입문자를 - 위암과 내시경. endotoday 이준행 · indentations of the esophagus spinal...
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내시경 입문자를 위한 식도 질환
성균관대학교 의과대학 내과 이준행
Mucosa of the normal esophagus
• 대동맥궁과 좌기관지에
의해 형성되는 2 - 3 cm
부위를 통칭
• 25 cm : 대동맥궁
• 27 cm : 좌측기관지
cf> 35 cm : 좌심방
정상식도내경 2.5 cm
Second physiologic narrowing
Indentations of the esophagus
Spinal indentation at 12 o’clock
Indentation by left main bronchus (yellow arrow) Indentation by left atrium
4-6 longitudinal symmetrical folds
Far distal esophagus, Rosette
Phrenoesophageal ligament
Ascending limb
Descending limb
Squamocolumnar junction
Infradiaphragmatic fascia
Diaphragm
Normal esophagogastric junction
PZ
3 cm
Stomach
Esophagus
Esophagogastric junction (EGJ)
= Proximal margin of gastric folds
= Distal end of palisade zone
= Pinchcock action (PCA)
= Squamocolumnar junction
Dynamic nature of EGJ (1)
Dynamic nature of EGJ (2)
Hiatal hernia
http://www.hosppract.com/issues/1998/11/cemitt.htm
Anatomy of sliding hiatal hernia
B-ring
A-ring
Diaphragmatic orfice
Squamocolumnar junction = B-ring
Hernia sac
Diaphragmatic orfice
Ampulla
Paraesophageal hernia
http://www.hosppract.com/issues/1998/11/cemitt.htm
hernia sac ulcer scar
diaphragmatic opening gastric folds
Paraesophageal hernia
Esophageal candidiasis
Esophageal candidiasis
CMV esophagitis, s/p allo PBSCT
CMV esophagitis in immunocompetent host
Herpetic esophagitis during adjuvant chemotherapy for rectal cancer
Herpetic esophagitis
Esophageal TB
Bx: inflammed granulation tissue
Incisor 27 cm
Esophageal tuberculosis: more cases
One or more mucosal
breaks, no longer than
5 mm, that do not
extend between the
tops of two mucosal
folds
Grade A
One or more mucosal
breaks, more than 5
mm long, that do not
extend between the
tops of two mucosal
folds
Grade B
One or more mucosal
breaks, that are
continuous between the
tops of two or more
mucosal folds, but which
involve less than 75% of
the circumference
Grade C
One or more mucosal
breaks, that involve at
least 75% of
the oesophageal
circumference
Grade D
LA classification
LA-A LA-B LA-B
Non-confluent erosions
Non-confluent erosions
LA-A LA-B
무증상 역류성식도염 + sentinel polyp
2년 2년
Confluent erosion and hiatal hernia
LA-D
Sentinel polyp (F/35, asymptomatic)
Sentinel, n [C] esp. old use or literary a person
employed to guard something
Sentinel polyp - detected during screening endoscopy
March 2004 March 2005
Sentinel polyp
AGC (PM cancer) mimicking sentinel polyp
EG junction in hiatal hernia
Ampulla
Gastro-esophageal junction
A-ring= muscular ring
B-ring= mucosal ring
Diaphragm
PZ
Normal Barrett esophagus Hiatal hernia Hiatal hernia + BE
Choi DW. Korean J Gastroenterol 2002;17:245-248
Palisade zone for the diagnosis of BE
Length of Barrett esophagus
M (cm)
C (cm)
• M: maximum length
• C: circumference
length
• 표기 예: C3M5
Barrett esophagus
Barrett esophagus
Long segment Barrett’s esophagus - a caucasian
2 years later
Barrett esophagus
Barrett adenocarcinoma (sm1 invasion)
Proximal end of the gastric fold
Squamocolumnar junction
adenocarcinoma
식도 SMT - no change for 7 years
2003 2010
Granular cell tumor of the esophagus
Granular cell tumor of the esophagus
Esophageal SMT - lipoma
Esophageal carcinoid
Esophageal SMT with calcified rim - r/o duplication cyst
Esophageal papilloma
Esophageal papilloma
Esophageal papillomatosis
Zenker’s diverticulum (M/62)
Mid-esophageal diverticulum
Esophageal foreign body
Esophageal foreign body - 굴껍질
Press-through pack (PTP)
Alkaline corrosive esophagitis
Lye stricture
Esophageal cancer after lye stricture
Invasive SCC (M/D), 2x1.8 cm, PM, 0/24
식도암의 내시경 진단
성균관대학교 의과대학 내과 이준행
맨 위와 맨 아래를 주의해야 합니다.
