대한내과학회지 : 제 88 권제 2 호 2015 http://dx.doi.org/10.3904/kjm.2015.88.2.156 의학강좌 - 개원의를위한모범처방 (Current Clinical Practice) 소화성궤양출혈의진단과치료 충남대학교의학전문대학원충남대학교병원내과 성재규 Diagnosis and Management of Peptic Ulcer Bleeding Jae Kyu Sung Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea Despite the generally declining trend in the incidence of peptic ulcers, peptic ulcer bleeding remains a prevalent and clinically significant condition. Additionally, despite the development of therapeutic endoscopy and acid-suppressive therapy, the overall mortality associated with peptic ulcer bleeding has remained at about 6% to 14%. Management of acute peptic ulcer bleeding requires prompt resuscitation, risk assessment, early endoscopic evaluation, and early initiation of pharmacotherapy. Advances in therapeutic endoscopic techniques and antisecretory therapies in the past few decades have reduced the incidence of recurrent bleeding and the mortality rate associated with this disease. Strategies to prevent recurrence have been defined for various causes of peptic ulcer bleeding. This article reviews the current diagnosis and management of acute peptic ulcer bleeding. (Korean J Med 2015;88:156-160) Keywords: Peptic ulcer hemorrhage; Diagnosis; Disease management 서론급성상부위장관출혈의발생률은연간인구 100,000명당 48-160건이며 [1] 소화성궤양출혈은상부위장관출혈의가장흔한원인으로약 36% 를차지한다 [2]. 헬리코박터파일로리제균과양성자펌프억제제사용의증가등에힘입어소화성궤양출혈의발생빈도가감소했다는보고가있지만아스피린, 비스테로이드소염제및항소판제사용의증가, 고령층의증가, 기저질환등에의해사망률은여전히 6-14% 로감소하지않고있는실정이다 [1,3,4]. 본고에서는실제진료현장에서소화성궤양출혈의진단과치료에대해알아보고자한다. 초기소생술과위험도평가환자는토혈, 흑색변, 혈변, 현기증등의증상으로내원하게되는데혈관내용적변화를예측하기위해맥박수및혈압 ( 기립성혈압변화포함 ) 측정등혈역학상태를평가하고 Correspondence to Jae Kyu Sung, M.D., Ph.D. Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282 Munhwa-ro, Jung-gu, Daejeon 301-721, Korea Tel: +82-42-280-7186, Fax: +82-42-253-4553, Email: jksung69@cnuh.co.kr Copyright c 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 156 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- Jae Kyu Sung. Peptic ulcer bleeding - 소생술을하는것이필요하다. 상당한혈관내용적손실이있으면안정시맥박수가분당 100회이상이고수축기혈압이 100 mmhg 미만이거나체위에따른혈압변화 ( 기립시분당 20회이상맥박수증가또는기립시수축기혈압이 20 mmhg 이상감소 ) 가나타난다. 점막이나경정맥검사, 소변배출량측정으로추가적인혈관내용적상태를추정할수있다. 우선적으로수분소실을교정하고혈역학안정성을복원하는것이중요하다. 대구경정맥카테터 (16-18게이지말초혈관카테터또는중심정맥카테터 ) 를이용하여정질성용액 (crystalloid fluids) 을정주한다. 또한산소공급을하고응고장애가있으면교정한다. 수혈의역치는기저질환, 혈역학상태등을고려하여개별화한다. 일반적으로헤모글로빈 7 g/dl 이상을목표하지만관상동맥질환 [5] 같은기저질환이있거나혈관내액이충원되기전에혈색소가일시적으로높은상태이나혈관내용적소실이있는경우 ( 저혈압, 빈맥 ) 에는좀더높은혈색소수준을목표로수혈해야한 다 [6]. 위험도평가를하여고위험군과저위험군으로분류하는것이필요한데, 이는재출혈및사망률을예측하고입원결정, 집중치료여부, 내시경검사의시기, 퇴원시기등을판단하는기준으로유용하다 [6]. 