pissn 2287-3368 / eissn 2287-3376 ORIGINAL ARTICLE Korean Journal of Acupuncture Vol.30, No.4, pp.319-328, 2013 http://dx.doi.org/10.14406/acu.2013.041 중증소화불량증환자에대해체침요법과자하거약침요법의치료효과에대한후향적비교연구 동의대학교한의과대학내과학교실 The Retrospective Comparative Study of General Acupuncture Therapy and Hominis placenta Pharmacopuncture Therapy on Severe Dyspepsia Ah-Ram Lee, Won-Il Kim Department of Oriental Internal Medicine, College of Oriental Medicine, Dong-Eui University Objectives : The purpose of this research was to compare the effect of general acupuncture therapy to Hominis placenta Pharmacopuncture therapy on pain and discomfort of severe dyspepsia in upper abdomen. Methods : We investigated 60 cases of patients with severe dyspepsia, who had been treated at Dept. of Internal Medicine, College of Oriental Medicine Dongeui University from May 2011 to September 2012. We divided patients into two groups : Group I was treated by general acupuncture(acu, n=30) and Group II was treated by Hominis placenta Pharmacopuncture therapy(pha, n=30). The symptoms and quality of life were measured with the Nepean dyspepsia index-korean version(ndi-k) at baseline and 2 weeks. The responsiveness of the NDI-K was evaluated by correlation with symptom scores. Results : In ACU group, the 13 symptom scores were significantly decreased after treatment(p<0.05). In PHA group, the 9 symptom scores were significantly decreased after treatment(p<0.05). In ACU group, the 3 Quality of life(qol) scores were significantly increased after treatment(p<0.01). In PHA group, the 3 QOL scores were significantly increased after treatment(p<0.05). Conclusions : General acupuncture therapy and Hominis placenta Pharmacopuncture therapy improves the symptoms and the quality of life in patients with severe dyspepsia. But there were no significant differences statistically between the two groups. Key words : severe dyspepsia, general acupuncture, Hominis placenta Pharmacopuncture, Nepean dyspepsia index-korean (NDI-K), Quality of life(qol) 서론 소화불량증 (dyspepsia) 은그리스단어 dys(bad) 와 pepsis(digestion) 에서유래된용어로증상의원인이위장관에서기인한것 으로알려진증상복합체 1) 이다. 주로 1차진료기관에서가장흔히접하게되는증상중의하나이고식사여부와는관계없이주로상복부중심으로복통이나불편감, 조기만복감, 상복부팽만감, 구역등의증상이나타나는경우를말한다 2). Received December 2, 2013, Revised December 18, 2013, Accepted December 18, 2013 Corresponding author: Won-Il Kim Deptartment of Oriental Internal Medicine, College of Oriental Medicine, Dong-Eui University, Yangjeong 2-dong, Busangjin-gu, Busan 614-710, Korea Tel: +82-51-850-8630, Fax: +82-51-867-5162, E-mail: omdstar@deu.ac.kr This study was a master's thesis of Oriental Medicine, Dong-Eui University Graduate School in 2013. CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2013, SOCIETY FOR MERIDIAN AND ACUPOINT 319
