목차 - 삼성서울병원 · 2016-01-26 · department of medicine, samsung medical center...

목차

응급실에서 담도 환자 보기 …………………………………………… 7

췌담도 질환에서 내시경 검사 ……………………………………… 27

응급실에서 췌장 환자 보기 ………………………………………… 53

2016 gastroenterology Winter School

Session 4. 췌담도

응급실에서 담도 환자 보기

이 규 택


증례 I, F/74

1. 당일낮부터발생한상복부동통으로 월요일저녁8시 30분에응급실내원

- 의식 (alert), V/S (36.3OC - 77/min – 153/90 mmHg)

응급실에서검사중밤 11시경발열및의식저하 -의식 (drowsy), V/S (39.3OC - 94/min – 135/62

mmHg – RR 29/min – SPO2 94% via O2:3 L/min)

- WBC; 13,130 (seg:83.7%), T.B.(1.7), AST/ALT (118/90), ALP (598), GGT (2453)

- CT: CBD stone with CBD dilatation

응급실에서 담도환자 보기 - Winter School 2016 -

Kyu Taek Lee M.D.

Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea

2016 gastroenterology Winter School 7

F/74

2. 응급실에서 C-line, A-line, Blood culture후 IM1, GS 연락,화요일새벽 1시6분임상강사연락옴

- 의식 (slightly drowsy), V/S (38.9OC - 85/min – 115/51 mmHg, RR 32/min, SPO2: 96% at O2 5L/min)

- 환자상태보고받고급성화농성담관염으로진단하고,담즙배액이응급으로필요하다고판단

- 환자 IV hydration 및항생제투여하며 V/S유지하고,아침 8시에 ERCP시행하도록조치

CT : Dilatated CBD & distal CBD stone

8 2016 gastroenterology Winter School

C.W. Acute suppurative cholangitis


증례 II, F/80 2. 경과

- 4시경 ER GI Fellow V/S stable하다고 notify - 6시 20분 intubation (SPO2: 90% at O2 4l/min) - 6시 30분환자의식상태가 Drowsy하다고 notify

오후 8시 PTBD시행: ICU입원하여 ventilator care & antibiotics

- 다음날오후 10시 48분사망 ( septic shock due to cholangitis)

증례 II, F/80

1. 하루전발생한심한복통과발열로토요일오후 3시24분에응급실내원

과거력) 9년전 Distal CBD stone으로본원에서 EST &removal of CBD stone 시술,그후 F/U loss

-의식 (drowsy), V/S (38.9OC - 105/min – 123/68 mmHg), SPO2 (92%)

- WBC; 6,460 (seg:85%), PLT (83,000), CRP (12.5) T.B.(5.9), AST/ALT (321/201), ALP (194)

- CT: multiple CBD stones with cholangiohepatitis


증례 III, M/29

1. 타병원에서담관담석으로 전날 ERCP시도하였으나담석제거실패하고,오전부터발열및복통이있어오후 2시에ER내원

과거력) 2014년 4월담낭절제술

-의식 (drowsy), V/S (40.6OC - 178/min – 76/45 mmHg), RR (30/min), SPO2 (99%) at room air

- WBC; 10,750 (seg:95%), PLT (177,000), CRP (12.5) T.B.(8.5), AST/ALT (245/416)

- 환자 irritable심하고호흡수 33회/min로증가하여,내원1시간만에 intubation + midazolam IV + ventilator +

norepinephrine IV


증례 III, M/29 2. 경과

- 6시경방사선과와 PTBD 상의했으나, IHD dilatation없어서시술어렵다고함.

- 6시 40분소화기내과에 ERCP의뢰되었으나, septic shock으로 intubation 및 ventilator care중으로ERCP진행에는어려움 (position change 어렵고,시술중 vital sign care해줄인력필요).

다음선택은?

타병원 ERCP


Acute suppurative Cholangitis

• Charcot’s triad : RUQ pain, jaundice, fever

• Prognosis: poor (when it is untreated)

• Conservative treatment with antibiotics (24 – 48hr) in mild courses: can be tried but, who can guarantee ?

• Biliary decompression by ERCP or PTC is essential for life saving: decreased mortality from 100% to 40%

증례 III, M/29 2. 경과

- 외과의뢰하여응급수술하기로함.

