슬라이드 1

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1 소화성궤양, Peptic Ulcer 성균관대학교의과대학내과이준행

2 소화 소화성궤양 궤양

3 보통분들에게물어보았습니다. 소화성궤양 이라면어떤증상이생각나십니까? 소화불량 더부룩 가스

4 소화제는소화에도움이되지않는약입니다. 소화제는만성췌장염환자에서부족한소화효소를보충하는약입니다. 보통사람이소화불량증세로소화제를먹는다고소화가촉진되는것은아닙니다.

5 위궤양, 십이지장궤양이라부릅시다. Peptic ulcer 라는영어를번역한소화성궤양으 로는환자에게적절히설명하기어렵습니다.

6 이준행교수는이렇게설명하고있습니다. 위궤양및십이지장궤양은비교적치료가간단한병에속하지만 (1) 암이아니라는점을확인해야하고, (2) 재발을막아야합니다. 다른어떤병보다재발이잦기때문입니다. 재발방지책은크게 3가지입니다. (1) 헬리코박터균을제거하는것입니다. 이를위하여일주일간항생제를처방합니다. 재검하여균이없어진것으로나오면 -- 일차제균치료의제균율은 80% 정도입니다 -- 경과관찰을권합니다. 성공적인제균치료후균이다시발견되는경우는 1년에 3% 정도입니다. (2) 뚜렷한이유없이아스피린이나소염진통제를드시지마십시오. 꼭필요한경우라도소화성궤양예방약을함께드시기바랍니다. (3) 금연은필수입니다. 이외에채식위주로싱겁게드시는것이도움이되며, 1년후내시경검사를받으십시오.

7 공격인자와방어인자의불균형

8 위산분비의 3 대자극원은 Histamine ECL cell Acetylcholine Gastrin camp + + Ca ++ Parietal cell + + H +,K + - ATPase K + Site of action (proton pump) H + Lumen Sachs G. Annu Rev Pharmacol Toxicol. 1995;35:

9 NSAID 관련소화성궤양 성균관대학교의과대학내과이준행

10 좋은녀석과나쁜녀석 - COX-1 & COX-2

11 Prothrombotic Less GI side effect 좋은작용과나쁜작용이있습니다. - COX-2 selectivity Prostacyclin Inhibition ( COX-2 mediated ) Thromboxane Inhibition ( COX-1 mediated ) Anti-thrombotic More GI side toxicity Rofecoxib Celecoxib Etoricoxib Lumiracoxib Diclofenac Ibuprofen ASA Naproxen

12 직접작용과간접작용이있습니다. - Mechanism of GI injury by NSAIDs NSAIDs Topical injury Systemic injury Active NSAID metabolite by hepatic metabolism Direct effect Ion trapping Blood flow Stasis Indirect effect Decrease in gastric mucosal prostaglandins by COX-1 inhibition

13 소화성궤양관련가장중요한족보입니다. - NSAID ulcer complications: risk factors Prior complicated ulcer Use of multiple NSAIDs (including aspirin) High-dose of NSAIDs Anticoagulant therapy Prior uncomplicated ulcer Age > 70 years H. pylori infection Glucocorticoid therapy Gabriel. Ann Intern Med 1991, Garcia Rodriguez. Lancet 1994, Silverstein. Ann Intern Med 1995

14 Dyspepsia: change of the medication, dose reduction, empirical treatment with H 2 RA or PPI H. pylori infection: eradication treatment in patients with risk factor(s) Active ulcer (NSAID discontinued): H 2 RA or PPI Active ulcer (NSAID continued): PPI Prophylactic therapy: misoprostol, PPI, COX-2 selective agent Lee JH. Korean J Gastroenterol 2009;54:

15 Helicobacter pylori 성균관대학교의과대학내과이준행

16 소화성궤양과헬리코박터 H. pylori NSAIDs Other 92% 70% 십이지장궤양 위궤양

17 Probability of Remaining in 한마디로재발을막기위해제균합니다 antibiotics Remission (%) placebo Week after Treatment P<0.001 Hentschel E. NEJM. 1993