특히현대인들은잦은감정의변화, 직업의다양성과전문성, 불규칙적인식사습관으로인해위장질환을호소하는경우가점차증가하고있으며 3), 환자들의삶의질저하와이들의병원방문및진료과정에소비되는사회경제적비용, 이와관련한산업현장에서의생산성저하등으로인한피해도증가하고있다 4). 한의학적으로소화불량은내상의범주에서痞滿, 噯氣, 嘈雜, 呑酸, 吐酸, 懊惱등의內傷轉變症과心下痞, 心痛, 오심, 구토등의음식상으로표현하고있다 2). 그중뚜렷한증상이있고심해서치료가필요한중증소화불량증에대한한방적치료는다양하며특히최근에는국내외의연구빈도가높아지면서치료효과에대한기대도높아지고있다. 임상적으로급성의중증소화불량증은침구치료가위주가되어시술되고있으며교과서등의문헌및실제진료에서도중요한치료법으로언급되고있다 2,5,6). 특히중증소화불량으로인한음식상, 복통, 위완통, 구토, 반위등의증상에일반적으로中脘 (CV12), 足三里 (ST36), 內關 (PC6), 公孫 (SP4), 三陰交 (SP6), 脾腧 (BL20), 膈腧 (BL17) 등의혈위를선혈하여활용하고있으며 7), 최근에는약침치료로不容 (ST19), 大巨 (ST27), 腎腧 (BL23), 脾腧 (BL20), 府舍 (SP13) 등의혈위에위적체, 상식, 자하거등의약침액을자입하여치료한다고기록되어있다 8,9). 최근임상에서다양한침구술기에대한효율성과경제성을갖춘적절한치료방법의선택필요성이제기되고있다. 이에대한근거가필요한시점에서기존의연구는주로한약의효과 10,11) 위주로이루어지고있고, 선행연구에서급성소화불량에대해체침과자락치료의비교연구 12) 가있으나체침과약침을대상으로치료효과를비교한임상연구는찾아보기힘든상황이다. 특히약침중에서도자하거약침이중증소화불량에우수하다는저자의임상적경험과문헌적근거 8,9) 들이있지만, 타질환관련연구 13-15) 만진행되고있고, 본질환에대한연구가없다. 따라서현재침구술기의기본치료라고할수있는체침과자하거약침을비교하여그효과를확인하고자하였다. 이에저자는 2011월 4월부터 2012년 9월까지동의대학교부속한방병원한방소화기내과에중증소화불량증을호소하며내원하여체침치료나자하거약침치료를시술받고호전되어치료가종료된환자들을대상으로차트를통하여후향적으로비교분석하였다. 차트기록상기능성소화불량증의특이적삶의질평가도구인 Nepean Dyspepsia Index-Korean(NDI-K) 16) 을이용하여치료에대한평가가완료되어있는각 30명씩을체침치료군과자하거약침치료군으로선정하고체침치료군을대조군으로하여자하거약침이중증소화불량증에효과가있는지를분석한결과지견을얻었기에 이에보고하는바이다. 대상및방법 1. 연구대상 2011년 4월부터 2012년 9월까지동의대학교부속한방병원소화기내과에상복부통증, 상복부불쾌감, 상복부쓰림, 상복부팽만감, 오심등의증상을주소로내원한환자중전문의의진찰및병력청취로중증소화불량으로진단되어체침이나약침치료를받고호전되어치료가종료된환자를대상으로차트를분석하여시행하였다. 차트기록상치료호전에대해구체적으로서술되어있고, 제외기준에해당하거나중복치료를받은환자를배제하고설문지와치료결과가기록완료된체침치료환자와약침치료환자각 30 명씩총 60명이선정되었으며환자의차트는헬싱키선언을준수하고본원의연구윤리규정에따라병원장의허가를얻은후에평가되었다. 2. 선정기준선정기준은차트상의나이를기준으로 20세이상 80세이하의남녀로 2주내에소화불량으로인해급성적으로발생한상복부통증, 상복부불쾌감, 상복부쓰림, 조기만복감, 식후포만감, 상복부압박감, 상복부팽만감, 오심등의증상을각각평가하였다. 증상이없는경우 0점, 의사가문진에의해상기시켜줄경우환자가증상이있다고느끼는정도이며치료가요구되지않는경우 1점, 환자가증상을느끼지만정상적인일상활동에거의지장이없는경우 2점, 환자가증상을느끼면서정상적인일상활동에방해를받는경우 3점으로평가하였다. 평가결과중등도 (2점 ) 이상의증상이최소 2개, 총점의합이 6점이상인경우중증소화불량환자로선정하였고, 이중에서약침과체침중어느한쪽만을총 5회이상치료받은환자를대상으로하였다. 3. 제외기준 1) 치료기간중중간에완치되거나내원하지않아총 5회미만의시술을받은환자 2) 체침과약침을중복치료받은환자 3) NDI-K 설문지작성이누락된경우나차트상으로비교불가능한경우 4) 과거력상위장관수술을받은자 ( 단, 맹장적출술은제외 ) 나위장관출혈, 기계적장폐색, 천공등이있었던환자 320 www.kjacupuncture.org
소화불량증에대한체침요법과약침요법의효과비교 5) 간암또는간경변증, 만성신부전, 울혈성심부전등의치료로소화기계통의효과평가에영향을줄수있는것으로알려진질환을가지고있거나지난 2년내에가지고있었던환자 4. 치료방법 1) 치료기간및방법 : 환자는일주일에 3회씩 2주간총 6회동안체침치료나자하거약침치료가각각시행되었고 Ex 제를복용하였다. 2) 침구치료 (1) 체침치료 : 동방침구제작소에서제작된 0.25 40 mm stainless steel needle 을사용하여소화불량에자주사용하는合谷 (LI4), 太衝 (LR3), 曲池 (LI11), 足三里 (ST36), 中脘 (CV12), 下脘 (CV10) 7) 등의혈자리에시침하여 1회 15분간유침하여시술되었다. (2) 약침치료 : 대한약침학회무균실에서조제한자하거약침을 1.0 cc 1회용인슐린주사기 (0.30 8 mm, ( 주 ) 신차메디칼 ) 를이용하여不容 (ST19), 大巨 (ST27), 天樞 (ST25), 肝腧 (BL18), 脾腧 (BL- 20), 胃腧 (BL21), 腎腧 (BL23) 7-9) 등의혈위에 1회 0.05 cc씩, 총시술량은 0.8 cc 시술되었다. 