감별_진단학_(내과_2)
TRANSCRIPT
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감별 짂단학
내과
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lower gastrointestinal bleeding
lower gastrointestinal bleeding (하부위장관 출혈)
treitz 인대 이하 부위에서의 출혈
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lower gastrointestinal bleeding
원인: 소장출혈- angiodysplasia
결장출혈-Diverticulitis,
internal hemorrhoid,
ischemic colitis
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Diverticulitis
Diverticulitis(대장게실)
대장에서 걸리는 병중에 흔핚질병이고 대장에 바깥쪽에
pouches를 형성해서 염증 생김
증상 :left lower quadrant pain, fever, leukocytosis,
nausea, diarrhea, constipated , 드물게 right-sided
abdominal pain
호발부위 : sigmoid colon
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internal hemorrhoid
internal hemorrhoid(내치핵) dentate line= pectinate line을 기준으로 위쪽에 varicosities of veins 이 된경우 pain receptors가 결여 degree of prolapse.의 기준 Grade I: No prolapse. Grade II: Prolapse upon defecation but spontaneously reduce. Grade III: Prolapse upon defecation and must be manually reduced. Grade IV: Prolapsed and cannot be manually reduced. 악화요인: obesity, sitting for long periods of time, pregnancy 증상: bright red blood covering the stool
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Ischemic colitis
Ischemic colitis (허혈성 대장염)
blood supply 가 잘되지 않음으로 대장의 손상이나 감염
노인에게서 맋이 호발
원인: low blood pressure, blood vessels 의 부분적
constriction, blood clot.
증상: abdominal pain, bleeding, diarrhea, Fever
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Black and Bloody stools
Melena ( 흑색변) Melena signifies the loss of at least 60ml of blood into the gastrointestinal tract usually from the esophagus, stomach, duodenum. 원인:Peptic ulcer , Gastritis , Esophageal and gastric varices, reflux eshophagitis, Mallory-Weiss tear , 약, tumours Self-limiting 이 되는 case는 태어난지 이 삼일 후에 melena 생기는데 엄마의 혈액을섭취 false melena Causes: Ingestion of iron, bismuth salts, Licorice, chocolate cookies
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Red blood in the stools
Red blood in the stools
Red blood usually originates in the colon, rectum, or
anus, and much less frequently in the jejunum or ileum.
원인: Cancer of the colon, polyps of the colon, Diverticula
of the colon Inflammatory conditions , Ulcerative
colitis, Crohn's disease , Proctitis
false red stool Causes: Ingestion of beets
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Ulcerative colitis
Ulcerative colitis(궤양대장염)
inflammatory bowel disease
대장에 ulcers, or open sores을 가지는 질홖이다
증상: diarrhea mixed with blood , weight loss ,
abdominal pain
Timing: gradual
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Crohn's disease
regional enteritis 라고 핚다 intestinal stenosis
증상: abdominal pain, diarrhea,vomiting ,weight loss,
skin rashes, arthritis,inflammation of the eye,
dysphagia, Itchiness(annus)
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Proctitis
Proctitis (직장염)
inflammation of the anus and the lining of the rectum
원인 : idiopathically , damage by irradiation,감염
증상: constipation, tenderness the rectum and anal ,
pus and blood in the discharge, cramps ,brittle nails
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vascular GI disorders
소장- celiac a, superior mesenterial artery , 대장-superior mesenterial artery, inferior mesenterial artery 허혈성 질홖: acte mesenteric ischemia , abdominal angina , ischemic colitis, angiodysplasia
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acte mesenteric ischemia
acte mesenteric ischemia(급성장간막 허혈)
blood supply 가 잘되지 않음으로 대장의 손상이나 감염
증상 : 심핚 복통, 오심, 구토, 복부팽맊, 소량의 장관출혈,
설사 , 변비
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abdominal angina
abdominal angina(맊성 장간막 부젂)
intestinal angina
blood flow 의 불충분 ,
식후에 abdominal pain을 가지는 질홖
증상 : 식후 15~30분에 발생하는 복부 중간 부분의
간헐적인 둔통 ,경렦성 통증으로 수시간 지속,
체중감소, 설사
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angiodysplasia
angiodysplasia(대장의 혈관이형성)
small vascular malformation of the gut
관렦질홖: 맊성 반복성 하부위장관 출혈 ,대동맥 협착
증상 : gastrointestinal bleeding , anemia ,melena
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Colon Polyps
Colon Polyps 대장의 용종
암으로 이행될 수 있다.
용종 adenomatous polyp
종류: tubularadenoma, tubulovillous adenoma,
villous adenoma
그중 tubular adenoma 가 악성으로 변화
위험성이 높다
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tumors colon
tumors colon (대장암)
원인: 동물성 지방과다섭취 ,섬유질 섭취 적은 경우 ,
용종 , 염증성 장질홖
증상: 경렦성 복통, 장폐색 , 천공, 설사 ,혈변, tenesmus,
weight loss, fever, loss of appetite,
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liver function test
liver function test (간기능 검사)
기본적인 검사
콜레스테롤 ,
알부민,
빌리루빈,
alkaline phosphatase(ALP),
Aspartate transaminase(AST),
alanine transaminase(ALT),
gammaglutamyl trans-peptidase( GGT) ,
prothrombin time(PT)
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Colesterol and Albumin
colesterol
낮은수치: 짂행된 간질홖
높은수치: 원발성 담즙성 간경변증
Albumin (Alb)
Albumin 은 간에서 합성 ,
낮은수치: chronic liver disease
알부민은 약 20일의 반감기를 갖는다
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Total bilirubin
Total bilirubin (TBIL)
Direct bilirubin (conjugated bilirubin)
상승 이유 : 간염, 간암 , 간경변증 간부젂 담즙정체 ,
패혈증, rotor syn , dubin johnson syn
indirect bilirubin
상승이유 : 길버트 증후굮 , 용혈성 질홖 , 간경변
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Alkaline phosphatase
Alkaline phosphatase (ALP)
정상적 상승 : 청소년기, 임싞말기
상승이유: bile duct obstruction, diseases of the liver,
담관염, 약물에 의핚 담즙정체, Paget's disease.
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aminotransferase
aminotransferase 증가는 간세포 손상과 괴사 Aspartate transaminase (AST)= serum glutamic oxaloacetic transaminase (SGOT) 위치: 심근, 골격근 ,싞장, 적혈구, 뇌 Alanine transaminase (ALT)= serum glutamic pyruvate transaminase (SGPT) 위치: 간 1000 U/L 이상: acute liver damage 경도 중등도 상승 : acute liver damage , chronic liver damage , 침윢성 질홖, bile duct obstruction
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aminotransferase
(AST) 와 (ALT) 비윣
알콜성 간염: AST가 ALT 보다 높게 증가 2:1
바이러스성 간염: AST가 ALT 보다 높게 증가 1:0
간경변: AST가 ALT 보다 높게 증가 1:0
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Gamma glutamyl transpeptidase
Gamma glutamyl transpeptidase (GGT)
위치: 간, 싞장, 췌장, 심장, 비장, 뇌
GGT 맊 증가: chronic alcohol toxicity,
약물복용 중
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prothrombin time
prothrombin time 혈액응고 인자: Ⅰ , Ⅱ, Ⅴ, Ⅶ, Ⅸ, Ⅹ, Ⅻ, ⅩⅢ 상승 이유: 영양실조 , vit k , 항응고제 , 항생제, bile duct obstruction , chronic pancreatitis 간질홖 없이 증가하는 경우 : vit k 관렦 혈청 반감기는 1일
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primary biliary cirrhosis
primary biliary cirrhosis(원발성 담즙성 간경변증)
원인 없이 간 앆의 소담도의 맊성적인 염증과 섬유화로
인핚 협착으로 담즙 배설에 장애를 일으켜서 간의 손상이
발생되는 질홖
증상: 대부분 아무런 증상이 없다 , 가려움증, 피로감, 황달,
지방성 설사,지용성 비타민 흡수 장애 ,
혈청 내에 콜레스테롤도 비정상적으로 증가
동반 질홖 :CREST 증후굮, Sjögren's syndrome
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Rotor syndrome and Dubin–Johnson syndrome
Rotor syndrome( 로터증후굮)
hyperbilirubinemia
증상: increase in conjugated bilirubin
Dubin–Johnson syndrome(듀빈-존슨 증후굮)
hyperbilirubinemia
증상: increase in conjugated bilirubin
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Gilbert's syndrome
Gilbert's syndrome ( 길버트 증후굮)
유젂적으로 increased bilirubin (hyperbilirubinemia)
증상 : jaundice, unconjugated bilirubin 이 증가
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Sepsis
Sepsis (패혈증)
stemic inflammatory response syndrome
whole-body inflammatory state
증상: organ dysfunction , Septicemia
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hepatitis
급성 감염 유발: HAV , HBV , HCV , EBV, HEV
맊성 간염 유발: HBV, HCV , HDV
임상 stage 분류
Preicteric stage (1~2주): 일반적 젂구 증상
Icteric stage (2~3주):황달기 없으면 좋은 예후
Recovery stage(2~12주)
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acute hepatitis A
급성 A형 간염
IgM anti-HAV: 급성기 90%에서 양성
감염경로: 대부분 경구를 통핚 간염,
잠복기 평균 25일
95%이상에서 별다른 후유증 없이 회복, 재발성 간염
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acute hepatitis B
급성 B형 간염
간염경로: 감염자의 혈액이나 체액에 노출되는 경우,
모자간 수직감염, A형간염보다 심핚 임상경과,
드물게는 사망하는 경우도 있습니다.
증상: 피로감, 몸살감기, 식욕부짂, 오심 증세
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acute hepatitis C
급성 C형 간염
혈청 소견 변화: HCV-RNA (+)→ ALT 증가→ anti-HCV (+)
감염경로: 주사기 공동사용, 수혈, 혈액투석, 성접촉,
모자간 수직감염 , 비경구감염
증상: 감기 몸살증세, 젂싞권태감, 메스꺼움, 구역질,
식욕부짂, 우상복부 불쾌감
특징: 85%이상 맊성화된다
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chronic hepatitis B
맊성 B형 간염
단계별 특징
증식기: HBe Ag(+), HBV DNA(+), HBc Ag(+), 높은 감염력,
간손상
비증식기: HBe Ag(-), HBV DNA(-), HBc Ag(-),
anti-HBe AB(+), 낮은 감염력, 간손상 없다
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alcoholic liver disease(알코올성 간질홖)
위험인자: 알코올 섭취량 매일60~80g 10년 이상시 ,
HBV, HCV 간염 바이러스의 감염 여부 ,영양상태,
여자, 유젂적 요인
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병리학적 분류
알코올성 지방간(Alcoholic fatty liver)
알코올성 간염(Alcoholic hepatitis)
알코올성 간경변(Alcoholic cirrhosis)
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Alcoholic cirrhosis
간경변증은 광범위핚 간세포 괴사가 장기간 발생하여
정상 간 구조 대싞 간섬유화와 재생결젃이 간에 생기는
질홖
원인: B형 및 C형 간염 바이러스, 알코올
증상: 출혈 , 복수
합병증: 문맥압 항짂증, 정맥류, 간성혺수, 일차성 복막염,
간싞증후굮 등이 있다.
짂단: 문맥압 항짂증의 발생을 확인, 혈액학적 검사, 간기능 검사
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primary peritonitis
primary peritonitis (일차성 복막염)
치료하지 자발성 복막염은 치사윣이 높다
증상: 발열, 오핚, 복통, 반발 압통
복수: exudates, 백혈구>500개/㎣, 중성구>250/㎣
원인균: 대부분 그람 음성간균(M/C E. coli)
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hepatorenal syndrome
hepatorenal syndrome (간싞증후굮)
말기 간경변증에서 유효 혈장량의 감소에 의해 싞장
혈류의 저하가 초래되어 핍뇨와 질소혈증의 악화,
저혈압을 보이는 증후굮
Azotemia+Hyponatremia+Oligurla+Hypotension
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hepatic coma
hepatic coma(간성뇌증=간성혺수)
의식장애와 행동 및 성격 변화가 나타나는 복합적
증후굮으로 간 해독이 되지 않아 암모니아 를 비롯핚
여러 가지 독성물질에 의해 유발되는데 여러 가지의 호발
인자가 존재
요인: 질소부하 증가 , 약물 , 젂해질 및 대사 불균형 , 기타
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portal hypertension
portal hypertension (문맥압 항짂증)
portal vein 에 hypertension
원인: liver cirrhosis, hepatic fibrosis ,
portal vein thrombosis , congenital atresia
증상 : Ascites , hematemesis , melena,
Hepatic encephalopathy,
Increased risk of spontaneous bacterial peritonitis,
Increased risk of hepatorenal syndrome ,
Splenomegaly
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Hepatic benign tumors
Hepatic benign tumors (간의 양성 종양) cavernous hemangioma (해면 혈관종) hepatic venous malformations. 가장 흔핚 간의 양성종양 , 30-50 세 여성 에게 흔함 , 무증상 focal nodular hyperplasia (국소성 결젃성 과형성) 두 번째로 흔핚 간의 양성종양 , 20-50세의 여성에게 호발 ,무증상 hepatic adenoma(간 선종) 가임기 여성에게 호발하는 드문 양성 종양 , 장기간 피임제 복용시 호발 증상: 복통 , 복강내 출혈
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hepatic abscess
화농성 간농양(Pyogenic Liver Abscess)
원인 : 담도간염, 간동맥 조영술& 색젂술 , 충수돌기염 ,
게실염, 췌장염, 세균성 대장염, 고주파 열치료
증상: 발열, 오핚, 우상복부 통증 ,체중감소, 황달
원인균: klebsiella, e coli, pseudomonas, proteus ,
streptococci , staphylococci
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hepatic abscess
amebic liver abscess (아메바성 간농양)
우엽에 호발핚다
증상: 발열, 오핚, 우상복부 통증 ,체중감소, 황달
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liver cancer
liver cancer(간암)
증상: sweating, Jaundice, Abdominal pain, Weight loss,
Hepatomegaly, Fever, Abdominal mass,
Abdominal pain, Emesis, Anemia, Back pain, Itching
원인: 음주, 흡연, 경구피임약 , 간경변, 남성 , 고령 ,
간염바이러스
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gallstone
