내시경적 제거가 가능한 직장 점막하 병변으로 오인한 자궁내막증 1예

Rectal Endometriosis That Is Difficult to Differentiate from Endoscopically Resectable Subepitherial Lesion

  • 정승규 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 이석호 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 손범석 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 이창균 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 이태훈 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 정일권 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 김선주 (순천향대학교 의과대학 천안병원 내과학교실) ;
  • 이지혜 (순천향대학교 의과대학 천안병원 병리학교실)
  • Chung, Seung-Kyu (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Lee, Suck-Ho (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Son, Bum-Suk (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Lee, Chang-Kyun (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Lee, Tae-Hoon (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Chung, Il-Kwun (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Kim, Sun-Joo (Department of Internal Medecine, Cheonan Hospital, Soonchunhyang University College of Medicine) ;
  • Lee, Ji-Hye (Department of Pathology, Cheonan Hospital, Soonchunhyang University College of Medicine)
  • 투고 : 2010.04.14
  • 심사 : 2010.08.07
  • 발행 : 2010.11.30

초록

장관에 발생하는 자궁내막증은 골반내 장기를 제외하면 가장 호발하는 부위이며 다양한 양상의 내시경 소견 및 증상을 보인다. 특히 가임기의 여성에서 구불결장 혹은 직장에서 무증상의 점막하 병변이 발견되었을 때는 감별진단에 포함시켜야 한다. 내시경적 치료술의 발전으로 다양한 점막하 병변에 대한 내시경적 절제가 시도되고 있다. 하지만 실패없는 내시경적 절제를 위해서는 시술전 내시경 초음파 등의 진단적 검사를 통하여 정확한 정보를 얻어야 한다. 저자들은 가임기 여성에서 별다른 증상 없이 내시경으로 발견한 점막하 병변을 내시경 초음파에서 점막하층에 국한된 것으로 오인하여 내시경적 점막하절제술을 시도하였으나 종괴의 고유근육층 유착으로 실패 후 수술적 절제로 자궁내막증으로 최종 진단된 1예를 문헌 고찰과 함께 보고한다.

Endometriosis occurs most frequently in the intestine. In the pelvic organs intestinal endometriosis presents with various symptoms and endoscopic findings. If an asymptomatic submucosal lesion is found in the sigmoid colon or rectum of reproductive women, a differential diagnosis should be done. Owing to advancements in endoscopic therapy, endoscopic excision has been attempted for various subepithelial lesions. To successfully do an endoscopic excision, accurate diagnosis should be obtained through diagnostic tests such as endoscopic ultrasonography prior to excision. Here the authors report a case of rectal endometriosis in an asymptomatic woman of reproductive age. They attempted endoscopic resection based on the endoscopic finding that the subepithelial lesion was limited to the submucosal layer in endoscopic ultrasonography. This conclusion turned out to be a mistaken one. Because of tumor adhesion to the proper muscular layer, we failed to successfully conduct an endoscopic excision. Ultimately, we did surgery and diagnosed rectal endometriosis.

키워드

참고문헌

  1. Olive DL, Schwartz LB. Endometriosis. N Engl J Med 1993;328:1759-1769. https://doi.org/10.1056/NEJM199306173282407
  2. Weed JC, Ray JE. Endometriosis of the bowel. Obstet Gynecol 1987;69:727-730.
  3. Kameyama H, Niwa Y, Arisawa T, Goto H, Hayakawa T. Endoscopic ultrasonography in the diagnosis of submucosal lesions of the large intestine. Gastrointest Endosc 1997;46:406-411. https://doi.org/10.1016/S0016-5107(97)70032-4
  4. Park YS, Park SW, Kim TI, et al. Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife. Gastrointest Endosc 2004;59:409-415. https://doi.org/10.1016/S0016-5107(03)02717-2
  5. Lee IL, Lin PY, Tung SY, Shen CH, Wei KL, Wu CS. Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy 2006;38:1024-1028. https://doi.org/10.1055/s-2006-944814
  6. Yamaguchi N, Isomoto H, Nishiyama H, et al. Endoscopic submucosal dissection for rectal carcinoid tumors. Surg Endosc 2010;24:504-508. https://doi.org/10.1007/s00464-009-0606-0
  7. Shim CS, Jung IS. Endoscopic removal of submucosal tumors: preprocedure diagnosis, technical options, and results. Endoscopy 2005;37:646-654. https://doi.org/10.1055/s-2005-861477
  8. Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet Gynecol Clin North Am 1997;24:411-440. https://doi.org/10.1016/S0889-8545(05)70311-9
  9. Bozdech JM. Endoscopic diagnosis of colonic endometriosis. Gastrointest Endosc 1992;38:568-570. https://doi.org/10.1016/S0016-5107(92)70518-5
  10. Chu PW, Su HY, Ko CS. Endometriosis of the colon and rectum mimicking colon cancer. Int J Gynaecol Obstet 2004;87:167-168. https://doi.org/10.1016/j.ijgo.2004.06.006
  11. Gress F, Schmitt C, Savides T, et al. Interobserver agreement for EUS in the evaluation and diagnosis of submucosal masses. Gastrointest Endosc 2001;53:71-76. https://doi.org/10.1067/mge.2001.111384
  12. Doniec JM, Kahlke V, Peetz F, et al. Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management. Dis Colon Rectum 2003;46:1667-1673. https://doi.org/10.1007/BF02660773
  13. Schroder J, Lohnert M, Doniec JM, Dohrmann P. Endoluminal ultrasound diagnosis and operative management of rectal endometriosis. Dis Colon Rectum 1997;40:614-617. https://doi.org/10.1007/BF02055389
  14. Roseau G, Dumontier I, Palazzo L, et al. Rectosigmoid endometriosis: endoscopic ultrasound features and clinical implications. Endoscopy 2000;32:525-530. https://doi.org/10.1055/s-2000-9008
  15. Puglielli E, Di Cesare E, Masciocchi C. Rectal endometriosis: MRI study with rectal coil. Eur Radiol 2004;14:2362-2363. https://doi.org/10.1007/s00330-004-2366-5
  16. Shaw A, Lund JN, Semeraro D, Cartmill M, Reynolds JR, Tierney GM. Large bowel obstruction and perforation secondary to endometriosis complicated by a ventriculoperitoneal shunt. Colorectal Dis 2008;10:520-521. https://doi.org/10.1111/j.1463-1318.2008.01505.x