Cervical esophageal cancer - 한달 전 내시경 검사를 받으셨다고 하는데…
EG junction cancer (M/D adenocarcinoma) - ESD 의뢰되었으나 수술 보냄, SM1 cancer 나옴
표재성 식도암의 내시경 소견
• 점막의 혼탁과 조잡
• 혈관망의 변화 혹은 소실 (점막하 혈관상의 소실)
• 점막 발적
• 융기성 병변 (높을 수록 심달도는 깊어짐)
• 함몰성 병변
• 식도의 비 정상적인 연동운동 (고유근층으로의 침범및 종괴형성)
Early esophageal cancer 0.7 cm - ESD was performed
Mucosal cancer (LP), 1.7 cm
Esophageal ESD - M/D squamous cell carcinoma (M2)
EEC, LP암 9 cm - 외부에서는 Lugol void area가 없다고 되어 있었는데…
Risk of lymph node metastasis in EEC - a single center experience at Samsung Medical Center (n=197)
Kim. J Gastroenterol Hepatol 2008;23(4):619-625
Kodama. Surgery 1998;123:432-439
Risk of lymph node metastasis in EEC - a multicenter study in Japan (n=1740)
표재성 식도암의 growth pattern
M3, early esophageal cancer
M3, 2.1cm, lymphatic (+), LN 2/52
Esophageal cancer - 2 mm cancer의 ESD를 위해 의뢰되었으나 … 수술 보냄 - 2x1.5cm, M/D SCC, muscularis mucosa로 나옴 ESD 안 하길 잘함
Early esophageal cancer type I - endolymphatic tumor emboli (+), LN 2/40
EEC, SM, LN (+)
Early esophageal cancer (SM3) - endolymphatic tumor emboli (+), LN (-)
젊은 여성 식도암 - SM cancer. LN (+) 1/42
Early esophgeal cancer - 2.4cm, SM invasion, LN (+) 2/46
Advanced esophageal cancer (M/71) - 3.5 cm, extension to adventitia, LN 0/59
Advanced esophageal cancer - extension to perimuscular adventitia, LN 3/62
식도암 + 위암
Esophageal cancer with liver mets
Esophageal melanoma - 식도 수술 후 간 전이
식도암인가 위암인가?
답: squamous cell carcinoma
식도암인가 위암인가?
답: squamous cell carcinoma
식도암인가 위암인가?
답: signet ring cell carcinoma
위암 후 식도암 / 식도암 후 위암
성균관대학교 의과대학 내과 이준행
EGC after Ivor Lewis operation
Esophageal cancer s/p STG for EGC (M/70)
• 2002. 5. 20. Subtotal gastrectomy
– Adenocarcinoma (W/D), intestinal type
– 1.6x1.6 cm, muscularis mucosa, RM (-) 0/36
• 2002. 9. 1st follow-up EGD
• 2004. 1. 2nd follow-up EGD
• 2005. 1. 3rd follow-up EGD
• 2005. 6. 4th follow-up EGD: 식도암
Esophageal cancer after surgery for EGC
Esophageal cancer after surgery for EGC
Invasive squamous cell carcinoma (M/D), 2.1x1.4 cm, extension to PM, RM (-), 0/24
식도암 수술 4년 후 incisor 40cm 위암
2.5cm SM cancer
식도암 ESD 3년 후 위암
내시경 실력을 키워서 환자에게 봉사합시다.