigmoid : ulcerative proctosigmoiditis
ulcerative proctitis°¡ bleeding°ú tenesmus·Î Ä¡·áÇÏ±â ¾î·Æ´õ¶óµµ
ÀÌ º´Àº ÈçÈ÷ mild³»Áö minimal systemic or extracolonic manifestationÀ» º¸ÀδÙ.
À̶§ ÁÖ Áõ»óÀº rectal bleeding°ú tenesmusÀÌ´Ù.
ÀÌ È¯ÀÚµéÀÇ ´ëºÎºÐÀº extensive ds·Î ÁøÇàÇÏÁö ¾Ê´Â´Ù.
³ª¸ÓÁö´Â proximalÂÊÀ¸·Î È®»êµÇ°í ´Ù¾çÇÑ Á¤µµ·Î ħ¹üµÈ´Ù.
¾à 85%ÀÇ È¯ÀÚ°¡ mild³»Áö moderate ds·Î ÀÔ¿øÇÏÁö ¾Ê°í Ä¡·áÇÒ¼ö ÀÖ´Ù.
15%°¡ fulminant course·Î °¡¼ Àüü °áÀåÀ» ħ¹üÇÏ°í ½ÉÇÑ bloody diarrhea¿Í systemic
sign & sxÀ» º¸ÀδÙ. ÀÌ·± ȯÀÚµéÀº toxic dilatation°ú perforationµÉ À§Ç輺ÀÌ ÀÖ¾î medical
emergencyÀÌ´Ù.
2. Crohn's disease
±âº»Àû º´¸®Àû Ư¡Àº ¼ÒÀåÀ̳ª °áÀåÀÌ °°´Ù.
ÀÓ»óÁõ»óÀº ÀÌ º´ÀÇ ÇØºÎÇÐÀû À§Ä¡¸¦ ¹Ý¿µÇϰí ÇÕº´ÁõÀÌ ¹ßÇàÇÒ °ÍÀÎÁö ¾î´ÀÁ¤µµ ¿¹ÃøÇϰÔ
ÇÑ´Ù.
*ÁÖ¿ä ÀÓ»óÀû Ư¡
fever, abdominal pain, diarrhea(ÁÖ·Î blood´Â ¾ø´Ù.)
generalized fatigability, weight loss
- colonħ¹ü½Ã ÁÖ Áõ»ó : diarrhea, pain
- rectal bleedingÀº U.Cº¸´Ù ´ú ÈçÇѵ¥ ±× ÀÌÀ¯´Â
(1) ¸¹Àº ȯÀÚ¿¡¼ rectal sparingµÇ°í
(2) transmural nature¶§¹®ÀÌ´Ù.
- anal fistula, fissure, perirectal abscess°°Àº anorectal cxÀÌ µ¿¹ÝµÈ´Ù.
recurrent perirectal inflammationÀ¸·Î anal canalÀº µÎ²¨¿öÁö°í, perianal fistulaȤÀº scar°¡
»ý±æ¼ö ÀÖ´Ù.
±¤¹üÀ§ÇÑ colonħ¹üÀ¸·Î colon dilatationÀÌ »ý±æ¼ö ÀÖ´Ù. ±×·¯³ª Crohn's disease¿¡¼´Â
colonic wallÀÌ µÎ²¨¿öÁö±â ¶§¹®¿¡ U.Cº¸´Ù´Â ´ú ÈçÇÏ´Ù.
extracolonic manifestation ƯÈ÷ arthritis´Â small bowel Crohn's disease(regional
enteritis)º¸´Ù colonic¿¡¼ ´õ ÈçÇÏ´Ù.
¼ÒÀåÀÌ Ä§¹üµÇ¸é ºÎ°¡ÀûÀÎ Áõ»ó, ¼Ò°ßÀÌ ³ªÅ¸³´Ù. ÀüÇüÀûÀ¸·Î ÀÌ º´Àº young adult¿¡¼
»ý±â°í ÇÇ·Î, ´Ù¾çÇÑ Ã¼Áß°¨¼Ò, RLQ discomfort or pain, diarrheaÀÇ history¸¦ °¡Áö°í ÀÖ´Ù.
low-grade fever, anorexia, N/V¶ÇÇÑ ³ªÅ¸³¯¼ö ÀÖ´Ù.
abdominal painÀÌ ÁøÇ༺À̰í, RLQ¿¡ ±¹Çѵǰí, colicky or crampy patternÀϼö Àִµ¥
À̰ÍÀº ´Ù¾çÇÑ Á¤µµÀÇ intestinal stenosis¸¦ ¹Ý¿µÇÑ´Ù.
diarrhea´Â ÁߵÀ̰í ÈçÈ÷ gross blood°¡ ¾ø´Ù. ¸¸¾à rectal involve°¡ ¾ø´Ù¸é tenesmusµµ
¾ø´Ù.
<P/E>
RLQ tenderness (fullness or mass¿Í µ¿¹ÝµÈ)
--> À̰ÍÀº adherent loops of bowel¶§¹®ÀÌ´Ù.