확증된점수화평가법으로서 Blatchford score (Table 1) [7] 와 Rockall score (Table 2) [8] 가있는데 Blatchford score는임상변수와검사실변수로이루어져있으며상부위장관출혈환자에서의학적처치 ( 수혈, 내시경치료, 수술치료 ) 필요성과사망의위험도를예측하는데유용하여 [7] 한가이드라인에서는모든상부위장관출혈환자는초기에 Blatchford score로평가하기를권유한다 [9]. Rockall score는내시경시행전임상변수로이루어진임상 Rockall score (clinical Rockall score) 와임상변수및내시경소견을포함하는완전 Rockall score (complete Rockall score) 로분류할수있으며재출혈과사망위험을예측하는데유용하다 [8]. Table 1. Blatchford score At presentation Score Blood urea, mmol/l 6.5-7.9 2 8.0-9.9 3 10.0-24.9 4 25 6 Hemoglobin for men, g/l 12.0-12.9 1 10.0-11.9 3 < 10.0 6 Hemoglobin for women, g/l 10.0-11.9 1 < 10.0 6 Systolic blood pressure, mmhg 100-109 1 90-99 2 < 90 3 Other variables Pulse 100 1 Melena 1 Syncope 2 Hepatic disease 2 Cardiac failure 2 Table 2. Rockall score Clinical variables Score Age < 60 0 60-79 1 80 2 Shock No shock 0 Heart rate > 100 beat/min 1 Systolic blood gastro < 100 mmhg 2 Comorbidity Nil major 0 Ischemic heart disease, congestive heart 2 failure, other major Renal failure, hepatic failure, disseminated 3 malignancy Endoscopic variables No lesion, Mallory-Weiss tear 0 Peptic ulcer, erosive disease, esophagitis 1 Cancer of upper gastrointestinal tract 2 Clean ulcer base, flat pigmented spot 0 Blood in upper gastrointestinal tract, active 2 bleeding, visible vessel, clot - 157 -
- 대한내과학회지 : 제 88 권제 2 호통권제 654 호 2015 - 내시경시행전약물치료와내시경검사내시경검사전고용량양성자펌프억제제정맥주사를고려할수있는데이는내시경상고위험출혈반 (high-risk stigmata) 비율을줄일수있으나재출혈, 수술또는사망률을감소시키지는못한다고알려져있다 [10]. 만약내시경검사가 24시간내이루어지기어려울경우나내시경을시행하기어려울경우출혈을줄이기위해고용량양성자펌프억제제정맥주사를하는것이좋겠다. 내시경검사는출혈의원인을찾고재출혈등의예후를예측하고내시경치료를할수있다는점에서중요한검사이다. 24시간이내에시행하는것이권장되며 [11] 만약빈맥, 저혈압, 토혈등의고위험임상상인경우에는환자의임상결과를향상시기위해 12시간내시행하는것이좋겠다 [6]. 출혈성궤양의내시경소견은일반적으로 Forrest 분류 [12] 에근거해서기술하는데이는재출혈의위험도를예측하여내시경치료가필요한지결정하는데유용하다 [13]. 내시경소견상분출성출혈 (Forrest class IA), 삼출성출혈 (class IB) 비출혈혈관노출 (class IIA) 인경우내시경치료가필요하다. 반면편평하고착색된반점 (class IIC) 이나깨끗한저부 (class III) 인경우에는내시경치료가필요없다 [14-17]. 혈괴가부착된소견 (class IIB) 인경우내시경치료를해야하는가에대해서는아직논란이있으나 Asia-Pacific 가이드라인에서는적어도 5분이상열심히물로씻어잘떨어지지않으면내시경치료를할것을권유한다 [18]. 차내시경검사는권장되지않으며재출혈의징후가있을때 2차내시경을시행한다 [6]. 위궤양은때로육안적으로위암과구별이어렵다. 반드시조직검사를시행하여위암과감별해야한다. 첫내시경검사에서조직검사가시행되지않았을경우가급적조속히내시경재검을하여조직검사를해야한다. 내시경시행후약물치료위산은혈액응고과정에손상을주고혈소판응집와해를촉진시키며섬유소용해에유리하게작용한다 [20]. 따라서위산분비를억제함으로써혈괴안정화를촉진시켜재출혈을낮출수있다. 그런데 H 2 수용체길항제는조기약제내성으로추정되는이유로인해의미있는치료결과를나타내지못했고 [21] 반면고용량양성자펌프억제제는재출혈률, 수술률및사망률을감소시킬수있었다 [22]. 그러므로현재우리나라 [23] 및여러가이드라인 [6,11] 에서고용량양성자펌프억제제점적투여를권장하고있다. 즉양성자펌프억제제 (omeprazole, pantoprazole, esomeprazole) 80 mg을 bolus 정맥주사후시간당 8 mg을 72시간동안지속점적주사한다. 소마토스타틴 (somatostatin) 과그유도체인 octreotide는위산과펩신분비를억제시키고위-십이지장점막혈류를감소시키는효과가있지만소화성궤양출혈에서의효과는증명되지못했다 [24]. 내시경치료 방사선중재치료, 수술 내시경지혈방법에는크게주사법 ( 에피네프린, 경화제, 조직접착제혹은병합 ), 응고술 (monopolar 혹은 bipolar electrocoagulation, heater probe 등의접촉방법혹은아르곤플라즈마와같은비접촉방식 ) 및내시경클립과같은기계적인지혈술이있다. 에피네프린국소주입단독요법은약 20% 의재출혈이보고되어단독치료로는권장되지않으며응고술이나기계적인지혈술을시행하기전에내시경시야의확보에도움이될수있다 [19]. 아직표준화내시경치료법은없고병합치료가권장되고있으며결국내시경의가가장익숙한지혈방법을선택하는것이좋겠다. 조기내시경시술이후 24시간이내에시행하는예정된 2 혈관조영술과동맥색전술은내시경으로급성출혈부위를찾지못했거나지혈되지않는환자에게시도할수있는비수술적진단및치료방법이다. 그외치료로서내시경치료가불가능하거나지혈에실패했을경우응급수술을시행한다. 퇴원후약물치료및재발방지모든소화성궤양출혈환자는헬리코박터감염여부검사를받아야한다 [11]. 그런데출혈을동반한궤양에서는위음성의가능성이높을수있다는점에유의해야한다 [25]. 따 - 158 -
