2015 복영증례 51/M C.C. Past Hx: DM, HTN (1998), Lab: WBC (11500/ μl ), CRP (0.71 mg/dl) 순천향서울병원황지영, 홍성숙 APCT (HAD #1) APCT (HAD#1) APCT (HAD #15)

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1 Case 복영증례 순천향서울병원황지영, 홍성숙 51/M C.C Abdominal pain and chilling (1 week ago) Diarrhea (a month ago) Past Hx: DM, HTN (1998), Alcoholic liver disease (2008) Lab: WBC (11500/ μl ), CRP (0.71 mg/dl) (HAD #1) (HAD#1) Impression (HAD #15) Infectious enterocolitis Antibiotics 1

2 (HAD #15) (HAD #16) DDx. of CFS 1Infectious enterocolitis 2Intestinal TB 3Intestinal Behcet s disease 4Crohn s disease, CMV colitis Pathologic diagnosis 1 Cecum : granulation tissue with acute nonspecific suppurative inflammation 2 Rectum : Ulceration with acute and chronic nonspecific inflammation 3 AFB (-), CMV IHC (-) (HAD #1~#16) (HAD #22~#36) HAD 1~ HAD Study CFS Study Lab Antibiotics (FQ, Ertapenem, Vancomycin, Teicoplanin) CMV PCR (+) Lab Antibiotics (Teicoplanin, Linezolid) + Ganciclovir (HAD #44) Impression Differential diagnosis CMV colitis Concurrent inflammatory bowel disease Intestinal TB, crohn s disease 2

3 2 HAD #36~#58 (HAD #58) HAD Study CFS biopsy AFB (-) No evidence of CMV infection Lab TB/NTM PCR (-) CMV PCR (-), CMV AB (-) CMV culture (-) Quanti FERON (TB) (-) Antibiotics (Teicoplanin, Linezolid) + Ganciclovir HERZ panca (-) ASCA (+) HAD #36~#58 HAD #36~#58 HAD HAD panca/asca Study CFS biopsy AFB (-) No evidence of CMV infection Lab TB/NTM PCR (-) CMV PCR (-), CMV AB (-) CMV culture (-) Quanti FERON (TB) (-) Antibiotics (Teicoplanin, Linezolid) + Ganciclovir HERZ panca (-) ASCA (+) panca(-) ASCA (+) (#57) Anti-neutrophil cytoplasmic antibodies(anca) found in 65% UC and 5-10% CD Study Antibodies to CFS yeast biopsy Saccharomyces cerevisiae(asca) found in 60-70% CD and 10-15% UC AFB (-) Combo of -panca/+asca 50% sens and 97% spec for CD Combo No of evidence +panca/-asca of CMV 57% sens and 97% spec for UC infection Lab TB/NTM PCR (-) CMV PCR (-), CMV AB (-) CMV culture (-) Quanti FERON (TB) (-) Antibiotics (Teicoplanin, Linezolid) + Ganciclovir HERZ panca (-) ASCA (+) HAD #58~#77 (HAD #70) HAD 58~61 62~70 71~74 75~ Study Lab (HAD #70) Antibiotics + HERZ+Mesalazine Steroid IV hydrocortisone p.o. PDL IV hydrocortisone p.o. PDL 3

4 Summary (HAD #16) : Suggestive of concurrent inflammatory bowel disease Intestinal TB, CD End ileostomy & small bowel biopsy (HAD #97) CFS (HAD #15): Intestinal TB Intestinal Behcet s CD, CMV colitis CMV PCR (+) Antibiotics CMV (-) TB (-) 70 Crohn s disease panca (-) ASCA (+) (HAD #70) Partial obstruction Diffuse (HAD ulceration, #1) marked transmural Infectious chronic (HAD #44) nonspecific inflammation, enterocolitis fibrosis, serosal granulation tissue with (HAD #58) interadhesion of bowel loop resulting in segmental narrowing of bowel lumen No evidence of chronic mucosal damage or viral infection The possibility of Crohn disease is less likely Final diagnosis? CMV Colitis Intestinal TB Crohn disease Cryptogenic multifocal ulcerous stenosing enteritis Ganciclovir HERZ Mesalazine + Steroid Cryptogenic Multifocal Ulcerous Stenosisg Enteritis (CMUSE) Chronic or relapsing subileus or ileus status resulting from multiple unexplained shallow ulcer and strictures without systemic inflammation of the small intestine Favourable therapeutic effect of systemic steroid Middle-aged or young patients Diagnosis: exclusion of other diseases that cause multiple ulcers in the small bowel Collagen vascular disease, coagulopathy, inflammatory vasculitis, T cell enteropathy, Crohn s disease, infectious enteritis, NSAIDinduced enteropathy, and traumatic injury.. Diagnostic criteria proposed by Perlemuter et al. 1) Unexplained small bowel strictures of adolescents and middle aged patients 2) Superficial ulcer in the mucosa and submucosa 3) Chronic or relapsing ulcerative stenosis of the small bowel after surgical resection 4) No signs of systemic inflammation 5) Improvement after administering corticosteroids Gut. 2001;48:

5 Pathologic findings (18 patients) Necrotic inflammatory ulcers with nonspecific inflammation, erosion with submucosal fibrosis, multifocal mucosal ulceration with chronic crypt inflammation, active ileitis with an ulcer, mucosal erosion, focal active inflammation Remission: 13/20 (65%) Persistent disease: 2/20 (10%) Relapse: 5/20 (25%) Corticosteroid response rate: 3/12 (25%) Case 2 70/F Past Hx S/P Total pancreatectomy for IPMN with focal invasion S/P Anterior resection for rectal cancer (T3N0M0) ( ) C.C: F/U 5

6 ( ) Biliary pancreas MRI ( ) MRCP, ERCP ( ) F/U ( ) F/U ( ) 6

7 F/U ( ) F/U ( ) F/U MRI ( ) PET-CT ( ) Impression Recurrence of IPMN of the pancreas Recurrent IPMN? Other mesenchymal cystic lesion? CA

8 65/M with noninvasive IPMN J Comput Assist Tomogr 2009;33: