입문자를 - 위암과 내시경. endotoday 이준행 · indentations of the esophagus spinal...

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.