대한내과학회지 : 제 90 권제 2 호 2016 http://dx.doi.org/10.3904/kjm.2016.90.2.93 특집 (Special Review) - 기능성위장관질환에있어서식이및영양요법 기능성위장관질환에있어서식이및영양요법 : 위식도역류질환 중앙대학교의과대학내과학교실 김범진 Diet and Nutritional Management in Functional Gastrointestinal Disorder: Gastroesophageal Reflux Disease Beom Jin Kim Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea Gastroesophageal reflux disease (GERD) is a common condition with a wide range of clinical manifestations. The clinical epidemiology of GERD is related to diet. It has been speculated that certain dietary factors may play a role in the pathogenesis or course of GERD. Physiological studies have shown a decrease in lower esophageal pressure and an increase in esophageal acid exposure in response to consuming a variety of foods. Subjects with GERD are sensitive to acidic juices, such as orange and tomato juices. Some patients are less tolerant to caffeine including coffee. Fatty foods and chocolate may weaken the lower esophageal sphincter, whereas protein may increase lower sphincter tone. Large meals distend the stomach, increase intragastric pressure, and facilitate gastroesophageal reflux. Alcohol consumption is another important risk factor for GERD. However, a wide-ranging review of the available data revealed conflicting findings regarding the impact of dietary factors on GERD. (Korean J Med 2016;90:93-97) Keywords: Gastroesophageal reflux; Diet; Lower esophageal sphincter 서론위식도역류질환 (gastroesophageal reflux disease, GERD) 은위내용물이식도로역류하여불편한증상을유발하거나이로인하여합병증을유발하는질환으로가슴쓰림이나신물이넘어오는것이대표적인증상이다. GERD 는환자의삶의질을저하시키고, 식도염을일으킬수있으며, 다른여러가지합병증을일으킬수있고, 호전과악화를반복하는만성경과를보인다. 이러한 GERD는서양에서는비교적흔하지만, 우리나라는아직까지서양에비해서낮은빈도로보고되고있다. GERD 의치료는현재프로톤펌프억제제를기본으로한약물요법이근간을이루고약물요법에반응하지않는일부환자에서수술등이적용되고있다. 그외생활습관개선과식이조절등이보조적인역할을한다. 생활습관개선이 GERD 치료에미치는영향은다양한인자가상호복합적으로작용하므로모든환자에게일반화시키기어렵다. 그러나생활습관개선이 GERD 환자의일부에서는증상의호전혹은장기적인증상재발방지에도움을줄수있다. Correspondence to Beom Jin Kim, M.D., Ph.D. Department of Internal Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea Tel: +82-2-6299-1355, Fax: +82-2-6299-2064, E-mail: kimbj@cau.ac.kr Copyright c 2016 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 93 - 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.
- The Korean Journal of Medicine: Vol. 90, No. 2, 2016 - 음식은 GERD를포함한상당수의기능성위장관질환에서증상의시작과악화에관여한다. 실제기능성위장관질환환자들은개인의주관적경험을통해스스로특정음식을증상유발인자로인식해회피하는경향이있다. 최근매스컴을통해특정음식과소화기증상의연관성및예방과치료를위한식이권고들이넘쳐나고있다. 그러나실제이를규명할수있는과학적인근거는빈약한실정으로식이요법은약물치료의보조적인역할로권고되고있다. 음식과관련된권고내용에는몇가지고려해야할점이있다. 한가지음식이라도여러가지영양성분으로구성되어있으므로주된영양소별접근이필요하다. 같은주된영양소를가진음식이라도개인마다섭취양이나속도, 조리방법이다를수있으므로일률적인제한은적절하지않을수있다. 본고에서는 GERD의생활습관중식이에관해특정음식과 GERD와의연관성에대해알아보고증상완화와악화에영향을주는음식들에대해정리해보고자한다. 본문술음주는가스트린자극을통해산분비를증가시키고, 하부식도조임근 (lower esophageal sphincter, LES) 의압력을낮추고, 자발적인 LES 이완을증가시키며식도연동과위배출운동성을저해하여 GERD를일으킬수있다 [1]. 음주는 GERD 증상이없는건강한사람에서 24시간식도산도가정상이더라도역류증상을일으키고식도산도를낮춘다 [2-5]. 무작위및단면연구들에서음주자들에서역류증상의유병률이증가된다고보고하였고 [6-9], Wang 등 [10] 의연구에서는비음주자의 16% 에서역류증상이있었고, 주당 210 g의음주자의 43% 에서역류증상이발생하였다 (odds ratio, 2.85; 95% confidence interval, 1.67-4.49; p < 0.01). 그러나대규모의다국적단면연구는유사한연관관계를보이지않았다 [11]. 환자-대조군연구에서 GERD 증상이있는음주환자를대조군인비음주자, GERD가있는환자및호두까기식도 (nutcracker esophagus) 를가진환자와비교하였을때, 대부분의음주자들은 6개월이상금주를하였을경우식도산도의호전없이도고압성 LES (LES hypertension), 고진폭식도수축 (high-amplitude esophageal contractions) 또는비연동성식도수축 (nonperistaltic esophageal contractions) 이호전되었다 [12]. 따라서금주가산도나 GERD 증상에직접영향을준다는충분한근거가없더라도금주후에식도운동성이상은호전되는것으로확인되었다. 커피와카페인산에민감한환자에게커피혹은카페인음료를식도내로주입하였을때흉부작열감을일으킨다고알려져있다 [13]. 그러나, 두개의큰역학조사에서는커피섭취와 GERD와는연관이없었고 [10,11], 최근노르웨이의조사에서커피섭취와 GERD는상관관계가없었다 [14]. 몇몇연구에서는규칙적으로디카페인커피를마셨을경우 LES 압력이증가하였고 [15,16], 다른연구에서는 GERD를가진환자에서대조군과비교하였을때역류횟수, 총역류시간, LES 압력에영향을주지않았다 [17]. 커피를제조하는과정, 로스팅방법, 공정과정등이 GERD 변수에영향을줄수있다는연구결과가있다 [18-21]. 디카페인커피를섭취한경우를카페인커피를섭취한경우와비교하였을때일부연구에서는산분비가유의하게적었다 [22]. Salmon 등 [23] 은환자들이커피에노출되는지여부에따라식후 LES 압력이낮게측정될수있어식후에커피를자주마시는사람들의경우는커피와 GERD와의상관관계에혼동을줄수있다고주장했다. GERD 환자에서금식이나표준시험식사를했을때커피가 LES 압력을낮춘다는일부보고도있다 [24]. 상충되는결과를감안할때카페인이나커피와 GERD와의연관성은아직명확하게밝혀지지않은상태이다. 따라서, GERD 환자에서커피나카페인류를통상적으로제한하는것은명확한근거가없다. 신과일과주스신과일은종종흉부작열감을일으킨다. 약 400명의 GERD 환자를대상으로한설문조사에서응답자의 72% 가오렌지나포도주스를섭취하였을때흉부작열감이증가하였다 [25]. 그러나 Price 등 [13] 은산에민감한환자 (bernstein 검사결과양성 ) 에서식도내로오렌지주스를주입한후민감하게반응했고, 심지어오렌지주스가 ph 7로조정되었을때도마찬가지였다는결과를감안하였을때 GERD 환자에서신과일이미치는영향은산도때문만은아니라고주장하였다. Cranley 등 [26] 은오렌지주스를주입하였을때대조군은 LES 압력이중가한반면, GERD 환자에서는 LES 압력이변하지않았다고보고하였다. 그러나 GERD에서신과일의회피효과에대한연구는아직까지보고되지않았다. 탄산음료탄산음료가 GERD를일으킨다는가정하에여러연구들이진행되었다 [27]. 한연구에서는다변량분석을통해탄산음료섭취가 GERD 증상의예측인자라고보고하였다 [28]. 건강 - 94 -
- Beom Jin Kim. Gastroesophageal reflux disease and diet - 인을대상으로한작은규모의연구에서는탄산수섭취, 카페인이첨가된콜라섭취또는디카페인콜라를섭취한경우를물을섭취한경우와비교하였을때 LES 압력이동등하게감소하였다 [29]. 그러나아직까지탄산음료중단효과에대한연구는없다. 초콜렛초콜렛은자주 GERD 의자극인자로언급된다. 초콜렛이식도산도와 LES에영향을준다는근거는제한적이다. 한연구에서초콜렛시럽 120 ml를섭취하였을때 LES 압력이유의하게낮아졌다 (p < 0.01) [30]. Murphy and Castell [31] 은전형적인 GERD 증상을가진 7명의환자에서검사용음료 ( 초콜렛과동일한삼투압과칼로리 ) 를섭취한경우와비교하였을때초콜렛섭취를한경우에산분비시간이유의하게길었다고보고하였다 (p = 0.04). 그러나, GERD 증상에대해초콜렛을제한하였을때의효과를언급한연구는없다. 매운음식환자들은자주매운음식을먹었을때흉부작열감을호소하지만매운음식섭취가 LES 압력이나식도산도에영향을준다고보고한연구결과는거의없다. 한연구에서는 GERD 환자의경우대조군과비교하여양파섭취로인해역류횟수가늘어나고 (p < 0.01) 식도의산노출시간이증가하였다 (p < 0.05) [32]. 많은환자들은매운음식이자신의 GERD 증상을악화시킨다고믿지만매운음식을회피했을때 GERD 증상에변화를일으킨다고보고는없다. 기름진음식 었을때민감도를높인다고추측하고있다. 무작위임상시험에서 GERD를가진 8명의환자와대조군 11명에서식도내로염산을주입한후위내로등장성식염수와 20% 지방용액을주입하였을때지방주입과관련된산에대한민감도와증상에서는유의한차이가없었다 [33]. 두개의연구에서는환자가십이지장내로지방용액과등장성식염수중어느것을주입했는지여부와는상관없이흉부작열감증상이나산주입에의한역류증상발병까지의시간이유의하게짧아졌다 [34,35]. 따라서, 지방주입이 LES 압력이나일시적인 LES 이완에는영향을미치지않는것으로생각된다. Nebel and Castell [36] 은건강인에서동일한열량을가진지방과단백질식사를섭취한후 LES의반응을평가한결과, 단백질식이를한경우에 LES 압력이증가되었던것에비해지방식이를한경우에는 LES 압력이유의하게낮아졌다고보고하였다. Becker 등 [37] 은고지방및저지방식이후에식도산분비를연구한결과지방량은식도의산도이상과는유의한연관이없다고하였다. 