3) 약물요법 : 두군의환자모두소화불량증으로야기된증상에유의한효과가있다고보고된반하사심탕 Ex제 ( 쯔무라제약 ) 17) 와청위단 ( 한국신약 ) 을각각 1포씩 2주간 1일에 3회식후 30분에복용하도록처방되었다. 5. 평가방법 1) 증상및삶의질평가 : 한방소화기내과에서는 NDI-K 를사용하여환자의증상에대한호전도와삶의질이평가되었다. NDI-K 는증상점수표, 삶의질에관한문항과가중치에대한문항으로구성되어있다. 증상점수표는상복부통증, 상복부불쾌감, 상복부쓰림, 가슴쓰림, 상복부경련, 가슴의통증, 조기만복감, 위산역류, 식후포만감, 상복부압박감, 상복부팽만감, 구역, 트림, 구토및숨쉬기어려움의 15가지증상을빈도, 강도및괴로운정도로나누어평가하였다. 빈도는지난 2주간증상이며칠동안있었는지 5단계로평가하였고증상의단계는 6단계로, 괴로운정도는 5단계로평가하였으며증상에대한총점수는각각의단계별로더한총합으로판단하였다. 삶의질에관한질문은 25문항, 4영역으로구성되어여기에는일상활동 / 업무의저해 (Inference daily activities/work) 13문항, 지식 / 조절 (Knowledge/control) 7문항, 먹고마시기 (Eating/drinking) 3문항, 수면장애 (Sleep disturbance) 2문항으로이루어져있다. 각문항은최저 1점에서최고 5점이지만계산할때는높은점수가삶의질이좋은것을의미하도록문항점수를거꾸로한다. 삶의 질에대한점수는네가지하위척도별로각각 100점기준으로환산되어계산되며점수가높을수록삶의질 (Quality of Life) 이높음을의미하였다. 2) 평가목표및방법 : 중증소화불량으로진단받은환자들은치료시작전 NDI-K 의증상점수표와삶의질항목에대한설문지가환자본인의주관적인판단을통해작성되었으며 2주후에다시 NDI-K 를통하여경과변화가평가되었다. 평가에대한목표는 치료시점전두군간의 NDI-K 증상점수표 15가지항목과총합의비교, 각군의 NDI-K 증상점수표 15가지항목과총합의치료전후변화, 치료시점전두군간의 NDI-K 삶의질네가지항목과총합의비교, 각군의 NDI-K 삶의질네가지항목과총합의치료전후변화 로정하여목표에대한결과를산출하여호전도를판단하였다. 6. 통계및검정연속형결과의값은평균 ± 표준편차로표시하였으며, 시험전후변화의유의성평가는대응표본 t-검정 (paired t-test) 을사용하였고, 시험전후변화의두군간의차이에대한검정은독립표본 t-검정 (independent t-test) 법을사용하였다. 범주형결과의정리에는도수와분율을사용하였으며, 군간차이검정에는피셔의정확검정 (Fisher's exact test) 을사용하였다. 정규성검정은 Kolmogorov-Smirnov test 또는 Shapiro-wilk test를수행하였고모든통계분석은 SPSS 18.0 for windows 를사용하였으며 p값 (pvalue) 이 0.05 미만인경우를통계적으로유의하다고판정하였다. 결과 1. 환자군의일반적특성진료가완료된환자분중차트상으로본연구의대상이되는환자를체침치료만받은군 (ACU) 과자하거약침치료만받은군 (PHA) 으로나눈결과각 30명이었다. 체침치료군에서는남녀가각각 8명 (26.7%), 22명 (73.3%) 이고평균나이는 48.50±13.32세였으며자하거약침치료군에서는남녀가각각 8명 (26.7%), 22명 (73.3%) 이고평균나이는 47.30±16.48 세였다. 두군간의남녀비, 평균연령에대해선유의한차이가없었다 (Table 1). 2. NDI-K 15개의증상점수표영역에서의점수변화 1) 치료전체침치료군과자하거약침치료군의 NDI-K 증상점수비교 : 치료전의체침치료군은상복부통증과트림이평균 5.23 www.kjacupuncture.org 321
점으로가장높았으며구토가평균 2.93 점으로가장낮았다. 치료전의자하거약침치료군은상복부불쾌감이평균 5.93 점으로가장높았으며상복부경련이평균 1.47 점으로가장낮았다. NDI-K 의 15개소화불량지수중치료전의자하거약침치료군은체침치료군에비해상복부통증, 구역, 조기만복감, 상복부쓰림, 가슴쓰림, 위산역류, 트림, 상복부경련, 가슴통증, 구토, 숨쉬기어려움의 11개항목과총점이낮았으며상복부압박감, 식후포만감, 상복부불쾌감, 상복부팽만감의네가지항목이체침치료군보다높은수치를보여줬으나치료시작전두군간의 NDI-K 증상점수표의개별증상점수와총점수를각각비교한결과두군간에유의한차이는없었다 (Table 2). 2) 체침치료군에서치료전후의 NDI-K 15개증상점수표의변화 : 체침치료후 NDI-K 증상점수표의변화를비교해보면 15개의증상점수와총점은모두감소하였으며상복부통증, 상복부압박감, 구역, 조기만복감, 식후포만감, 상복부불쾌감, 가슴쓰림, 위산역류, 트림, 구토, 숨쉬기어려움의 11항목과총점에서유의한감소를 보였다 (p<0.05). 특히상복부통증은평균 3.30 점감소되어가장많이감소하였고상복부팽만감은평균 1.13 점감소되어가장적게감소하였다. 나머지항목인상복부쓰림, 상복부경련, 가슴통증, 상복부팽만감의점수도감소했지만유의성은없었다 (Table 3). 3) 자하거약침치료군에서치료전후의 NDI-K 15개증상점수표의변화 : 자하거약침치료후 NDI-K 증상점수표의변화를비교해보면상복부경련을제외한 14개의증상점수와총점은모두감소하였으며상복부통증, 상복부압박감, 구역, 조기만복감, 식후포만감, 상복부불쾌감, 상복부쓰림, 트림, 상복부팽만감의 9항목과총점에서유의한감소를보였다 (p<0.05). 