대한소화기내시경학회
제 88회 집담회
Interesting small bowel lesions
2010.6.15.
인하대병원 소화기내과
전임의 정현정
Welcome to our hospital!!!
Case : M/46, hematochezia
Chief Complaint :
Hematochezia
Present Illness :
30여년 전 폐결핵으로 완치판정, 1986년 오목가슴으로
수술한 과거력이 있는 자로, 내원 당일 8시간전부터 발생
한 복통과 혈변 (3~4차례, 300~400cc)으로 응급실 내원
Past History : DM/HTN/TB/Hepatitis (-/-/+/-)
-- old TB, 완치
Social History : Alcohol/smoking (-/-)
occupation : FM doctor
Past & Current Medical History :
OP – pectus excavatum 으로 OP (1986년)
BPH (+) - Tamsulosin(Harnalⓡ)
recurrent oral ulcer - dexamethasone gargle
NSAIDs 간헐적 복용
Review of Systems
general weakness (+)
headache (-)
dizziness (+)
palpitation (-)
dyspnea (-)
DOE (-)
abdominal pain/discomfort (-/-)
hematemesis/melena/hematochezia (-/-/+)
Physical Examination
v/s 100/72 mmHg – 102/bpm – 20/bpm – 36.5℃
m/s alert
acutely ill-looking appearance
anemic conjunctivae (+)
chest : clear breathing sound without rale
abdomen : normoactive bowel sound
no tenderness/rebound tenderness
not palpable mass
Laboratory test
CBC 10360 - 10.2 – 30.6% - 268K
* Hb change : 10.2 – 8.0 – 5.2 g/dL
PT(INR) 1.00
aPTT 33.3 sec
ABGA 7.39 - 37- 85 – 22 – 96%
Total protein / albumin 7.0/3.9 g/dL
AST/ALT 19/16 IU/L
BUN/Cr 19.1/0.87 mg/dL
EGD – HD#1
Abdomen CT – HD#1
S.M.A Angiography –HD#1
Colonoscopy –HD#2
Enteroscopy HD#2
Enteroscopy – HD#2
Medical progress
HD#1 (Friday) :
1.Hb change : 10.2→8→6.2 g/dL
 p-RBC 6u 수혈 후 10.1 g/dL로 상승
2.Procedure
emergency duodenoscopy  abdomen CT
 angiography
3. ICU admission
Medical progress
HD#2 (Saturday) :
1.Hb : 10.1→8.7→6.2 g/dL까지 하강
RBC : p-RBC 2u transfusion, 지혈후 추가
수혈 없이 8.2 g/dL 까지 상승, 유지
2.Procedure
colonoscopy (fresh blood in terminal ileum)
 small bowel enteroscopy  Hemostasis
by clipping
Medical progress
• 이후 stable vital sign, Hb 보여 ward
transfer
• F/U bleeding : capsule endoscopy 
negative 소견 보여 discharge
Final Diagnosis
#1. Ileal Dieulafoy’s lesion bleeding
#2. r/o Bechet’s disease
#3. r/o NSAID induced erosion
Review
• Obscure GI bleeding
– approximately 5 % of GI bleeding
– diagnostic & therapeutic yield of enteroscopy
(PE & DBE): 12~80%
cf. capsule enteroscopy(CE)
- diagnostic yield 45~80%
J. Westerhof et al. Netherlands J Med 2009;67(7):260-65
• Dieulafoy lesion
– 1.5% of UGI bleeding
– injection therapy (75%) vs mechanical method (92%)
J. Regula et al. Best Pract Res Clin Gastroenterol. 2008;22(2):313-28.
Review
Okajaki H. et al. J Gastroenterol ; 2009 (44):550–555
Review
Small bowel Dieulafoy bleeding
case reports in Korea
SJ Boo. et al. Korean J Gastrointest Endosc 2010;40:157-163
Thank you for your attention!!