20명의건강인을대상으로한연구에서고지방식이를한경우저지방식이를한경우에비해산분비가유의하게증가하였고, 많은용량을섭취한환자들은산분비가증가하였다 [38]. 다른무작위연구에서고지방식이를한경우와저지방식이를한경우를비교하였을때 LES 압력, 일시적인 LES 이완, 역류의횟수, 식도산분비등에차이가없었다 [39,40]. 지방함량보다는음식의칼로리함량에따라영향을받는지에대한논의는여러상반되는연구결과가있다 [39,41]. 앞서언급한연구를바탕으로식사의지방함량이 GERD 결과에영향을주는지에대한정보는부족하다. 최근연구에서도 GERD 환자의식이에지방을제한하도록하는근거는없다. 지방이역류를증가시킬뿐만아니라식도에산이노출되 Table 1. Dietary recommendations for patients with GERD Food group Recommended Avoid Grains, breads Any with low-fat content Any prepared with whole milk or high fat Meat, meat substitutes Low-fat meat, chicken, fish, turkey Cold cuts, sausage, bacon, fatty meat, chicken fat/skin Vegetables All vegetables Fried or creamy style vegetables, tomatoes Fruits Apples, berries, melons, bananas, peaches, pears Citrus, such as oranges, grapefruits, and pineapple Milk or milk products Skim or low fat milk and low-fat or fat free yogurt Whole milk and chocolate milk Fats, oils None or small amounts All animal and vegetable oils Sweets, desserts No or low fat Chocolate desserts made with oil and/or fat Beverages Decaffeinated, non-mint herbal tea, juices (except citrus), and water Alcohol, coffee (regular or decaffeinated), carbonated beverages, tea, and mint tea GERD, gastro-esophageal reflux disease. - 95 -
- 대한내과학회지 : 제 90 권제 2 호통권제 666 호 2016 - 결 지금까지 GERD와음식에관련된연구결과들을 Table 1에요약하였다. GERD 의병태생리는음식외에도여러인자의복합적인상호작용으로이루어지므로특정음식의일률적인제한이나권고는아직까지제한적이라고할수있다. 음식은여러가지영양소를포함하고있으므로 GERD의식이요법은주된영양소에따른개별적인접근이필요하다. 최근기능성위장관질환에서 Fermentable Oligo-, Di-, Mono-saccharides And Polyols (FODMAP) 등음식의역할이주목을받기시작하면서과학적인증거들이축적되고있으나, 대부분의연구들이서양인들을대상으로한서양음식에관한내용으로그대로우리나라진료에적용시키기는무리가있다. 향후한국인에적합한 GERD의식이요법에대한전향적연구가필요하다. 론 중심단어 : 위식도역류질환 ; 식이 ; 하부식도조임근 REFERENCES 1. Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol 2000;95:3374-3382. 2. Kaufman SE, Kaye MD. Induction of gastro-oesophageal reflux by alcohol. Gut 1978;19:336-338. 3. Vitale GC, Cheadle WG, Patel B, Sadek SA, Michel ME, Cuschieri A. The effect of alcohol on nocturnal gastroesophageal reflux. JAMA 1987;258:2077-2079. 4. Rubinstein E, Hauge C, Sommer P, Mortensen T. Oesophageal and gastric potential difference and ph in healthy volunteers following intake of coca-cola, red wine, and alcohol. Pharmacol Toxicol 1993;72:61-65. 5. Grande L, Manterola C, Ros E, Lacima G, Pera C. Effects of red wine on 24-hour esophageal ph and pressures in healthy volunteers. Dig Dis Sci 1997;42:1189-1193. 6. Rosaida MS, Goh KL. Gastro-oesophageal reflux disease, reflux oesophagitis and nonerosive reflux disease in a multiracial Asian population: a prospective, endoscopy based study. Eur J Gastroenterol Hepatol 2004;16:495-501. 7. O Leary C, McCarthy J, Humphries M, Shanahan F, Quigley E. The prophylactic use of a proton pump inhibitor before food and alcohol. Aliment Pharmacol Ther 2003;17:683-686. 