특히상복부불쾌감은평균 3.10 점감소되어가장많이감소하였고상복부경련은오히려평균 0.40 점증가되어 15개의증상항목중유일하게증가하였다. 나머지항목인가슴쓰림, 위산역류상복부경련, 가슴통증, 구토, 숨쉬기어려움의점수는감소했지만유의성은없었다 (Table 4). 4) 치료후체침치료군과자하거약침치료군의 NDI-K 증상변화비교 : 치료후두군의증상항목중자하거약침치료군의상복부 Table 1. Clinical Characteristics of Two Groups Treated with ACU and PHA ACU PHA Fisher's exact test p-value t-test Total number 30(100%) 30(100%) Gender(n[%]) Male 08(26.7%) 08(26.7%) 1.0 Female 22(73.3%) 22(73.3%) Mean age(y) 48.50±13.32 47.30±16.48 0.758 ACU means General acupuncture treated group and PHA means Hominis placenta Pharmacopuncture Therapy treated group. Table 2. Score of NDI-K Symptoms in the Two Group before Treatment Symptom(0 14) ACU PHA p-value Pain in upper abdomen 5.23±3.67 4.70±3.59 0.572 Pressure in upper abdomen 4.83±3.95 4.97±2.82 0.881 Nausea 4.70±3.37 3.23±3.02 0.082 Inability to finish a regular meal 4.27±3.88 3.60±2.93 0.456 Fullness after eating 4.43±5.47 5.47±3.05 0.304 Discomfort in upper abdomen 4.83±3.97 5.93±3.32 0.250 Burning in upper abdomen 4.60±4.55 3.73±2.86 0.381 Heartburn 3.90±3.95 2.63±2.68 0.152 Bitter tasting fluid that comes to your mouth 3.43±3.50 2.97±3.25 0.595 Burping 5.23±3.06 4.50±3.16 0.365 Cramps in upper abdomen 2.40±3.77 1.47±1.78 0.226 Chest pain 3.63±3.83 2.33±2.59 0.130 Vomiting 2.93±3.39 1.87±2.24 0.157 Bad breath 3.93±4.18 2.17±2.85 0.061 Bloating in upper abdomen 4.67±3.50 5.73±3.28 0.228 Total symptom score(0 210) 63.03±32.67 55.30±22.48 0.290 322 www.kjacupuncture.org
소화불량증에대한체침요법과약침요법의효과비교 경련을제외하고모든증상점수는감소하였으며자하거약침치료군이체침치료군보다상복부통증, 구역, 가슴쓰림, 위산역류, 트림, 상복부경련, 가슴통증, 구토, 숨쉬기어려움의 9개항목과총점에서보다적게감소했으며, 상복부압박감, 조기만복감, 식후포만감, 상복부불쾌감, 상복부쓰림, 상복부팽만감의 6개항목에서체침치료군보다많이감소하였다. 하지만 15개의항목과총점중가슴쓰림만제외하고는두군간에유의한치료효과의차이가나타나지않았으며다만체침치료군이가슴쓰림항목에대해자하거약침치료군보다더유의한치료효과를나타내었다 (p<0.05)(table 5). 3. NDI-K 삶의질영역에서의점수변화 1) 치료전체침치료군과자하거약침치료군의 NDI-K 삶의질점수비교 : 치료전의체침치료군은지식 / 조절면이평균 62.0 점으로가장낮았으며수면장애부분에서평균 71.0 점으로가장높았다. 치료전의자하거약침치료군은먹고마시기부분에서평균 64.44 점으로가장낮았으며수면장애면에서평균 73.0 점으로가장높았다. NDI-K 의네가지삶의질영역중치료전의자하거약침치료군은체침치료군에비해일상활동 / 업무의저해, 지식 / 조절, 먹고마시기, 수면장애, 총점수에서높은점수를나타냈으나유의한차이는 Table 3. Mean changes of NDI-K Symptoms score in the Group Treated with ACU Symptom(0 14) After score Mean change p-value Pain in upper abdomen 1.93±2.12 3.30±3.08 0.000** Pressure in upper abdomen 2.73±2.38 2.10±3.28 0.002** Nausea 2.60±2.72 2.10±3.80 0.005** Inability to finish a regular meal 2.50±2.76 1.77±3.68 0.014* Fullness after eating 2.97±2.22 1.47±3.36 0.024* Discomfort in upper abdomen 3.23±2.33 1.60±3.78 0.028* Burning in upper abdomen 3.30±2.79 1.30±4.36 0.114 Heartburn 1.47±2.26 2.43±3.87 0.002** Bitter tasting fluid that comes to your mouth 2.20±2.74 