- 저녁 9시수술: CBD exploration and removal of CBD stone with T-tube insertion

- 2주간입원치료후회복하여퇴원


Fate of Gallbladder Stone

Two biliary conditions meet in ER

• Stone : pain, fever, jaundice - biliary colic, cholecystitis, cholangitis

• Jaundice : benign vs malignant


Management of GB stone (II)

• Method of treatment

- Laparoscopic cholecystectomy : Tx of choice

- Oral dissolution therapy : Ursodeoxycholic acid (UDCA) decrease cholesterol saturation of bile dose; 8 – 10 mg/kg

effective in functioning GB, patent cystic duct, cholesterol stone,

Ix; symptomatic (< 10%), number < 3, size < 10 mm

Management of GB stone (I)

• Principle of asymptomatic GB stones : wait & see

• Indication of treatment

- symptomatic GB stones : biliary colic

- associated complications: acute cholecystitis, gallstone pancreatitis, gallstone fistula

- increased risk of gallstone complications : calcified or porcelain GB, previous attack of acute cholecystitis regardless of current symptomatic status, large sized GB stones (>3 cm), congenitally anomalous GB


증례 IV, M/48

1. 갑자기발생한심와부동통으로 응급실내원

과거력)간암으로 9차례 TACE 시술.

- T.B.(5.8), AST/ALT (209/298), ALP (206), GGT (618), PLT (70,000), PT (79%)

- CT & MRI: Biliary tree dilatation의 evidence 없음,Slightly interval progression of suspicious viable tumor in S4 of liver

ERCP가필요한 경우

• Imaging study (US, CT, MRCP)에서 CBD stone 이보일때

• Imaging study에서 CBD dilatation이있으면서 LFTabnormality (특히 ALP상승)이있을때

• 단순히 amylase, lipase만상승되어있고, CBD dilatation없거나 LFT가정상화되었을때는불필요


Hemobilia


Acoustic shadowing Positional change, Dependent position → GB stone

Thickened GB wall → cholecystitis

Pericholecystic fluid collection → cholecystitis

Diagnosis of Acute Cholecystitis

US (best method) • detects stone and thickened gallbladder wall • 90-95%에서 gallstone이발견.

Radionucleotide biliary scan (Confirm) • nonvisualization of GB (fails to visualize the gallbladder at

one hour) • normal scan filling the gallbladder virtually eliminates acute

cholecystitis

CT : 합병증(기종성담낭염,천공)의심,다른질환(췌장염,기복증,복강농양)배제


Treatment of Acute Cholecystitis

• NPO and Hydration

• L-tube insertion : ileus (+)

• Pain control (meperidine, NSAIDs)

• IV antibiotics : 경한경우에그람음성균을겨냥한단일제제,중한경우에그람음성,양성,혐기성균을모두겨냥한복합제제

• Laparoscopic cholecystectomy – treatment of choice, Call GS doctor in ER

• PTGBD :중한경우나합병증(GB empyema, GB abscess) 동반되었으나환자상태가수술불가능한경우

DISIDA Scan (Normal)

15 min. 45 min.

GB


담도결석 (choledocholithiasis)

•대부분(85%)은 cholesterol stone으로 GB stone이내려온것 (GB stone의 10-15%가담도로내려감).

• CBD자체에서형성되는담석은대부분 pigment stone (hemolysis, parasite infestation, congenital anomaly..)으로수술후에재발을잘함.

•합병증 – cholangitis, obstructive jaundice (ALP – directbilirubin – aminostrasferase 순으로),pancreatitis, secondary biliary cirrhosis, malabsorption…

담도결석 (choledocholithiasis)


CBD stone extraction after EST

Management of Bile Duct Stones

• Principle in management of common bile duct stones - treat all cases irrespective of symptoms - methods of treatment : Endoscopic sphincterotomy (EST) ; Tx of choice Open CBD exploration • Principle in management of intrahepatic bile duct stones - Hepatectomy: limited to one lobe, associated with

atrophy and stricture - Percutaneous transhepatic cholangioscopy-lithotripsy

( PTCS-L )


Decision tree for Obstructive Jaundice

• History, P/Ex, routine Lab → ALP or AST/ALT elevated → Biliary tract obstruction a consideration ? → US or CT → dilated bile duct → ERCP or PTC

• Drainage procedure in malignant obstruction - PTBD in intrahepatic bile duct obstruction - Endoscopic drainage (ENBD, ERBD) in extrahepatic bile duct obstruction

Jaundice Patient in ER

• Obstructive Jaundice vs Cholestatic Jaundice

- History : abdominal pain, fever, prior biliary surgery, old age

- P/Ex : fever, abdominal tenderness, palpable abdominal mass, abdominal scar

- Lab : Predominant elevation of serum ALP relative to aminotransferase, PT normal or normalizes with vitamin K administration, elevated serum amylase or lipase


ENBD

PTBD


응급실에서유의사항

• 금요일밤에급성담관염이의심되는환자가응급실에내원했는데어떻게 draiage를할까?

