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CASE PRESENTATIONGS intern 장규호
Chief complaint
Nausea
Patient ID : 0328635 Sex /Age : F/44
Present illness
44 세 여환 HCV LC 로 현재 본원 GI f/u 중인 자 .
본원 내원 전 E.varix bleeding 으로 수 차례 타병원에서 EVL 시행한 병력 있으며 올해 3 월 본원 GI 입원하여 E. varix, s/p EVL 한 차례 더 시행한 병력 있음 .
퇴원 이후 특이 소견 없이 지내다가 7/29 nu-asea 심해 울산병원 내원하여 DFS 시행하였고 Esophageal varix, Cardiac varix 확인되어 7/30 EVL 시행후 OP 위해입원함 .
Past medical history
HTN/DM/Hep/Tb : +/+/+(HCV)/- Esophageal varix s/p EVL #10 Cardicac varices s/p EVL #2
Social Hx Smoking : (-) Alcohol : (-)
Surgical Hx : Cholecystectomy(07’)
Review of systemGeneral Fever(-), chilling(-), poor oral intake(-), general weakness(-)
Respiratory Cough/sputum/rhinorrhea(-/-/-), dyspnea(-), cyanosis(-)
Cardiovascular Chest pain(-), chest discomfort(-)
Gastrointestinal Abdominal pain(-), RUQ pain(-), diarrhea/constipation(-/-)
Musculoskeletal Myalgia(-), arthralgia(-), paresthesia(-)
Genitourinary Dysuria/frequency/urgency/voiding difficulty (-/-/-/-)
Physical ExamVital sign BP: 115/77mmHg- HR 59 회 / 분 - RR 20 회 / 분 -BT 36.0℃
Mental state: Alert
General appearance Not so ill looking
Body measurements Height : 150.4cm, weight : 45.6kg, BMI : 20.1
HEENT Anemic conjunctiva/Anicteric sclera(-/-)
Chest Symmetric chest wall movement without deformity Clear breathing sounds without crackle Regular heart beat without murmur
Abdomen Soft and distended abdomen(-)Hypoactive bowel sound(-) Tenderness(Murphy sign)/rebound tenderness(-/-), Hepatomegaly/splenomegaly(-/-) Palpable mass(-)
Back/Extremities CVA tenderness(-/-) Pretibial pitting edema(-/-)Joint swelling/tenderness/heating/redness(-/-/-/-) Varicose vein(-), dermopathy(-)
Skin Jaundice(-)
Initial Lab
CBC WBC 17490, Hgb 8.1, PLT 210K, ANC 13030
Chemistry AST/ALT: 40/33 IU/L total/direct bilirubin: 0.2/0.1 mg/dl BUN/Cr.: 12.8/0.73 mg/dl total protein/albumin: 5.5/3.2 g/dl
Electrolyte Na/K/Cl: 139/4.8/108
Cardiac varixEVL(140729)
CT(140731)
Initial Problem list
#1.esophageal varix #2.HCV-LC #3.HTN #4.DM
ADMISSION NOTE
HD 1
#1.esophageal varix S : n-s O : V/S - BP: 115/77mmHg- HR 59
회 / 분 - RR 20 회 / 분 -BT 36.0℃
A : esophageal varix P : Kobayashi OP
Operation(141015) Preoperation diagnosis
Hepatic sclerosis Postoperation diagnosis
HCV/LC Operation(Kobayashi OP)
Paraesophago-gastirc devascularization/ Esopageal R&A/ TV /Pyloroplasty
OP findings liver macronodularity Ascites - mild splenomegaly
POD 1
S : 수술부위 통증 O : V/S - BP: 142/96mmHg- HR 78
회 / 분 - RR 20 회 / 분 -BT 36.4℃ A : esophageal varix P : ICU care, NPO, pain control
POD 3
S : 수술부위 통증 O : V/S - BP: 138/87mmHg- HR 81 회 / 분 - RR 20 회 / 분 -BT 36.3℃ Hgb – 8.1 A : esophageal varix P : transfusion, NPO, pain control
VARIX TREATMENT
1.Endoscpic therapy
definitive treatment of choice for ac-tive variceal hemorrhage Endoscopic variceal ligation (EVL)
it involves placing small elastic bands around varices
Endoscopic sclerotherapy (ES) injection of a sclerosant solution into the
varices
EVL and ES are initially successful in 70 to 100 percent of patients
Gastric varix
Bleeding from gastric varices is diffi-cult to control endoscopically
TIPS may be less effective than surgery Flow through collaterals that feed the
gastric varices often persists after TIPS
2. Management if endoscopic therapy fails
definition of failed treatment for acute variceal hemorrhage Fresh hematemesis or nasogastric aspiration of
≥100 mL of fresh blood ≥2 hours after the start of a specific drug treatment or therapeutic endoscopy
Development of hypovolemic shock A 3-gm drop in hemoglobin (or a 9 percent drop in
hematocrit) within any 24-hour period if no transfu-sion is administered
rebleeding occurs a second time, more defini-tive therapy (TIPS placement or surgery) is re-quired.