1.43±3.50 0.033* Burping 3.23±3.14 2.00±3.11 0.001** Cramps in upper abdomen 1.17±2.05 1.23±3.85 0.090 Chest pain 2.30±2.41 1.33±3.81 0.065 Vomiting 1.37±2.24 1.57±3.65 0.026* Bad breath 2.10±2.78 1.83±4.28 0.026* Bloating in upper abdomen 3.53±2.26 1.13±3.17 0.060 Total symptom score(0 210) 36.43±18.19 26.60±29.33 0.000** *p<0.05, **p<0.01 by Paired t-test. Table 4. Mean changes of NDI-K Symptoms score in the Group Treated with PHA Symptom(0 14) After score Mean change p-value Pain in upper abdomen 2.20±2.62 2.50±2.39 0.000** Pressure in upper abdomen 2.50±2.57 2.47±3.41 0.000** Nausea 2.03±1.65 1.20±2.94 0.033* Inability to finish a regular meal 1.57±2.03 2.03±2.61 0.000** Fullness after eating 2.50±2.49 2.97±2.63 0.000** Discomfort in upper abdomen 2.83±2.95 3.10±3.30 0.000** Burning in upper abdomen 2.30±2.34 1.43±3.32 0.025* Heartburn 2.07±2.29 0.57±2.39 0.204 Bitter tasting fluid that comes to your mouth 1.97±2.30 1.00±2.91 0.070 Burping 2.53±2.08 1.97±3.26 0.003** Cramps in upper abdomen 1.87±2.62 0.40±2.86 0.450 Chest pain 2.00±2.75 0.33±3.50 0.606 Vomiting 1.60±1.59 0.27±2.19 0.508 Bad breath 1.83±2.12 0.33±2.17 0.407 Bloating in upper abdomen 2.93±2.38 2.80±3.35 0.000** Total symptom score(0 210) 32.73±23.22 0-22.57±20.69 0.000** *p<0.05, **p<0.01 by Paired t-test. www.kjacupuncture.org 323
없었다 (Table 6). 2) 체침치료군에서치료전후의 NDI-K 삶의질의변화 : 체침치료후 NDI-K 삶의질의변화를비교해보면네가지영역과총점은모두증가했으며일상활동 / 업무의저해, 지식 / 조절, 먹고마시기의세가지영역과총점수에서유의한증가를보였다. 특히일상활동 / 업무의저해는평균 16.97 점증가하여가장많이증가하였고수면장애는평균 7.00 점증가하여가장적게증가하였다 (Table 7). 3) 자하거약침치료군에서치료전후의 NDI-K 삶의질의변화 : 자하거약침치료후 NDI-K 삶의질변화를비교해보면네가지영역과총점은모두증가했으며일상활동 / 업무의저해, 지식 / 조절, 먹고마시기의세가지영역과총점수에서유의한증가를보였다. 특히일상활동 / 업무의저해는평균 9.69 점증가하여가장많이증가하였고수면장애는평균 2.67 점증가하여가장적게증가하였다 (Table 8). Table 5. Mean changes of NDI-K Symptoms score in Two Group Treated with ACU and PHA Symptom(0 14) ACU PHA p-value Pain in upper abdomen 3.30±3.08 2.50±2.39 0.265 Pressure in upper abdomen 2.10±3.28 2.47±3.41 0.673 Nausea 2.10±3.80 1.20±2.94 0.309 Inability to finish a regular meal 1.77±3.68 2.03±2.61 0.747 Fullness after eating 1.47±3.36 2.97±2.63 0.059 Discomfort in upper abdomen 1.60±3.78 3.10±3.30 0.107 Burning in upper abdomen 1.30±4.36 1.43±3.32 0.894 Heartburn 2.43±3.87 0.57±2.39 0.029* Bitter tasting fluid that comes to your mouth 1.43±3.50 1.00±2.91 0.604 Burping 2.00±3.11 1.97±3.26 0.968 Cramps in upper abdomen 1.23±3.85 0.40±2.86 0.067 Chest pain 1.33±3.81 0.33±3.50 0.294 Vomiting 1.57±3.65 0.27±2.19 0.100 Bad breath 1.83±4.28 0.33±2.17 0.094 Bloating in upper abdomen 1.13±3.17 2.80±3.35 0.052 Total symptom score(0 210) 26.60±29.33 22.57±20.69 0.541 *p<0.05 by Independent