• Drainage가필요한환자가 Antiplatelet or anticoagulant drugs (aspirin, warfarin, ticlopidine, clopidgrel…) 을복용하고있는데,빨리시술이필요하면?

ERBD (Plastic stent)


췌담도 질환에서 내시경 검사

이 광 혁


ERCP(Endoscopic Retrograde CholangioPancreatography)

• ERCP• EST• CBD stone removal• ERBD• ENBD• Photodynamic therapy• Endoscopic papillectomy

EUS (Endoscopic UltraSound)

• EUS– Contrast Enhancement

– Elastography

• EUS-tissue diagnosis– Fine needle

– TruCut needle

– Procore needle

• EUS-guided therapy– Drainage, Anastomosis

– Ablation, Injection

2016.01.30 winter school

성균관대학교의과대학내과학교실

삼성서울병원소화기내과

이 광 혁

췌담도 질환에서내시경소화기내과전임의


Esophago-gastro-duodenoscopy

Need an Expert? Yes!

• 우리나라– 전임의 1년은위및대장내시경수기익힌뒤– 최소한 1년은투자해야

• Advanced endoscopic course in USA– ERCP Fellowship: 1 year

– EUS Fellowship: 1 year


Endoscopic perforation: Side-view endoscope, Shortening

Side view


EUS

ERCP – cannulation


Close observation of Complications

• Change of abdominal pain, Vital sign, P/E• Infection: Cholangitis, Cyst infection• Bleeding: CBC• Perforation: Simple abdomen, chest PA• Pancreatitis: Amylase/Lipase

Conventional, ProCore ®

• Stiffness in use– 22G = 25G•Deep location

– 19G • Therapeutic • Flexible model


Pancreatitis : ERCP/EUS-FNA• Same as acute pancreatitis from other causes• Severity assessment• Protease inhibitor (Gabexate, nafamostatin,

ulinastatin)

Perforation

• Instrumental perforation supportive• Retroperitoneal abdominal CT• Endoscopic perforation surgery



ERCP(Endoscopic Retrograde

CholangioPancreatography)

For diagnosisEUS, MRCP >? ERCP


Accessories in ERCP

• Catheter• Guide-wire• Papillotome• Stent

– Metal– Plastic

• Balloon– Dilatation– Retrieval

• Basket– Lithotripsy

Endoscopic Sphincterotomy (EST)

• Therapeutic intent• Complication: Perforation, Bleeding• Techniques

– Depth - 1/2 - 2/3 outside AOV– Direction - 12 o’clock position– Limit - Oral protrusion– Speed - Control


Papillotome

• Pull-type sphincterotome• Needle knife sphincterotome• BillrothⅡ sphincterotome

BillrothⅡNeedle knifePull type

Catheter & Guide-wire


Stent

Plastic stentMetal stent

Balloon & Basket


Plastic VS metal stentTotal N = 20 large-bore plastic

endoprostheses(14 French)

self-expanding metal stents (SEMS)(24 French)

88.9% 100%

<30days failure 20% 0%

>30days failure 50% 18.2%

Re-intervention 2.4 +/- 2.6 0.4 +/- 0.5

Plastic endoprostheses versus metal stents in the palliative treatment of malignant hilar biliary obstruction. A prospective and randomized trial. Wagner HJ et al Endscopy 1993; 25: 213–18

Plastic stent

• Removable • Benign stricture• Exchange – 3 months• Shapes


Percutaneous drainage

Palliative management of malignant biliary obstructions• Percutaneous drainage• Endoscopic drainage


Treatment of distal obstruction

• Placement of self-expanding metal stent is the treatment of choice from some randomized trials.

1. Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Davids PHP et al. Lancet 1992; 340: 1488–92.

2. A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Knyrim K et al. Endoscopy 1993; 25: 207–12.

3. A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Prat F et al. Gastrointest. Endosc. 1998; 47: 1–7.

Endoscopic drainage

Bilirubin


Covered metal stent

• Prevention of tumor ingrowths (?)• Cholecystitis (?)• Obstruction of branched duct (?)

Covered metal stent: prevention of tumor ingrowths (?)