Transjugular intrahepatic por-tosystemic shunt
Absolute contraindications heart failure, severe pulmonary hypertension,
uncontrolled systemic infection or sepsis, se-vere tricuspid regurgitation.
Relative contraindications hepatocellular carcinoma, portal vein thrombo-
sis, and severe coagulopathy or thrombocy-topenia
Complications portosystemic encephalopathy, technical com-
plications (eg, cardiac arrhythmias, traversal of the liver capsule), and TIPS stenosis
Surgery
The ideal patient for surgical therapy well-preserved liver function who fails
emergent endoscopic treatment no complications from the bleeding or
endoscopy contraindication to TIPS placement
two basic types of operations shunt operations nonshunt operations
Shunt operations Nonselective (figure A)
decompress the entire portal tree and divert all flow away from the portal system, such as porta-caval shunts
Selective (figure B) compartmentalize the portal tree
into a decompressed variceal system while maintaining sinu-soidal perfusion via a hyperten-sive superior mesenteric-portal compartment, such as a distal splenorenal shunt
Partial Those that incompletely decom-
press the entire portal tree and thereby also maintain some he-patic perfusion
Non-shunt operations esophageal transection (in which the distal
esophagus is transected and then stapled back together after varices have been lig-ated) bleeding can occur from the suture line, and
varices recur after a variable period of time because transection does not treat the portal hypertension.
devascularization of the gastroesophageal junction used in patients who are not candidates for a
shunt operation such as those with extensive portal vein thrombosis with extension into the splenic and superior mesenteric veins
Shunt OP vs non-shunt OP
Shunt OP 술후 간 혈류량 감소로 인한 간부전 간성뇌증
Non-shunt OP 문맥압 감압효과는 없지만 간혈류 유지 가능 술후 간부전이나 간성뇌증 유발하지 않음 재출혈의 위험성이 높음
Sugiura operation
단점 : 1 차 수술 4~6 주 후 2 차 수술이 필요함 1 차 수술의 시간이 오래걸리며 광범위한 devascularization으로 출혈 및 문합부 누출 발생
Kobayashi operation
1.Spleenectomy 2. 복부식도와 위근위부 devascularization & Truncal vagotomy3.EEA stappler 를 이용한 식도절단 및 문합술4.Pyloroplasty
식도정맥류에 대한 Kobayashi procedure
술후 식도정맥류 변화 술후 2~4 주후 식도조영술 시행 정맥류 완전소실 : 23 예중 12 예 현저한감소 : 9 예 약간의변화 : 2 예
원격 추적 조사 술후 3 개월 ~4 년 10 개월까지 추적조사한 21 예 중 2 예 (9.5%) 사망 - 술후 2 개월 - 간성혼수 - 술후 9 개월 - 재출혈 & 간성혼수
재출혈 2 예 (9.5%)- 고식적치료와 경화요법으로 지혈식도협착 -5 예 (23.8%)
식도정맥류의 Kobayashi 술식의 효과
Reference
Uptodate Methods to achieve hemostasis in pa-
tients with acute variceal hemorrhage 식도정맥류에 대한 Kobayashi procedure
외과학회지 vol30, No6, June, 1986 식도정맥류의 Kobayashi 술식의 효과
외과학회지 vol40, No2, February, 1991