t-test. Table 6. Quality of Life Score of NDI-K Symptoms in the Two Group before Treatment Quality of Life(0 100) ACU PHA p-value Interference daily activities/work 63.28±18.75 65.95±18.54 0.582 Knowledge and control 62.00±18.58 65.05±16.87 0.509 Eating/drinking 63.56±23.92 64.44±21.25 0.880 Sleep disturbance 71.00±22.03 73.00±24.66 0.742 Total symptom score(0 400) 259.84±68.13 268.44±72.480 0.637 Table 7. Mean Changes of NDI-K Quality Life Score in the Group Treated with ACU Quality of Life(0 100) After score Mean change p-value Interference daily activities/work 80.26±12.01 16.97±16.19 0.000** Knowledge and control 76.00±13.91 14.00±16.87 0.000** Eating/drinking 80.00±18.11 16.44±22.81 0.000** Sleep disturbance 78.00±18.46 7.00±23.51 0.114 Total symptom score(0 400) 314.26±51.480 54.42±56.60 0.000** **p<0.01 by Paired t-test. 324 www.kjacupuncture.org
소화불량증에대한체침요법과약침요법의효과비교 Table 8. Mean Changes of NDI-K Quality Life Score in the Group Treated with PHA Quality of Life(0 100) After score Mean change p-value Interference daily activities/work 75.64±17.43 9.69±17.27 0.005** Knowledge and control 73.71±19.14 8.67±19.00 0.018* Eating/drinking 73.78±21.37 9.33±19.46 0.014* Sleep disturbance 75.67±18.88 2.67±26.51 0.586 Total symptom score(0 400) 298.80±67.020 30.36±61.160 0.011* *p<0.05, **p<0.01 by Paired t-test. Table 9. Mean Changes of NDI-K Quality Life Score in Two Patients Groups Treated with ACU and PHA Quality of Life(0 100) ACU PHA p-value Interference daily activities/work 16.97±16.19 9.69±17.27 0.097 Knowledge and control 14.00±16.87 8.67±19.00 0.255 Eating/drinking 16.44±22.81 9.33±19.46 0.199 Sleep disturbance 7.00±23.51 2.67±26.51 0.506 Total symptom score(0 400) 54.42±56.60 30.36±61.160 0.119 4) 치료후체침치료군과자하거약침치료군의 NDI-K 삶의질변화비교 : 치료후두군의삶의질네가지영역은모두증가했으며, 자하거약침치료군이체침치료군에비해일상활동 / 업무의저해, 지식 / 조절, 먹고마시기, 수면장애, 총점수의증가량이모두적었으나통계적으로유의한차이는보이지않았다 (Table 9). 고찰 소화불량은일상생활에서흔히접하는다양한증상중의하나이며일반적으로상복부에서지속적또는재발성으로느껴지는동통이나불편감을말한다 2). 소화불량증의원인은매우다양하나크게나누어서소화성궤양, 위암, 위식도역류질환과같은위장관계질환, 간질환, 담췌질환, 약물, 음식, 전신질환등의기질적질환을동반하는경우가있고 17) 그것을제외한 50% 이상이위장관내시경을비롯한검사를통해증상을설명할만한기질적병변을확인할수없는기능성소화불량증이있다 18). 한의학에서소화불량은내상전변증과음식상이라고표기한것이외에도 동의보감 에서는 氣口脈必緊盛胸膈必痞塞噯氣如敗卵氣臭亦有頭痛身熱但身不痛爲異耳, 飽悶惡食不食噯氣作酸下泄臭屁或腹痛吐瀉重則發熱頭痛左手關脈平和右手關脈緊盛此傷食也 라하여소화불량의증상을기술하고있으며, 복통을각각寒腹痛, 熱腹痛, 死血腹痛, 食積腹痛, 痰飮腹痛, 蟲腹痛등의여섯가지로나누었는데이중식적복통의경우噯氣, 噯腐呑酸, 不慾飮, 脈沈滑, 或弦, 腹脹滿疼痛, 拒按, 惡食, 大便秘結하여痛瀉減하는특징을보여준다고하였다 19). 또한 금궤요략 에서는腹滿, 寒疝, 宿食이세질병이모두脾胃와관련이있어창만또는동통의증상이있고병위가비슷하며아울러치방을서로응용할수있기때문에하나로보는등 20) 다양한증상의양상으로나타나고있다. 소화불량의치료에서東垣은 惟氣不足故補益惟氣有餘故消導 가치료원칙이라하여허실에따라보익지제와소도지제로구분하여치료한다고하였다 19). 논문으로는자락 12) 이나九六補瀉자침의효과에대한연구 21) 등의침구치료에대한보고와내소화중탕 10), 반하사심탕 11) 등과같은한약치료의유효성에대한연구보고가있으며최근소화불량증에한방치료의효과가높다는연구 22) 도지속적으로보고되고있다. 