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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» ¾ÇÈ­½ÃŲ´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