À̶§ ȯÀÚ´Â mild anemia, mild to moderate leukocytosis, ESR¡è°¡ ÀÖÀ»¼ö ÀÖ´Ù.
acute ileitis´Â abrupt onset with fever, leukocytosis, RLQ painÀ» °¡Áø´Ù. ÀÓ»óÀû Ư¡
À¸·Î´Â acute appendicitis¿Í °¨º°ÇÒ¼ö ¾ø´Ù.
Áø´ÜÀº laparotomy·Î ÇÒ¼ö ÀÖ´Ù. Ư¡ÀûÀÎ beefy red terminal ileum, boggy mesenteric
fat, succulent mesenteric LN¸¦ º¸ÀδÙ. appendicitis´Üµ¶Àº ÀÌ·± Ư¡À» ³ªÅ¸³»Áö ¸øÇÑ´Ù.
<Cx>
(1) Intestinal obstructionÀÌ ÈçÇÑ ÇÕº´ÁõÀÌ´Ù.(20-30%)
i) initial stage
acute inflammation°ú ħ¹üµÈ ÀåÀÇ edema¶§¹®. ÈçÈ÷ terminal ileum¿¡¼
ii) ÁøÇàÇÔ¿¡ µû¶ó
fibrosis»ý°Ü¼ bowelÀÇ fixed narrowing¶§¹®
(2) fistula formation
chronic crohn's disease»Ó¸¸ ¾Æ´Ï¶ó chronic regional enteritisÀÇ ÈçÇÑ ÇÕº´ÁõÀÌ´Ù.
ÀåÀÇ ÀÎÁ¢ÇÑ ºÎºÐ»çÀÌ¿¡¼ ¹ß»ýÇϰí retroperitoneal space·Î burrow¸¦ Çü¼ºÇϱ⵵ ÇÑ´Ù.
»ó´ç¼öÀÇ È¯ÀÚ¿¡¼ ÀÌ º´ÀÇ Ã¹ ÀÎÁö°¡ persistent rectal fissure, perirectal abscess,
rectal fistula·Î ³ªÅ¸³¯¼ö ÀÖ´Ù.
(3) Crohn's disease°¡ bowel wall thickeningÀ» µ¿¹ÝÇÏ´Â transmural dsÀ̱⠶§¹®¿¡
intestinal perforationÀº ÈçÄ¡¾Ê´Ù.
(4) stomach°ú duodenumÀ» ħ¹üÇϱ⵵ ÇÑ´Ù.(antrum°ú duodenusÀÇ 1st, 2nd portion)
Áõ»óÀº peptic ulcer ds¿Í ºñ½Á
(5) malignancy
long-standing Crohn's disease¿¡¼ small-bowel & colonic malignancy¹ß»ýÀÌ Áõ°¡µÇ°í
ÀÖÁö¸¸ U.CÀÇ ºóµµ¿¡ ºñÇÏ¸é ³·´Ù.
(6) stone
extensive ileal ds·Î bile salt malabsorptionÀÌ »ý±â´Âµ¥ À̰ÍÀ¸·Î bile salt poolÀÌ °¨¼Ò
Çϰí bileÀÇ lithogenecity°¡ Áõ°¡ÇÑ´Ù.
ȯÀÚÀÇ 30%±îÁö gallstoneÀÌ »ý±ä´Ù.
intact colon¿¡¼ oxalateÈí¼ö°¡ Áõ°¡Çؼ hyperoxaluria°¡ »ý°Ü urinary oxalate stone
¹ß»ýÀÌ Áõ°¡ÇÑ´Ù.
diarrhea·Î ÀÎÇÑ Å»¼ö´Â renal stoneÇü¼ºÀÇ predisposing factorÀÌ´Ù.
6. Áø´Ü
IBDÀÇ Áø´ÜÀº diarrhea or bloody diarrhea, persistent perianal sepsis & abdominal painÀ»
°¡Áö´Â ¸ðµç ȯÀÚ¿¡¼ »ý°¢ÇØ¾ß ÇÑ´Ù.
1) Lab - ºñƯÀÌÀû, inflammatory RxÀÇ Á¤µµ¿Í ÁßÇÔÀ» ¹Ý¿µ
¨ç anemia
by i) occult blood loss
ii) chronic inflammation on the BM
iii) folate or vit B12 malabsortion
¨è electrolyte abnormality( hypokalemia, hypomagnesemia )
¨é hypocalcemia
±¤¹üÀ§ÇÑ Á¡¸·Ä§¹ü, vit D malabsorptionÀ» ¹Ý¿µÇÑ´Ù.
¨ê hypoalbuminemia
by i) protein losing enteropathy
ii) amino acid malabsorption
¨ë steatorrea
´Ù¾çÇÑ Á¤µµ·Î ³ªÅ¸³´Ù.
bile salt depletion, mucosal damage¶§¹®
¨ì liver fxÀÌ»ó ( ALP¡è )
fatty liver, early sclerosing cholangitisµ¿¹Ý
2) Sigmoidoscopy & Radiologic study
IBDÁø´Ü¿¡ °¡Àå Áß¿ä
Sigmoidoscopy´Â chronic diarrhea, rectal bleedingÀÖ´Â ¸ðµç ȯÀÚ¿¡¼ ½ÃÇàÇØ¾ß ÇÑ´Ù.
air-contrast barium enema examÀº U.C³ª Crohn's dsÀÇ earliest mucosal change¸¦
º¸¿©ÁÖ¸ç º¸ÅëÀÇ Ba enema examÀº Ãʱ⿣ Á¤»óÀÌ´Ù.
