1. Case presentation 소화기내과 R1 손주웅 / Prof. 동석호

2. 김 O 덕 (M/45) 11532169 adm : 07.10.10  C.C : Abd. pain o/s) 내원 약 3 주전  Present illness  6 개월 전부터 2 형 당뇨병으로 치료받아오 던 자로 내원 전 6 개월간 6kg 의 체중감소가 있었으며, 3 주 전부터는 복부와 등에 통증 이 발생하였고 점차 심해지는 양상보여, 내 원 5 일전 개인의원에서 치료 받았으나 증상 호전 없어 응급실 통해 내원함

3.  Past medical history DM/HTN/Hepatitis/Tbc (+/-/-/-) medication : metformin 500mg tid glimepiride 3mg bid Op Hx (-)  Family history none  Personal history alcohol (+) : 소주 1 병 /day, 07 년 5 월부터 quit smoking (+) : 30pack/years

4. Review of Systems  General : Fatigue(-), Wt. loss(+):6 개월 6kg  Skin : Rash(-), Pigmentation(-)  H & N : Headache(-), Neck stiffness(-)  Respiratory : Cough(-),Sputum(-),Dyspnea(-)  Cardiac : Chest pain(-), Orthopnea(-)  Gastrointestinal : A/N/V/D/C(-/-/-/-/-), Steatorrhea(-) Abd. pain(+):LUQ, Jaundice(-)  Renal & Urinary: dysuria (-), hematuria(-)  Musculoskeletal: Myalgia(-), back pain(+)  Nervous : Syncope(-), Seizure(-)

5. Physical examination  V/S : 110/90mmHg-70/min-20/min-36.3 0 C 1.General : Alert mentality Acute ill-looking appearance 2.Skin : No rash, No pigmentation Skin turgor : intact 3.Head & Neck : No lymph node enlargement No neck vein engorgement 4.Eye & ENT : Isocoric pupil with PLR(++/++) Whitish sclera, pinkish conjunctiva

6. Physical examination 4.Thorax : Clear breathing sound without rale Regular heart beat without murmur 5.Abdomen : Soft & flat Normoactive bowel sound Tenderness(+) :LUQ Rebound tenderness(-) 6.Back&Extremitiey: CVA Td(-/-) Pretibial pitting edema (-/-) 7.Neurology : Sensory : intact, Motor : intact

7. Initial Problem list 1.Abd. pain 2.Back pain 3.Weight loss 4.Type 2 DM

8. Initial assessment & plan #1. Acute pancreatitis r/o gastric ulcer r/o GI malignancy P) Amylase, Lipase Abd. CT Gastroscopy, Colonoscopy EUS Tumor marker

9. Lab finding  CBC/DC 10950/mm 3 -15.6g/dL-45.8%-248K/mm3 (seg : 60.8%) INR 1.04 aPTT 37.1  Chemistry TB/DB 0.41/0.11 mg/dL AST/ALT 20/35 U/L ALP/rGT 88/40 U/L Prot./Alb 7.2/4.7 g/dL Glucose 244 mg/dL BUN/Cr 11/0.8 mg/dL LD/CK 300/41 U/L Na/K/Cl 136/4.0/104 mmol/L CRP 0.6 mg/dL

10. Lab finding  Chemistry Amylase 61 U/L Lipase 5 U/L  Tumor marker CEA 6.28 ng/mL CA 19-9 >12000 U/mL

13. Echoendoscope GF-UCT2000, Olympus, Tokyo, Japan

16. EUS guided FNA

17. Pathology

19. Bone scan

20. L-spine MRI

21. Treatment plan #1. Pancreatic ca. with liver meta.  chemotheraphy  gemcitabine  pain control  Morphine  EUS guided Celiac plexus block

22. Clinical course Celiac plexus block 2007-10-23 gemcitabine iv morphine 40mg tid 로 discharge mg

23. Celiac plexus block JOP 2004;5(4):315-21

24. Final diagnosis #1. Pancreatic ca. with liver meta. #2. Type 2 DM

25. 최 O 상 (M/79) 10844585 adm : 07.10.1  C.C : known pancreatic cyst  Present illness  평소 특이병력 없이 지내던 환자로 2007 년 7 월 본원 외과에서 Hemorrhoidectomy 시행 하였고 당시 시행한 Abd. CT 에서 pancreatic cyst 발견하여 evaluation 위해 내 원.

26.  Past medical history DM/HTN/Hepatitis/Tbc (-/-/-/-) Op Hx (+) : hemorrhoidectomy (07.7 월 )  Family history none  Personal history alcohol (-) : 소주 1/2 병 주 3~4 회 10 년전 stop smoking (-)

27. Review of Systems  General : Fatigue(-), Wt. loss(-), Fever(-)  Skin : Rash(-), Pigmentation(-)  H & N : Headache(-), Neck stiffness(-)  Respiratory : Cough(-),Sputum(-),Dyspnea(-)  Cardiac : Chest pain(-), Orthopnea(-)  Gastrointestinal : A/N/V/D/C(-/-/-/-/-), Abd. pain(-)  Renal & Urinary: dysuria (-), hematuria(-)  Musculoskeletal: Myalgia(-),Weakness(-), back pain(-)  Nervous : Syncope(-), Seizure(-)

28. Physical examination  V/S : 100/60mmHg-72/min-20/min-36.3 0 C 1.General : Alert mentality Not so ill-looking appearance 2.Skin : No rash, No pigmentation Skin turgor : intact 3.Head & Neck : No lymph node enlargement No neck vein engorgement 4.Eye & ENT : Isocoric pupil with PLR(++/++) Whitish sclera, pinkish conjunctiva

29. Physical examination 4.Thorax :Clear breathing sound without rale Regular heart beat without murmur 5.Abdomen : Soft & flat Normoactive bowel sound Td(-), RTd(-) Palpable mass (-) 6.Back & Extremitiey: CVA Td(-/-) Pretibial pitting edema (-/-) 7.Neurology : Sensory : intact, Motor : intact

30. Lab finding  CBC/DC 9000/mm 3 -15.8g/dL-46.2%-245K/mm3 (seg : 71.1%) INR 1.03 aPTT 34  Chemistry TB/DB 0.75/0.17 mg/dL AST/ALT 17/14 U/L ALP/rGT 95/22 U/L Prot./Alb 6.1/3.4 g/dL Glucose 92 mg/dL BUN/Cr 9/0.8 mg/dL Amylase 104 U/L LD/CK 297/49 U/L Na/K/Cl 137/3.7/104 mmol/L CRP <0.5 mg/Dl  Tumor marker CEA 1.65 ng/mL CA 19-9 <2 U/mL

31. Abd. CT

32. Initial assessment & plan #1. Pancreatic cyst r/o pancreatic pseudocyst r/o intraductal papillary mucinous tumor P) EUS guided FNA

34. Analysis of cystic fluid  Viscosity : mucous  CEA : 1.56 ng/mL  Amylase : 75 U/L

35. Pathology

36. Final diagnosis Intraductal papillary mucinous tumor