9 월 월례집담회 토픽데이 (In

flammatory Bowel Diseas
e and Mimickers)
연세의대 신촌 세브란스 병원
복부 영상의학과

강사 이진영

CASE 1
• Female, 69 yrs old
• C.C: abdominal pain(onset: 5 days ago)
• Lab finding: non-specific
• PMHx: nonspecific

Arterial phase .

Portal phase .

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• No perienteric infiltration of fat. • Homogeneous wall enhancement on por tal phase. • No ascites or LN enlargement. Case summary • Ileocecal wall and three short segmental ileal wall thickening with bowel dilatatio n. . • Rt omental infiltration and nodules.

Differential diagnosis Relatively Multiple wall Distal ileum homogeneous thickening with with enhancement skip lesion marked narrowing either neoplastic Crohn’s disease Crohn’s disease or non-neoplastic GI GVHD Tuberculous enteritis (more frequent Mesenteric Behcet disease with vasculitis non-neoplastic entities) Tuberculous AIDS related infection enteritis (CMV. actinomycosis) Lymphoma Lymphoma Metastasis Metastasis .

melanoma. no significant lymph node enlargement Metastasis Low possibility due to very rare disease entity. no fibrofatty mesenteric change. multiple short segmental involvement But no tuberculous lymphadenopathy in this case . no fistula formation. breast cancer. no mural stratification Lymphoma Low possibility due to significant obstruction sign. no comb sign. lung cancer Tuberculous enteritis Relatively high possibility due to circumferential wall thickening. cecal involvement. such as mesnteric side ulceration. no history of underlying primary malignant lesion. Differential Possibility diagnosis Crohn’s disease Low possibility due to no typical finding. no pseudosacculation. such as stomach cancer.

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Colonoscopy finding IC valve 직상방 3cm length stenotic lesion of terminal ileum. hyperemia. 조직검사 및 결핵균 검사 . edma 소견 관 찰 . mucosal nodularity.

. Colonoscopy finding Cecurm 의 appendical oriice 주변으로 mild erythema 와 edema 소견 관찰됨 . biopsy 시행시 약간 hard 한 느낌으로 subepithelial lesion 있을 가능성 있겠음 . 조직검사 시행 .

Terminal ileum: Signet ring cell carcinoma in the mucosa and submucosa – B. Pathology report • Colonoscopic biopsy – A. Cecum: Signet ring cell carcinoma in the mucosa and submucosa • 본원 다학제 결론 – Multifocal signet ring cell carcinoma 로 잠정적 추론 .

including the stomach. esophagus and l arge intestine. – Early peritoneal seeding. gallbladder. . genitourinary tract. of small bowel is extremely rare. Less commonly in the rectosigmoid colon. pancreas. Signet ring cell carcinoma of intestine • Involve many organs. • Very poor prognosis. low incidence of liver metastasis • Signet ring cell ca. lung. • But most frequently in the stomach. br east.

• Several case reports – Signet Ring Cell Carcinoma Of The Ileum The Internet Journal of Surgery. 2009 Volume 25 Number 1 • Our case – Multifocal signet ring cell carcinoma in cecal and ileum .

CRP 59.C: 2004 년 Crohn’s disease 진단 받음 . 31 years old • C. 최근 fever.7mg/L . CASE 2 • Female. 계속 외래 F/U 중 . abdominal pain 호소 . 2006 년 본원 전원 .

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Aug 5. 2015 .

. – Comb sign. pseudodiverticulum of small bowel. involving appendix tip. – Multiple enlarged lymph nodes at ileocolic chain. – Prominent inflammatory stricture at distal ileal loop. • Past – Multisegmental asymmetric wall thickening with hyperenhancement in distal ileum. – Severe pelvic fat infiltration. Case summary • Current – Multiloculated abscesses adjacent to thickened distal ileal loop.

Active Crohn’s disease with complicated abscesses formation. 2. 1. Appendiceal tip perforation with periappendiceal abscess. less likely . • DDx. Differential diagnosis • DDx.

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Laparoscopic ileocecectomy cecum Thickned distal ileum ileum loop and Inflammatory lesion .

consistent with Crohn's disease – Appendix: Free of carcinoma . regional (5/17): Metastasis in 5 out of 17 regio nal lymph nodes (pN2a) – Lymphovascular invasion: Not identified – Associated lesions: Mucosal atrophy with histologic evidence of chronic crypt change. Pathology report • ◇ Main diagnosis: Signet ring cell carcinoma with n euroendocrine differentiation (mixed adenomeuroen docrine carcinoma) – Location: distal ileum.9cm – Depth of invasion: Invades subserosa (pT3) – Resection margin : Free of carcinoma – Lymph nodes. pyloric gland metaplasia.9x4. and non-c aseating granuloma. gross type: ulcerative – Size: 5.

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주변 조직이나 장기와 유착 . signet ring cell ca is very rare • 그러나 크론병에서 발생하는 소장암의 경우 산발적인 소장암보다 signet ring cell ca 의 발생 비율이 높다 • Diagnosis of small bowel cancer in Crohn patient – 대부분 다른 이유로 시행한 수술 후 우연히 이루어짐 • 크론병에서 발생한 소장암은 임상양상과 영상검사의 소견이 장관의 비후 . 침범 등으로 크론병과 유사하여 진단이 어렵기 때문 . Small bowel cancer in Crohn’s disease patient • Small bowel cancer in Crohn’s disease patient – 12-60-fold increase in risk of small bowel cancer – Arising from IC valve and stricture segment – Almost adenocarcinoma.

50:51-55 – A Case of Small Intestinal Signet Ring Cell Carcinoma in C rohn’s Disease . fistula formation – Duration of the disease (at least 10 years) – Diagnosis before age 30 years – Male • Case report 대한소화기학회지 2007. Small bowel cancer in Crohn’s disease patient • Risk factor of small bowel cancer in crohn pt – Stricure.

signify presence of carcinom a . Small bowel cancer in Crohn’s disease patient • CT finding suggesting small bowel cancer – Sacculated loop with asymmetric thickening. – Loss of mural stratification – Moderate enhancement after IV contrast – Enlarged adjacent mesenteric lymph nodes – Lack of response in healing of fistula on medical therapy.