Colonic mucosa¸¦ Á÷Á¢º¸°í BxÇϴ°ÍÀÌ °¡Àå sensitiveÇÑ ¹æ¹ýÀÌ´Ù.
Sigmoidoscopy´Â ¼³»çȯÀÚ¿¡¼ »çÀü¿¡ enema preparationÇÏÁö ¾Ê°í ½ÃÇàÇÒ¼ö ÀÖ´Ù.
¸ñÀûÀº mucosal inflammationÀÌ ÀÖ´ÂÁö È®ÀÎÇϰí initial examÀ¸·Î¼ ¹Ýµå½Ã full extent¸¦
º¸¾Æ¾ß ÇÒ Çʿ䰡 ¾øÀ»¶§ ½ÃÇàÇÑ´Ù.
±×·¯¹Ç·Î óÀ½ 8-10cm³»¿¡¼ change°¡ ÀÖ´Ù¸é ÀüÀå¿¡ °ÉÃÄ ±â±¸¸¦ Åë°úÇÒ Çʿ䰡
¾ø¾î¼ acute inflamedµÇ¾úÀ»¶§ discomfort¸¦ ÀÏÀ¸Å°Áö ¾Ê´Â´Ù.
(1) Ulcerative colitis
loss of mucosal vascularity
diffuse erythema
friability of the mucosa
exudate consisting of mucus, blood, pus
mucosal friabilityÀÇ uniform involvement°¡ Ư¡ÀûÀÌ´Ù.
- acute ill pt¿¡¼± full colonoscopic exam of colonÀº IxÀÌ µÇÁö ¾Ê´Â´Ù.
- more chronic ds¿¡¼ mucosa´Â granular app.¸¦ º¸À̰í pseudopolypÀÌ Á¸ÀçÇÑ´Ù.
(2) Crohn's disease
ulceration : tiny, aphthous erosion or deep, longitudinal fissure
mucosa´Â uniformÇÏ°Ô Ä§¹üµÇÁö ¾Ê°í friability & diffue granularityµµ Ư¡ÀûÀÌÁö ¾Æ´Ï´Ù.
¿ÀÈ÷·Á cobblestone app(mucosal surfaceÀÇ coarse irregularity)°¡ submucosal
inflammationÀ» ¹Ý¿µÇϰí Crohn's dsÀÇ Æ¯Â¡Àû ¼Ò°ßÀÌ´Ù.
pseudopolyposis, edema, strictureµµ º¼¼ö ÀÖ´Ù.
Colonic mucosal Bx´Â ħ¹üµÈ °÷¿¡¼ äÃëÇÑ specimenÀÇ 30-50%¿¡¼ granuloma¸¦
º¸¿©ÁØ´Ù.
Skip areas & rectal sparingÀÌ Æ¯Â¡ÀûÀ̱⠶§¹®¿¡ Crohn's ds¸¦ evaluationÇϴµ¥´Â
sigmoidoscopyº¸´Ù´Â colonoscopy°¡ ´õ ³´´Ù.
5-15%¿¡¼ ħ¹üµÇÁö ¾ÊÀº °ÍÀ¸·Î º¸ÀÌ´Â °÷¿¡¼ ½ÃÇàÇÑ rectal Bx¶ÇÇÑ microscopic
granulomatous inflammationÀ» º¸¿©ÁØ´Ù.
4) Barium study
(1) Ulcerative colitis
disease extentÁ¤µµ¸¦ º¼¼ö ÀÖ°í stricture, pseudopolyposis, or carcinoma¿Í °°Àº
°ü·ÃµÈ ¸ð¾çÀ» º¼ ¼ö ÀÖ´Ù.
* earliest features - irritability, incomplete filling, fine ulceration(serration)
* chronic stages - bowel shortening, flexure depression, bowel lumen narrowing,
rigidity
symmetric, ahaustral, tubular appearance with depressed mucosal pattern
(2) Crohn's disease
rectal sparing, skip lesion, irregular thickening & fibrosis -> stricture
formation(multiple)
10-15% : entire colon involve(uniformly). UC¿Í DDxÈûµë
terminal ileum : ÈçÈ÷ involve
stomach, duodenum - mucosal infiltration & stiffening -> infiltrative tumor¿Í ºñ½Á
5) CT : CD¿¡¼ intraabdominal abscess¿Í phlegmon, thickened, separated bowel loop°ú
°¨º°
6) Colonoscopy
colonic IBDÁø´Ü¿¡ powerful tool
endoscopic exam with Bx = most sensitive technique
polypoid lesion, stricture, unclear X-ray feature
Cancer surveillance