18 헬리코박터진단 Test Sensitivity Specificity (%) serum ELISA urea breath test biopsy urease test histology culture ACG guideline, 1998

19 헬리코박터진단과치료적응증 peptic ulcer : regardless of the stage of ulcer low grade MALT-associated lymphoma : stage IE1 after endoscopic mucosal resection (EMR) of early gastric cancer (EGC) Korean J Gastroenterol 1998:32:275-89

20 헬리코박터 1 차제균치료 PPI-based triple therapy for 1-2 weeks - PPI (omeprazole 20 mg or lansoprazole 30 mg or pantoprazole 40 mg) bid - amoxicillin ( not ampicillin ) 1,000 mg bid - clarithromycin (or metronidazole) 500 mg bid Korean J Gastroenterol 1998:32:275-89

21 소화성궤양의증상과증후 성균관대학교의과대학내과이준행

22 Symptoms Epigastric pain Duodenal ulcer 90 min to 3 h after a meal (hunger pain) 70% awakes the patient from sleep (between midnight and 3 A.M.) frequently relieved by antacids or food Gastric ulcer precipitated by food Nausea and weight loss occur more common

23 DU, recurrent - GERD 를많이보는의사가증상으로잡을수있는궤양을놓침

24 Symptoms The mechanism of abdominal pain in ulcer : unknown. - Acid-induced activation of chemical receptors in the duodenum - Enhanced duodenal sensitivity to bile acids and pepsin - Altered gastroduodenal motility

25 Suggestion of ulcer complication Dyspepsia constant, not relieved by food or antacids, or radiates to the back penetrating ulcer (pancreas) Sudden onset of severe, generalized abdominal pain perforation Pain worsening with meals, nausea, and vomiting of undigested food gastric outlet obstruction Tarry stools or coffee ground emesis bleeding

26 Signs of PUD Epigastric tenderness : most frequent finding in GU or DU Tachycardia and orthostasis : dehydration secondary to vomiting or active gastrointestinal blood loss Severely tender, boardlike abdomen : perforation Succussion splash : retained fluid in the stomach suggesting gastric outlet obstruction

27 소화성궤양의 3 대합병증 - 출혈, 천공, 협착 성균관대학교의과대학내과이준행

28 출혈 Ia, pumping Ib, oozing IIa, exposed vessel IIb, adherent clot Modified Forrest Classification

29 다발성관절통으로 NSAIDs 를반년이상복용하다가갑작스런복통 (M/58) 수술장 : Stomach LB AW 0.5cm sized ulcer perforation 있으며그주변으로 inflammatory change 로 stomach wall fibrosis, edema 심함.

30 방사선치료후발생한궤양천공

31 이환자에서어떤 physical 소견이있을까요? - Gastric outlet obstruction with severe reflux esophagitis

32 소화성궤양의내시경소견 성균관대학교의과대학내과이준행

33 소화성궤양의내시경병기 (stage) Active 궤양과부종 Healing 재생상피와주름 Scar 궤양없고주름만

34 위궤양 (A-1 stage)

35 매우큰위궤양이아물어가는모습

36 위궤양반흔

37 소화성궤양약물치료 성균관대학교의과대학내과이준행

38 소화성궤양의증상 Epigastri c pain Duodenal ulcer 90 min to 3 h after a meal (hunger pain) 70% awakes the patient from sleep (between midnight and 3 A.M.) frequently relieved by antacids or food Gastric ulcer precipitated by food Nausea and weight loss occur more common

39 소화성궤양치료전략 Before the discovery of H. pylori "no acid, no ulcer." old dictum by Schwartz Nowadays Acid secretion is still important. Eradication of H. pylori Therapy/prevention of NSAID-induced disease