- 성재규. 소화성궤양출혈의진단과치료 - 라서처음에음성이면다시검사하여확인하는것이권장된다 [6,11]. 헬리코박터제균은소화성궤양출혈의재발을방지할수있는가장중요한치료이므로헬리코박터감염이확인된경우제균해야한다. 후에제균이확인되면비스테로이드나항혈소판제가필요하지않는한산분비억제제유지요법은필요없다 [6]. 항궤양제는일반적으로 4-8주투여하며투약종료후내시경재검을하여출혈병소가치유되었는지확인해야한다. 특히위궤양출혈인경우첫내시경조직검사에서양성위궤양으로진단된경우라하더라도약물치료후반드시내시경재검을통해위암이아님을확인해야한다. 비스테로이드소염제연관성궤양에서의출혈인경우비스테로이드소염제중단이가능하다면 H 2 수용체길항제또는양성자펌프억제제로치료하고만약중단이불가능하다면양성자펌프억제제를투여해야한다. 재발방지를위한예방법으로가능하면비스테로이드소염제를중단하지만중단할수없는경우에는 cyclooxygenage-2 억제제와양성자펌프억제제를병용치료한다 [6]. 저용량아스피린을사용하는환자에서의출혈성궤양인경우치료는일반적인비스테로이드소염제관련소화성궤양출혈환자에서와동일하다. 미국소화기학회가이드라인에의하면재발방지를위해아스피린복용의필요성을확인하여 2차예방, 즉기저심혈관질환이있어서복용한경우면출혈이멈춘후가능한조속히아스피린을다시투약하고장기적으로양성자펌프억제제를병용투여한다. 하지만 1차예방, 즉기저심혈관질환이없다면대부분의환자에서아스피린복용을중단시킨다 [6]. 헬리코박터음성이고비스테로이드소염제와무관한특발성궤양인경우에치료는양성자펌프억제제를 1차약제로선택하여투여한다. 아직명확한재발방지법은없는실정이지만장기적으로매일양성자펌프억제제를투약하기를권한다 [6]. 결론내시경기술과약물치료의발달에도불구하고출혈성소화성궤양의사망률은큰변화가없는실정이다. 이질환이의심되는환자가내원시조기에출혈량및위험도를평가하고수액공급등적절한조치가필요하다. 24시간내내시경검사를시행하여진단, 치료및재출혈등의예후를예측 하고고용량양성자펌프억제제를투여하여재출혈방지를도모해야할것이다. 또한향후장기적재발방지를위해헬리코박터등의원인에따른대책을숙지하여예방해야할것이다. 아울러내시경재검을통해궤양치유여부를확인하고위암을감별해야한다. 중심단어 : 소화성궤양출혈 ; 진단 ; 치료 REFERENCES 1. van Leerdam ME, Vreeburg EM, Rauws EA, et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterology 2003; 98:1494-1499. 2. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut 2011;60:1327-1335. 3. Theocharis GJ, Thomopoulos KC, Sakellaropoulos G, Katsakoulis E, Nikolopoulou V. Changing trends in the epidemiology and clinical outcome of acute upper gastrointestinal bleeding in a defined geographical area in Greece. J Clin Gastroenterol 2008;42:128-133. 4. Czernichow P, Hochain P, Nousbaum JB, et al. Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas. Eur J Gastroenterol Hepatol 2000;12:175-181. 5. Wu WC, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001;345:1230-1236. 6. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-360; quiz 361. 7. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318-1321. 8. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-321. 9. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K; Guideline Development Group. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ 2012;344:e3412. 10. Sreedharan A, Martin J, Leontiadis GI, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 2010;(7):CD005415. 11. Barkun AN, Bardou M, Kuipers EJ, et al. International con- - 159 -
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