Covered Uncovered p

Patency (days) 392±60 308±42 0.736 1

Obstruction (%) 9% (9/36) 15% (15/41) 0.273

Patency 148.9 143.5 0.531 2

Obstruction (%) 21% (21/98) 19% (20/108) 0.842

Cholecystitis 5.6% (5/88) 1.0% (1/100) 0.104

1. Yoon WJ, Lee JK, Lee KH, Lee WJ, Ryu JK, Kim YT, Yoon YB. A comparison of covered and uncovered Wallstents for the management of distal malignant biliary obstruction. Gastrointest Endosc 2006;63:996-1000.

2. Park do H, Kim MH, Choi JS, Lee SS, Seo DW, Kim JH, Han J, Kim JC, Choi EK, Lee SK. Covered versus uncovered wallstent for malignant extrahepatic biliary obstruction: a cohort comparative analysis. ClinGastroenterol Hepatol 2006;4:790-6.


Bilateral stent-parallel

30

74/F obstructive jaundice

Double stent system

AJR 2011; 197:W942–W947


Photodynamic therapy

Bilateral Stent – Y stent

31/M obstructive jaundice


EUS

Endoscopic ultrasound in Pancreaticobiliary disease

Endoscopic papillectomy

• AOV adenoma• Pancreatic duct stent


EUS guided tissue acqusition

• 1. pathological diagnosis– Cytology– Histology – Immunohistochemical staining

• 2. molecular diagnosis in the future– DNA, RNA, protein– Small amount High throughput analysis– Expansion Functional analysis

Radial type Vs Linear type


Small pancreatic mass

Pancreatic Cystic Neoplasm

• Solid component• Fluid analysis

– CEA– Amylase

• Poor cytological yield


Contrast enhancement EUS

Vascularity

Elastography & EUS-FNA


Therapeutic applications

• Drainage and Anastomosis– Pseudocyst, pancreatic abscess– Biliary tract, Pancreatic duct, Jejunum

• Ablation– CPN block, cyst ablation, solid mass ablation– Ethanol, chemotherapeutics, fiducial, biological agent

EUS guided tissue diagnosisfor pancreatic cancer

Scenario RequiredMetastatic YesAdvanced unresectable YesBorderline resectable YesResectable Maybe, yesUndetectable Yes


Pancreas + Biliary tract Summary for future

ERCP(Endoscopic Retrograde CholangioPancreatography)


EUS (Endoscopic UltraSound)

• EUS• EUS-FNA• EUS-TCB• EUS-guided therapy

– Drainage

– Anastomosis

– Ablation

– Injection


응급실에서 췌장 환자 보기

이 종 균


Q1. 췌장염이 맞나요?

Severe constant abdominal pain Serum amylase and/or lipase > 3N image finding exclusion of other causes

응급실에서 췌장환자보기

이종균

성균관대학교의과대학내과학교실


Radiologic findings

Chest X-ray - pleural effusions, atelectasis, ARDS

Simple abdomen- ileus- sentinel loop ; isolated dilated loop of small bowel overlying the pancreas

Amylase onset; 2-12 hours, duration; 3-5 days unrelated to severity salivary gl., liver, intestine, kidney, fallopian tube tumor - lung, esophagus, breast, ovary Normal or low level in acute pancreatitis

after 3-5 days acute exacerbation in chronic pancreatitis hypertriglyceridemia

Lipase longer duration, more specific to pancreas

Laboratory findings


CT

Diagnosis Exclusion of other surgical

abdomen Severity of pancreatitis Local complications

췌장염의 중증도를 가장 정확하게 알 수 있는 발생 2-3일 후

장기 부전이 지속되거나, 폐혈증의 소견을 보이거나, 임상적으로악화되는 경우

(대한췌담도학회 가이드라인)

Ultrasonography

Limited visualization of pancreas by intestinal gas or adipose tissue

Single best noninvasive test for detecting cholelithiasis


Alcoholic pancreatitis

알코올 섭취

하루 60-80g

2-3년 이상

최근 1주 이내 음주

증상은 처음이지만 조직학적으로는 만성 변화

Q2. 원인이 뭔가요?

Support diagnosis Prevent progression and recurrence


Mild pancreatitis Severe pancreatitis interstitial edema mortality < 2%

parenchymal necrosis systemic organ failure or local

complications such as necrosis, pseudocyst, abscess

mortality 10~15%

Q3. 얼마나 심한가요?