40 소화성궤양약물치료 Acid neutralizing / inhibitory drugs Antacids H 2 receptor antagonists Proton pump inhibitors (PPI) Cytoprotective agent Bismuth Sucralfate Prostaglandin analogues Therapy of H. pylori Therapy of NSAID-related gastric or duodenal injuries

41 CPX: 상부위장관출혈 성균관대학교의과대학내과이준행

43 위장관출혈도여러가지입니다. Hematemesis : vomiting of blood Melena : passage of stools rendered black and tarry Hematochezia : passage of red blood per rectum Occult bleeding : blood in the stool detected by card test for hemoglobin peroxidase

44 토혈 CPX 증례 42 세남자가피를토하여응급실로왔다. 혈압 120/72 mmhg 맥박 102회 / 분 호흡수 18회 / 분 체온 36.8 C

45 진료문항 (CPX) 접근 3 axis 병력청취 신체진찰 환자 ( 보호자 ) 교육

46 진료문항 (CPX) 접근 3 axis - 토혈 병력청취 토혈의양상및응급조치가필요한증상확인 토혈의유발원인파악 건강위험도및병적상태평가 신체진찰 토혈의유발요인과원인파악 환자 ( 보호자 ) 교육 정보제공

47 토혈병력청취 1 - 토혈의양상및응급조치가필요한증상확인 토혈 vs 객혈 토혈의양 언제부터 몇번 색깔 : 선홍색, 검붉은색, 피떡 변색깔 : 흑색변, 혈변 어지럽거나숨이차지않은지?

48 토혈병력청취 2 - 토혈의유발원인파악 토혈과거력 중요감별진단에대하여질문 소화성궤양 Mallory Weiss Varix bleeding 위암 식도암

49 토혈병력청취 3 - 건강위험도및병적상태평가 흡연 혈액응고장애 항응고제, 항혈소판제, NSAIDs

50 상부출혈과하부출혈의비교 (1) Upper Lower Location proximal to Treitz lig. distal to Treitz lig. Manifestation hematemesis/melena hematochezia Nasogastric tube blood bile/no blood Peristalsis increase normal BUN/Cr increase normal

51 상부출혈과하부출혈의비교 (2) Massive upper GI bleeding hematochezia Upper GI bleeding distal to pyloric channel no blood via nasogastric tube Small bleeding from small bowel or right colon melena

52 상부위장관출혈의흔한원인 Gastric ulcer Duodenal ulcer Varix Mallory-Weiss syndrome Gastritis or erosion Esophagitis or esophageal ulcer Stomach cancer

53 상부위장관출혈의 내시경치료 성균관대학교의과대학내과이준행

54 재출혈위험. Forrest 분류. Ia, pumping Ib, oozing IIa, exposed vessel IIb, adherent clot

55 내시경지혈술방법 Electrocauterization Bipolar catheter Heat probe Hot biopsy forcep Epinephrine injection treatment Endoscopic cliping APC Thrombin ALTO spray, Ulcermin spray Surgery

56 Ethanol injection

57 Coaptive coagulation

58 Two types of clip application

59 (weeks) Initial EGD +/- hemostasis (if possible, histology and CLOtest) Second-look EGD (only if clinically indicated) Follow-up EGD with histology High dose continuous intravenous PPI for 72 hours Standard dose PPI H. pylori eradication (starting at first OPD visit) Urea breath test

60 경청해주셔서감사합니다.

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< C0D3BBF3B0C7B0AD20C3E1B0E8C7D0BCFAB4EBC8B82DBFACBCF6B0ADC1C22E687770> 2013 년대한임상건강증진학회춘계합동학술대회 연수강좌 소강당 소화성궤양진단및치료 박영규 분당제생병원가정의학과 목차 1. 소화성궤양의정의와역학 2. 소화성궤양의병인 3. 소화성궤양의증상 4. 소화성궤양의진단 5. 소화성궤양의치료 6. 헬리코박터균과제균치료 - 조직학적인용어 소화성궤양의정의 - 위장관벽조직의결손이점막하층또는그이하까지발생한상태 - 위산과펩신으로인해발생한병변