이렇게소화불량에대한한약및침구치료가유효하다는사실이여러연구에서밝혀진바있지만약침에대한연구는미미한실정이다. 소화불량에대해약침학에서는속쓰림, 트림, 구역질, 상복부불쾌감, 위장의팽만감등의증상, 즉음식섭취후일어나는소화장애상태에대하여위적체, 상식, CC, 자하거약침을사용하여족삼리 (ST36), 중완 (CV12), 하완 (CV10), 불용 (ST19), 양문 (ST21), 천추 (ST25), 간수 (BL18), 비수 (BL20), 신수 (BL23) 등의혈위에시술한다고되어있으며 8) 다른약침관련문헌에서도기제나윤제를이용하여배수혈, 불용 (ST19), 부사 (SP13), 대거 (ST27) 등의혈위에시술한다고표기되어있다 7,9). 자하거 (Hominis placenta) 는건강한사람의태반을烘製하여건조한것으로, 溫性無毒하며폐, 간, 신 www.kjacupuncture.org 325
三經으로귀경하여補氣補陽益精하는효능이있으며 23), 자하거약침은사람의태반에서추출한것으로추출전후에간염바이러스를포함한수종의바이러스나세균에대한안정성검사가시행되어품질관리를한후용매추출법, 염산가수분해법, 산소분해법, 분자분획법등의방법에따라이루어진다. 자하거약침의효능은급만성간염, 간경화, 위궤양등의소화기계질환, 대상포진, 말초신경염등의신경계질환, 부정맥, 말초순환장애등의순환기계질환, 기관지염, 천식등의호흡기계질환, 갱년기장애, 생리불순등의부인과질환, 전립선비대, 신장염등의비뇨기계질환, 아토피, 기미등의피부과질환, 알레르기성비염등의이비인후과질환, 두통, 요통, 퇴행성관절염등의통증질환, 만성피로, 무력감등의노화방지같이다양한임상방면으로사용되고있으며 7) 연구 13-15) 또한활발하게진행되고있다. 임상적으로약침은침구와한약의병행또는대체치료로여러방면의질환에서널리사용되어왔으나급만성소화불량에대해서는비교적다용되지는않고있다. 다만체침으로잘낫지않고치료가오래걸리는중증의소화불량에대한약침학회에서나온약침학교과서를근거로하여사용할수있는혈위에자하거약침을시술하여임상적으로유효한효과를거두었다. 따라서이를규명하기위해 2011 월 4월부터 2012 년 9월까지동의대학교부속한방병원한방소화기내과에중증소화불량증을호소하며내원하여각각체침치료와자하거약침치료를받은환자중기능성소화불량증의특이적삶의질평가도구인 NDI-K 를이용하여치료와평가가완료되어치료가종료된환자를차트를후향적으로분석하여선정된각 30명씩을대상으로체침치료를대조군으로설정하여두군간의치료효과에대해비교분석하였다. NDI 는 Tally 등 24) 에의해서개발된기능성소화불량증의질병특이적삶의질평가도구로신뢰도와타당도, 내적일치도가검증되어있고, 증상변화와전반적삶의질점수의변화에대한반응도가높았으며 25-27) 또한구성타당도, 변별타당도및공존타당도에대해검정된바있다 24,25). 본연구에서는 NDI 를한국판으로번안한 NDI-K16 를사용하여소화불량증의증상및삶의질에대해평가되었다. 이번연구에서체침치료군과자하거약침치료군의일반적인특성은두군모두남자 8명여자 22명으로두군간의남녀비에대한유의한차이는없었고평균나이에서도체침치료군 48.50±13.32 세, 자하거약침치료군 47.30±16.48 세로두군간의유의한차이가없었다 (Table 1). 단, 남녀비가각각 4:11 로전반적으로여성이더많은것으로나타났는데이것은국내의다른보고 11,27) 와일치하는결과로여성호르몬이위장관운동을억제시키기때문으로추정 하고있다 28,29). 치료전체침치료군과자하거약침치료군의 NDI-K 15개증상점수비교에서자하거약침치료군은 11개의항목과총점이체침치료군보다낮았으며, 치료전의자하거약침치료군은 4개의항목이체침치료군보다높은수치를보여줬으나, 치료시작전두군간의 NDI-K 증상점수표의개별증상점수와총점수를비교한결과두군간의유의한차이가없어체침치료를대조군으로한비교연구가가능하였다 (Table 2). 체침치료군에서치료전후의 NDI-K 증상점수표의변화를비교해보면 15개의증상점수와총점은모두감소하였으며그중 11개의항목과총점에서유의한감소를보였다 (p<0.05). 특히상복부통증은평균 3.30 점감소되어가장많이감소하였고상복부팽만감은평균 1.13 점감소되어가장적게감소하였다 (Table 3). 자하거약침치료군에서치료후 NDI-K 증상점수표의변화를비교해보면상복부경련을제외한 14개의증상점수와총점이모두감소하였으며그중 9개의항목과총점에서유의한감소를보였다 (p<0.05). 상복부경련은오히려평균 0.40 점증가되어 15개의증상항목중유일하게증가하였다 (Table 4). 두군간의비교에서체침치료군에비해자하거약침군의증상개선항목이더적은것으로나타났다. 치료전후두군간증상항목비교에서자하거약침치료군의상복부경련을제외하고모든증상점수는감소하였으며, 자하거약침치료군이 9개항목과총점에서체침치료군보다적게감소했으며 6개항목에서체침치료군과비교하여더많이감소하였다. 체침치료군이자하거약침치료군에비해가슴쓰림항목에대하여유의한치료효과를나타내지만 (p<0.05) 나머지 14개의항목과총점은두군간에유의한차이가없었다 (Table 5). 이결과는중증소화불량으로인해나타난다양한증상에대해서자하거약침치료가기존의체침치료와비교하여동등한효과를가진것으로볼수있으며, NDI-K 증상점수 15항목중에서가슴쓰림한가지항목에대해유의한차이가나타난것에대해서는치료전자하거약침치료군이체침치료군에비해가슴쓰림을호소한환자수가적어서점수상경감의차이가크지않았던것으로볼수있다. 치료전체침치료군과자하거약침치료군의 NDI-K 삶의질점수비교에서는 NDI-K 의네가지삶의질영역중치료전의체침치료군은일상활동 / 업무의저해, 지식 / 조절, 먹고마시기, 수면장애, 총점수에서낮은점수를나타냈으나두군간에는역시유의한차이가없어, 체침치료를대조군으로한비교연구가가능하였다 (Table 6). 체침치료군에서치료후 NDI-K 삶의질변화를비교해보면네가지영역과총점은모두증가했으며일상활동 / 업무의저해, 지식 / 조절, 먹고마시기의세가지영역과총점수에서유의한증가를보 326 www.kjacupuncture.org
