CASE PRESENTATION 2007313075 Chief complaint Bowel dysfunction Malnutrition

CASE PRESENTATION 성균관대학교 의과대학 2007313075 손의영

Chief complaint • Bowel dysfunction, Malnutrition • Onset 2011 -09

Present Illness • 2010 -12 -01 • 27+4 weeks, 1150 g, vaginal delivery 로 출생 (SGA) • RDS 있어서 IV로 surfactant replacement therapy 시행 • 2010 -12 -03 • Large PDA로 Pedea 3일 사용 후 PDA closure • 2010 -12 -10 ( 생후 10일) • Perforated NEC로 응급 수술 • Ileocecal resection(terminal ileum ~ mid ascending colon), Double barrel Ileo-ascending colostomy (IC valve의 7 cm 상방, ascending colon) 시행

Present Illness • 2011 -12 -24 ( 생후 24일) • 1차 수술 이후 장루로 stool passing 없어서 2차 수술 • Explo-laparostomy, multiple segmental resection of small intestine, small bowel anastomosis, adhysiolysis, revision of ileostomy • 당시 상부 jejuno-ileum에 NEC가 진행되어 severe adhesion과 multiple bowel necrosis가 있었음. • 이후 수차례 수술 시행 • 타병원에서 입원 중 Enterocutaneous, malnutrition 발생하여 본원 전원

Present Illness • 2011 -10 -20 • 이전 수술 이후 Bowel passage 되지 않고 LFT 지속적으로 증가

Review of system • 측정 불가

Physical examination • General appearance • Not active • Abdomen • Ileostomy, colostomy state • Enterocutanous fistula • Flat abdomen, soft on palpation • Normoactive bowel sound • Chest • Symmetric expansion • Hepatomegaly/splenomegaly/shifting dullness (-/-/-) • Regular heart beat without murmur • Pain/tenderness/rebound tenderness (-/-/-) • Supraclavicular node (-/-) • Palpable abdominal mass (-/-) • Axillary node (-/-) • Percussion resonance, symmetric • Vesicular breath sound without crackle, wheezing, • External genitalia • Hyperpigmentation (-) rhonchi • Skin lesion (+) • Axilla, scalp, foot, arm area, hand, perioral area

Problem List • #1. Prematurity, SGA • #2. Perforated NEC (Ileostomy, colostomy state) • #3. Enterocutaneous fistula • #4. Malnutrition

Impression • Short bowel syndrome

Operation procedure (2011 -10 -11) • Adhesiolysis & Bowel resection and anastomosis • Very severe adhesion : adhesiolysis 어려움 • Duodenum 25 cm 하방, jejuno-colostomy • Jejunum wall longitudinal repair (3 cm) • T-colon wall vertical repair(1 cm)

Post-operational plan • TPN support • Ursodeoxycholic acid LFT 안정화

Short bowel syndrome • Symptoms • 흡수장애, 설사 • 지방변 설사, 성장장애, hyponatremia, hypokalemia, acidemia • Management • 정맥 영양법 시행 • 수액공급 • Cholestyramine • H 2 -receptor inhibitor