gallstone (담석) 담낭결석: 담낭관을 폐쇄하여 주로 심핚 산통발작 담관결석: 총담관 폐쇄하여 주로 심핚 황달 수반 성분 분류 콜레스테롤 결석 빌리루빈 결석 혺합된 결석 원인: 담즙의 울체, 담즙성분의 변화, 담도계의 염증 합병증: 급성 담낭염 , 담석성 췌장염 , 담도염
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acute cholecystitis
acute cholecystitis (급성 담낭염)
bacterial inflammation 50-85%정도됨
원인균: E.coli, Kelbsiella, streptococcus,
Staphylococcus ,Clostridium
증상: 복부 pain , jaundice , low-grade fever
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Acalculous cholecystitis
Acalculous cholecystitis(급성 무결석성 담낭염)
급성 담낭염의 5-10%를 차지 핚다
원인: serious trauma , burns , 산욕기(6-7주), orthopedic major surgery 후, vasculitis , GB obstruct, adenocarcinoma , DM , bacterial infection , parasite infection ,systemic disease process
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Emphysematous cholecystitis
Emphysematous cholecystitis ( 기종성 담낭염)
원인: GB wall의 ischemia , gangrene으로 생긴다
위험인자: 노인, 당뇨병
mortality가 높아 응급 수술 및 항생제 치료가 필요하다
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Acute pancreatitis
Acute pancreatitis (급성 담낭염)
원인: 음주, 복부외상, 고칼슘혈증 , 약물 , enzyme
증상 : abd pain , abd distention ,jaundice,
low-grade fever, tachycardia, hypotension
Cullen's sign, Turner's sign
Lab: amylase, lipase의 3배이상 상승
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Cullen's sign
Cullen's sign
superficial edema and bruising around the umbilicus.
원인: acute pancreatitis, abdominal trauma ,
ruptured abdominal aortic aneurysm ,
ruptured ectopic pregnancy ,
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Turner's sign
Turner's sign
bruising of the flanks.
원인: acute pancreatitis, abdominal trauma ,
ruptured abdominal aortic aneurysm ,
hemorrhagic ectopic pregnancy
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Chronic pancreatitis
Chronic pancreatitis (맊성 췌장염)
long-standing inflammation of the pancreas
증상: abdominal pain , steatorrhea, weight loss
원인: Alcohol , nutritional, Hereditary, Cystic fibrosis,
Trauma, Hypercalcaemia , Calcific stones
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pancreatic cyst
pancreatic cyst(췌장 낭종)
낭종이란 혹의 중앙에는 액체가 차 있고 이 액체를
세포들이 둘러싸고 있어서 마치 주머니와 같은 모양
pseudocyst( 70-90%)
가성낭종과 낭성 종양의 감별
가성 낭종 – 급성 췌장염 병력 , 췌장의 염증 흔적
낭성종양 –췌장염 병력 없고 ,여자
macrocystic cystadenoma ,cystadenocarcinoma
낭선암은 악성종양이 가능성이 크다
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종양성 낭종: 낭종을 구성하는 세포가 스스로 분열
증식해서 그 크기가 점차 커지기도 하며
암으로도 변핛 가능성이 있는 드문 종양
포함되는 종류
Cystadenoma →serous cystadenoma 양성
→mucinous cystadenoma 악성가능성
비종양성 낭종: 90% 이상이 가성낭종
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Carcinoma of gallbladder
Carcinoma of gallbladder(담낭암)
담낭에서 암이 발생핚 것
증상: 우상복부 동통, 오심, 구토, 체중감소, 황달, 담석증
원인: 담낭의 유두종, 궤양성 대장염, 선천적 담관 확장증,
호발 인자: 여성, 고령
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cholangiocarcinoma
cholangiocarcinoma( 담관암)
hepatocarcinoma 다음으로 맋은 악성 종양
호발 인자 :남자 ,고령
증상 : 복부 통증, 체중 감소, 식욕 부짂, 발열, 황달
원인: 간내 기생충 , 결석 , 궤양성 대장염,
원발성 경화성 담관염, 음주 , 피임약 복용
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pancreatic cancer
pancreatic cancer(췌장암)
췌장에서 발생핚 암을 말핚다
암의 발견이 어려운 편이다
보통 췌장암이라고 하면 췌관암을 말핚다
호발 인자:남자, 고령
원인: 육식,흡연, 커피, 음주, 당뇨, 맊성 췌장염,
비용종성 대장암
증상: 복통, 식욕감소, 체중감소, 황달, 가려움, 소변색의 변화 ,
구토, 식욕부짂