단일 의료기관에서 경험한 자발성 장벽내 혈종 14예에 대한 임상적 고찰
Clinical characteristics of spontaneous intestinal intramural hematoma: a single-center experience
1
조회
0
다운로드
3
인용
0
참고문헌
키워드
초록
목적: 자발성 장벽내 혈종은 대부분 항응고 치료의 드문 합병증으로 발생하며, 최근 항응고제 사용 증가로 이 질환의 빈도도 증가할 것으로 추정된다. 저자들은 자발성 장벽내 혈종의 임상적 특징과 예후에 대해 분석하고자 하였다. 방법: 2001년 3월부터 2009년 2월까지 서울아산병원에서 특징적 CT 소견으로 자발성 장벽내 혈종으로 진단 후 치료받은 14예의 의무기록을 후향적으로 분석하였다. 결과: 환자들의 연령 중앙값은 67세였고, 심방세동, 심장 판막 치환술, 허혈성 뇌졸중 등의 동반 질환을 가지고 있었으며, 모두 항응고제를 복용하고 있었다. 발현 증상은 복통(14명), 구역/구토(9명), 흑색변/혈변(8명) 등이었다. 내원 시 international normalized ratio (INR)의 중앙값은 7.7 (1.6~15.1 이상)이었고, 13명(93%)에서 INR이 3.5 이상이었다. 하행결장에 발생한 1예를 제외하고 모두 소장에 발생하였는데, 공장 및 회장이 각각 7명, 4명으로 호발 부위였다. 금식 및 항응고제 중단, 신선동결혈장과 비타민 K 투여를 통한 응고장애 교정 등 보존 치료로 모두 호전되었다. 증상 호전과 응고장애 교정 후 12명에서 항응고 치료를 재개하였고, 평균 37.4개월의 추적 기간 동안 재출혈 등 합병증은 발생하지 않았다. 결론: 자발성 장벽내 혈종은 주로 항응고제 과다 사용 시 발생하였고, 보존 치료로 빠르게 호전되었으며, 항응고 치료 재개 후에도 재출혈 등의 합병증은 없었다. 추후 대규모 연구를 통해 항응고 치료 재개의 안전성 및 재개 시점에 대한 확인이 필요하다.
Abstract
Background/Aims: Spontaneous intestinal intramural hematoma is a rare complication occurring most commonly in patients receiving anticoagulant therapy. The present study aimed to analyze the clinical features and prognosis of this condition. Methods: We retrospectively analyzed the medical records of 14 patients who were diagnosed with spontaneous intestinal intramural hematoma based on characteristic computed tomography findings and treated for this condition at Asan Medical Center from March 2001 to February 2009. Results: The median age of patients was 67 years. All patients were receiving anticoagulant therapy. The most common presenting symptoms were abdominal pain (14 patients), nausea/vomiting (9 patients), and melena/hematochezia (8 patients). The median international normalized ratio (INR) was 7.7 (1.6- >15.1). The INR was above 3.5 in 13 patients (93%). Hematomas most commonly involved the jejunum (7 patients), followed by the ileum (4 patients). All patients rapidly recovered without short-term complications after medical treatment, including correction of coagulation abnormalities. Twelve patients resumed anticoagulant therapy after symptomatic resolution and correction of coagulation abnormalities, and no complications, including rebleeding, occurred during the mean 37.4 months of follow-up. Conclusions: Spontaneous intestinal intramural hematoma rapidly improved after medical treatment, and no complications occurred. It may be safe to carefully resume anticoagulant therapy in patients at high risk of thromboembolism.
참고문헌 (26)
- Spencer R, "Intramural hematoma of the intestine, a rare cause of intestinal obstruction: review of the literature and report of a case", Surgery, 41, pp.794~804 (1957)
- Bettler S, "Incidence of intramural digestive system hematoma in anticoagulation: epidemiological study and clinical aspects of 59 cases observed in Switzerland (1970-1975)", Schweiz Med Wochenschr, 113, pp.630~636 (1983)
- Hirsh J, "Oral anticoagulant drugs", N Engl J Med, 324, pp.1865~1875 (1991)
- 권창일, "경피배액술로 치료한 십이지장 벽내 혈종 1예", 대한소화기학회지, 49(1), pp.45~49 (2007), 대한소화기학회
- Gutstein DE, "Nontraumatic intramural hematoma of the duodenum complicating warfarin therapy", Mt Sinai J Med, 64, pp.339~341 (1997)
- Abbas MA, "Spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome", Arch Surg, 137, pp.306~310 (2002)
- Polat C, "Anticoagulant-induced intramural intestinal hematoma", Am J Emerg Med, 21, pp.208~211 (2003)
- Uzun MA, "Intestinal obstruction due to spontaneous intramural hematoma of the small intestine during warfarin use: a report of two cases", Eur J Emerg Med, 14, pp.272~273 (2007)
- Sutherland GA, "Intussusception and Henoch’s purpura", Br J Dis Child, 1, pp.23~28 (1904)
- 박영숙, "A형 혈우병 환자에서 소장의 벽내 혈종 1예", 대한소화기학회지, 41(2), pp.145~149 (2003), 대한소화기학회
- Devroede GJ, "Intramural hematoma of the duodenum and jejunum", Am J Surg, 112, pp.947~954 (1966)
- Kahn A, "Intramural hematoma of the alimentary tract in two hemophilic children", Helv Paediatr Acta, 31, pp.503~507 (1977)
- Eiland M, "Intramural hemorrhage of the small intestine", JAMA, 239, pp.139~142 (1978)
- Birns MT, "Intramural hematoma of the small intestine presenting with major upper gastrointestinal hemorrhage: case report and review of the literature", Gastroenterology, 77, pp.1094~1100 (1979)
- Lane MJ, "Spontaneous intramural small bowel haemorrhage: importance of non-contrast CT", Clin Radiol, 52, pp.378~380 (1997)
- Sorbello MP, "Spontaneous intramural small bowel hematoma induced by anticoagulant therapy: review and case report", Clinics, 62, pp.785~790 (2007)
- Chaiteerakij R, "Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review", J Med Assoc Thai, 91, pp.1285~1290 (2008)
- Goldfarb WB, "Coumarin-induced intestinal obstruction", Ann Surg, 161, pp.27~34 (1965)
- Herbert DC, "Anticoagulant therapy and the acute abdomen", Br J Surg, 55, pp.353~357 (1968)
- Abbas MA, "Spontaneous intramural small-bowel hematoma: imaging findings and outcome", AJR Am J Roentgenol, 179, pp.1389~1394 (2002)
- Wiot JF, "Duodenal hematoma induced by coumarin", Am J Roentgenol Radium Ther Nucl Med, 86, pp.70~75 (1961)
- Jones WR, "Intramural hematoma of the duodenum: a review of the literature and case report", Ann Surg, 173, pp.534~544 (1971)
- Sevenet F, "Isolated intramural hematoma of the sigmoid. A rare complication of anticoagulant treatment", Ann Gastroenterol Hepatol, 28, pp.67~69 (1992)
- Jacques M, "Submucous hematoma of the cecum under anticoagulant therapy", J Chir, 123, pp.186~187 (1986)
- Segaul AI, "Intramural hematoma of the small intestine as a complication of anticoagulant therapy", Am J Surg, 107, pp.891~894 (1964)
- Macari M, "Intestinal ischemia versus intramural hemorrhage: CT evaluation", AJR Am J Roentgenol, 180, pp.177~184 (2003)