8. Avidan B, Sonnenberg A, Schnell TG, Sontag SJ. No association between gallstones and gastroesophageal reflux disease. Am J Gastroenterol 2001;96:2858-2862. 9. Talley NJ, Piper DW. Comparison of the clinical features and illness behaviour of patients presenting with dyspepsia of unknown cause (essential dyspepsia) and organic disease. Aust N Z J Med 1986;16:352-359. 10. Wang JH, Luo JY, Dong L, Gong J, Tong M. Epidemiology of gastroesophageal reflux disease: a general population-based study in Xi an of Northwest China. World J Gastroenterol 2004;10:1647-1651. 11. Stanghellini V. Relationship between upper gastrointestinal symptoms and lifestyle, psychosocial factors and comorbidity in the general population: results from the Domestic/International Gastroenterology Surveillance Study (DIGEST). Scand J Gastroenterol Suppl 1999;231:29-37. 12. Grande L, Monforte R, Ros E, et al. High amplitude contractions in the middle third of the oesophagus: a manometric marker of chronic alcoholism? Gut 1996;38:655-662. 13. Price SF, Smithson KW, Castell DO. Food sensitivity in reflux esophagitis. Gastroenterology 1978;75:240-243. 14. Nilsson M, Johnsen R, Ye W, Hveem K, Lagergren J. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut 2004;53:1730-1735. 15. Cohen S, Booth GH Jr. Gastric acid secretion and loweresophageal-sphincter pressure in response to coffee and caffeine. N Engl J Med 1975;293:897-899. 16. Cohen S. Pathogenesis of coffee-induced gastrointestinal symptoms. N Engl J Med 1980;303:122-124. 17. Boekema PJ, Samsom M, Smout AJ. Effect of coffee on gastro-oesophageal reflux in patients with reflux disease and healthy controls. Eur J Gastroenterol Hepatol 1999;11:1271-1276. 18. DiBaise JK. A randomized, double-blind comparison of two different coffee-roasting processes on development of heartburn and dyspepsia in coffee-sensitive individuals. Dig Dis Sci 2003;48:652-656. 19. Brazer SR, Onken JE, Dalton CB, Smith JW, Schiffman SS. Effect of different coffees on esophageal acid contact time and symptoms in coffee-sensitive subjects. Physiol Behav 1995;57:563-567. 20. Van Deventer G, Kamemoto E, Kuznicki JT, Heckert DC, Schulte MC. Lower esophageal sphincter pressure, acid secretion, and blood gastrin after coffee consumption. Dig Dis Sci 1992;37:558-569. 21. Wendl B, Pfeiffer A, Pehl C, Schmidt T, Kaess H. Effect of decaffeination of coffee or tea on gastro-oesophageal reflux. Aliment Pharmacol Ther 1994;8:283-287. 22. Pehl C, Pfeiffer A, Wendl B, Kaess H. The effect of decaffeination of coffee on gastro-oesophageal reflux in patients with reflux disease. Aliment Pharmacol Ther 1997;11: 483-486. 23. Salmon PR, Fedail SS, Wurzner HP, Harvey RF, Read AE. Effect of coffee on human lower oesophageal function. Digestion 1981;21:69-73. - 96 -
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