소화불량증에대한체침요법과약침요법의효과비교 였다 (p<0.05)(table 7). 자하거약침치료군에서치료후 NDI-K 삶의질의변화를비교해보면네가지영역과총점은모두증가했으며일상활동 / 업무의저해, 지식 / 조절, 먹고마시기의세가지영역과총점수에서유의한증가를보였다 (p<0.05)(table 8). 두군모두네가지영역중같은세가지영역에유의한증가를보여증상의개선항목이같은것으로나타났다. 치료후체침치료군과자하거약침치료군의 NDI-K 삶의질변화비교에서는치료후두군의삶의질네가지영역이모두증가했으며자하거약침치료군은일상활동 / 업무의저해, 지식 / 조절, 먹고마시기, 수면장애, 총점수에서체침치료군보다적게증가했으나두군간의유의한차이는보이지않았다 (Table 9). 이는두군모두치료효과가삶의질개선에탁월한효과를보여준다는결과로인식할수있으며두군간의삶의질개선정도는유의한차이가나지않는다고판단할수있다. 다만수면장애에대해두군모두유의한호전을보이지않았는데가슴쓰림의결과와동일하게두군모두치료전수면장애를호소하는환자가상대적으로적어서치료후호전의정도가크지않았던것으로볼수있다. 이상의결과를종합하면체침치료, 자하거약침치료모두특별한부작용없이중증소화불량증의다양한증상들을호전시키고삶의질을개선시키는데효과적인치료로볼수있으며체침치료와비교하여자하거약침치료의효과도큰차이가없는것으로나타나앞으로약침치료를중증의소화불량증뿐아니라만성, 기능성소화불량증에도확대하여효과적인치료법으로선용될수있는가능성을제시해준다. 또한 5회미만의치료에서완치되어대상으로선정되지않는환자들을포함한다면두군모두전체적인치료율이연구결과보다더높았을것으로추정된다. 다만체침과의비교연구에서다양한약침제제가있음에도불구하고자하거약침만을대상으로한것과차트분석을통한후향적관찰연구의한계상치료와평가를완료한환자들만대상으로한분석연구로중간에증상이악화되거나치료와관련된어떤요소로인해치료를완료하지못한분들은분석이되지않아최종적인자하거약침의효과분석에영향을미칠수있다는한계가있다. 따라서전향적인설계를통한치료효과의정확한분석이필요하며소화불량증에응용할수있는상식, 위적체등의다양한약침제제들을사용한추가적인연구와첩약이나한약제제등의약물과의비교연구, 기능성, 기질성소화불량증을포함한만성적인소화불량증에대해서도추가적인연구가진행되어야할것으로생각된다. 결론 2011 년 4 월부터 2012 년 9 월까지중증소화불량으로동의대학 교부속한방병원한방소화기내과에내원하여체침치료나자하거약침치료를받은환자를대상으로후향적차트분석에서선정기준을만족하고 NDI-K 를이용하여치료전후의증상과삶의질평가가완료된각 30명을선정하여체침과자하거약침치료의효과를비교분석한결과다음과같은결론을얻었다. 체침치료군과자하거약침치료군모두중증소화불량의증상에대해대체적으로유의한치료효과를나타내었다. 군간비교에있어서체침치료군이중증소화불량의증상중가슴쓰림에대해자하거약침치료군보다유의한효과를나타내었으나그이외의증상에대해서는두군간에유의한차이는없었다. 삶의질에대한지표에대해서수면영역을제외하고두군모두유의한효과를나타내었으며, 군간의효과비교에서는유의한차이가없었다. 이상의결과는체침뿐아니라자하거약침도중증소화불량증에적절한치료법으로응용될수있는가능성을보여주는것이다. 감사의글 This study was a master's thesis of oriental medicine, Dong-Eui University graduate school in 2013. References 1. Talley NJ, Philips SF. Non-ulcer dyspepsia : potential causes and pathophysiology. Ann Intern Med. 1988 ; 108 : 865-79. 2. Departments of Digestive System in Korean Colleges of Oriental Medicine. Text of Digestive System. Seoul : Koonja. 2008 : 264, 345. 3. Kim JE, Lee PL, Park DI, Hyun JG, Kim YH, Shim SG. Relationship between autonomic nerve dysfuction and gastric emptying time in patients with functional dyspepsia. Korean J Gastoenterol. 2000 ; 36(5) : 573-82. 4. Hu WH, Talley NJ. Functional (non-ulcer) dyspepsia ; unexplained but not unmanageable. Med J aust. 1998 ; 12 : 417-33. 5. Park YC, Jo JH, Son CG, Hong GE, Jeong IC, Kang WC, et al. Effect of acupuncture treatment for functional dyspepsia: a randomized controlled trial. The Journal of Korean Acupunc- www.kjacupuncture.org 327
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