Gallstone pancreatitis

의심 소견: 담석, 담관 확장, cholestatic LFT

대부분 작은 담석: 90%는 자연 배출

중증 췌장염 또는 48시간 내에 호전되지 않는 경우에는 내시경적괄약근절개술

담석성 췌장염은 대부분 만성화되지 않는다


APACHE II scoring system

Ranson Criteria Modified CriteriaAt admission (Alcoholic) (Biliary)

Age > 55 years > 70 yearsWBC > 16,000/mm3 > 18,000/mm3

Glucose > 200 mg/dl > 220 mg/dlLDH > 350 IU/L > 400 IU/LAST > 250 IU/L > 440 IU/L

During initial 48 hHct decrease > 10 % > 10 %BUN increase > 5 mg/dl > 2 mg/dlCalcium < 8 mg/dl < 8 mg/dlPO2 < 60 mm Hg < 60 mm HgBase deficit > 4 mEq/l > 5 mEq/lEstimated fluid sequestration

> 6 l > 6 l


CT severity index

Grade of Acute Pancreatitis PointsA. Normal pancreas 0B. Pancreatic enlargement alone 1C. Peripancreatic fat infiltration 2D. One peripancreatic fluid collection 3E. Two or more fluid collection 4

Degree of pancreatic necrosisNo necrosis 0< one third 2one third – one half 4more than one half 6

CT Severity Index (CTSI) Morbidity Mortality0-3 8% 3%4-6 35% 6%7-10 92% 17%

(Balthazar EJ, Radiology, 1990)


Q4. 어떤 합병증이 동반되어 있나요?

Local necrosis +/-

infection pseudocyst abscess ascites bleeding

Systemic ARDS hypotension renal GI bleeding DIC metabolic CNS

Mild pancreatitis vs. Severe pancreatitis


Rel

ativ

e In

cide

nce

Onsetof Pain

12 24 36 48 60 72 84 90 Hours

Interventional Window

Interstitial edematous pancreatitis

Necrotizing pancreatitis

4 weeks

Revised Atlanta classification 2012

Acute necrotic collection (ANC) Walled-off necrosis (WON)

Pancreatic pseudocystAcute peripancreaticfluid collection

Sterileor

Infected


Prophylactic antibiotics

Severe pancreatitis and greater than 30% necrosis Quinolone, (Imipenem), for 2 weeks Increased risk of fungal or multi-resistant organisms

Should only be used to treat documented infection

Cause of death in severe AP

Days No. of patients Cause of death

1-10 13 cardiac failure (11)MOF (2)

11-20 3 cardiac failure (1)gangrene of small intestine (1)MOF caused by infected necrosis (1)

21-30 2 MOF (1)cardiac failure caused by infected necrosis (1)

45-153 3 MOF caused by infected necrosis (3)

MOF; multiple organ failure

(Appelros S, Eur J Surg, 2001)

MOF

Infected necrosis2 wk


Management of severe pancreatitis

ICU carehemodynamic monitoring (V/S, U/O, CVP) mechanical ventilation with PEEP

Fluid administrationmaintain pancreatic microcirculationprevent pancreatic ischemic necrosis and organ

failure NPO and TPN or enteral tube feeding Prevention and management of complications

Q5. 치료는어떻게하나요?

Rest NPO for 2-3 days Pain contol


Fluid administration

10~20ml/kg bolus and then 3ml/kg/h infusion for the first 24 hours

Lactated Ringer’s should be used as the fluid of choice

Over-aggressive hydration may worsen the outcome

초기 수액요법이 중요하다


Peipancreatic fluid collection Pseudocyst

Wait and see if no symptom Drainge procedure after 6 weeks in patients with

symptoms (pain, fever, bleeding)

2 D 6 M1 M

Enteral nutrition

• gut-barrier function• ↓ septic complication,

hyperglycemia, catheter related infection

• early start is recommended (<48~72 h)

• occasionally limited d/t ileus, GI intolerance


급성췌장염 의심환자에서 꼭 알아야 할 것!

1. 췌장염이 맞나요? 다른 질환을 꼭 배제해야!

2. 원인이 뭔가요? 원인이 불분명하면 다른 질환 가능성 다시 검토 원인 교정 및 재발 방지

3. 얼마나 심한가요? 치료가 다르다

4. 어떤 합병증이 동반되어 있나요? 사망 원인 – 다발성 장기부전, 괴사, 감염

5. 치료는 어떻게 하나요? 초기 수액, ICU, 항생제(?), 시술 시기 및 적응증

Pancreatic or peripancreatic necrosiswalled-off necrosis Sterile of Infected necrosis

30~50% mortality rate Suspicion

newly developed signs of organ failure

fever after initial response to conservative tx.

gas (+) on CT scan Endoscopic necrosectomy in

organized necrosis (walled-off pancreatic necrosis)

Surgical necrosectomy & lavage


목차 - 삼성서울병원 · 2016-01-26 · department of medicine, samsung medical center...

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