J Korean Med. 2016;37(3):27-38 pissn 1010-0695 eissn 2288-3339 Original Article 기능성소화불량증환자와건강인의어제혈색택비교연구 김민지, 고석재, 박재우 경희대학교한의과대학비계내과학교실 Skin Color Measurement of LU10; Comparison between Functional Dyspepsia Patients and Healthy Controls Min-ji Kim, Seok-Jae Ko, Jae-Woo Park Department of Gastroenterology, College of Korean Medicine, Kyung Hee University Objectives: According to Korean Medicine theory, the skin color of LU10 serves as a diagnostic clue to dyspeptic symptoms. The aims of this study were (1) to find the difference of skin color in LU10 region between functional dyspepsia (FD) and healthy control (HC) and (2) to examine the relationship between LU10 skin color parameters and dyspeptic symptoms. Methods: 39 participants (29 FD and 10 HC) have participated in this study. They were asked to complete gastrointestinal scale (GIS), gastrointestinal symptom rating scale (GSRS), Nepean dyspepsia index (NDI), functional dyspepsia-related quality of life (FD-QoL), visual analogue scale (VAS) for dyspeptic symptoms, food retention questionnaire (FRQ) and cold heat questionnaire (CHQ). L* (luminance), a* (red-green balance) and b* (yellow-blue balance) values of LU10 region were calculated through digital images of the participant's hand. Then we evaluated test-retest reliability of L*, a* and b* values of LU10 region. Additionally, we compared L*, a* and b* values of LU10 between FD and HC, and examined the relationship between LU10 color parameters and seven questionnaires scores. Results: Only L* values in LU10 region were significantly higher in FD compared with HC. GIS scores and the subset scores of NDI had a positive correlation with L* values significantly. Correlation coefficients of test-retest reliability of skin color measurement of LU10 ranged from 0.871 to 0.936 representing very strongly statistically significant (P<0.001). Conclusions: We confirmed the difference of skin color in LU10 region between FD and HC, and relationship between LU10 skin color parameters and dyspeptic symptoms. Key Words : Functional dyspepsia, L*, a*, b*, LU10, Korean medicine, Diagnosis 서론한의학의진단방법에는망진 ( 望診 ), 문진 ( 聞診 ), 문진 ( 問診 ), 절진 ( 切診 ) 이있으며, 이를약칭하여사진 ( 四診 ) 이라부른다 1. 망진은환자에게서가장먼저파악할수있는부분으로 2, 의사가시각을통하여환 자의정신상태, 면색 ( 面色 ), 형체 ( 形體 ), 동태 ( 動態 ), 국소상황, 설상 ( 舌象 ) 및분비물과배설물의색, 질, 양등의변화를관찰하는방법이다 1. 靈樞本臟篇 에서 視其外應以知內臟, 則知所病矣 라고하였고 3, 丹溪心法 에서는 欲知其內者當以觀乎外, 診於外者, 斯以知其內, 蓋有諸內者必形諸外 1 라고하여 Received:4 May 2016 Revised:7 September 2016 Accepted:7 September 2016 본논문은 2016 년도경희대학교대학원석사학위논문임. Correspondence to: 박재우 (Jae-Woo Park) 서울시동대문구회기동 1 번지경희대학교한의과대학비계내과학교실 Tel:+82-02-440-6219, Fax:+82-2-440-7143, E-mail:pjw2907@khu.ac.kr 27
(328) 외부에나타난변화를관찰하여내재한병변을유추해내는망진의방법은한의학적이론에근거한진단방법이라고볼수있다. 망진의방법중찰색 ( 察色 ) 은여러부위의색택 ( 色澤 ) 과피부상태를살피는방법으로, 색의변화는시시각각변하여기운의변화를반영하므로찰색을통해지금현재에가지고있는병의상태와그변화를판단할수있어장점이있다 2. 어제 ( 魚際 ) 혈부위색택을관찰하는망진법은 靈樞經脈篇 에서진어제락맥법 ( 診魚際絡脈法 ) 으로처음언급된이후 4, 靈樞論疾診尺篇 에서 掌中熱者腹中熱掌中寒者腹中寒, 魚上白肉有靑血脈者胃中有寒 5 이라고하였고, 楊 6 은어제혈이위한 ( 胃寒 ) 과위열 ( 胃熱 ) 을진단하는데효과적이며, 어제혈부위의색택과소화기증상과의관련성을언급하여진어제락맥법을구체화하였다. 이는어제혈의색택변화를관찰함으로써소화관혹은내장의기능상태를간접적으로평가하는데문헌적근거가되며, 만성소화불량환자들에게서어제혈망진법이진단의생체지표로활용될수있는가능성을언급하고있다. 현재까지망진에대한객관화연구는설진과 7, 홍채진단 8, 사상체질의안면계측 9 등다양한분야에서이루어졌으며, 최근에는디지털카메라를활용하여안면부색분석을시행하여망진과변증설문지와의상관성을분석한연구가시행되어신뢰성이검증되었다 10. 이로써고가의색측정장비인색차계 (spectrometer) 없이도디지털카메라와디지털이미징소프트웨어만을활용하여간편하게색변수 (color parameter) 의분석을시행하여신뢰성있는정량적평가가가능해졌다. 따라서본연구도선행연구의방법을차용하여소화관혹은내장의기능상태를간접적으로반영한다고알려져있는어제혈의색택변화를디지털카메라를활용하여기능성소화불량증환자군과건강대조군간비교분석함으로써어제혈망진법의유용성을검증하고자하였다. 연구대상및방법 1. 연구대상본연구는 2015년 2월 1일부터 2015년 10월 23 일까지강동경희대학교한방병원에서모집된실험군 31명, 건강대조군 10명을상대로진행되었으며, 참가자총 41명중개인적사유중단 1명, 프로토콜위반으로분석에서제외된경우 1명을제외하여최종적으로 39명이시험을완료하였다. 실험군대상자는 30세에서 49세사이의 Rome Ⅲ criteria 11 에서기능성소화불량증 (functional dyspepsia, FD) 기준의아형중식후포만감, 팽만감, 조기만복감을주로호소하는식후불편감증후군 (PDS) 유형의환자만을모집하였다. 대조군으로소화불량이없는동일한연령대의건강인을모집하였다. 본연구는강동경희대학교한방병원기관생명윤리심의위원회의심의 (KHNMC-OH-IRB 2014-08-002) 를거쳤으며, 모든연구대상자는충분한설명을듣고, 자발적으로연구에참여하기를원하는자에한해서서면동의를획득한이후진행되었다. 2. 연구방법 1) 디지털카메라를활용한어제혈촬영모든참가자는촬영 2시간전부터손을씻지않도록사전교육을하였고, 일정한온도 (22~23 ) 와습도가유지되는실내에서 30분이상대기하도록하였으며, 채혈, 필기, 휴대폰사용, 손씻기, 박수치기, 뜨겁거나차가운물체의접촉등손을사용하는활동을제한하였다. 촬영은외부의자연광이차단된실내에서동일한위치에서진행되었으며, 주로사용하는반대측손을장측을앞으로하여촬영하였다. 조명은 LED 광원 (CN-T96, ProDean, USA) 및실내외부형광등으로일정하게유지하였고, 후면에 60ⅹ80cm 크기의브라이트박스 (Photoballey, Korea) 를설치한후, 삼각대에고정한디지털카메라 (IXUS 105, Canon Co., USA) 를사용하여 10cm 거리에서촬영하였다 28
기능성소화불량증환자와건강인의어제혈색택비교연구 (329) Fig. 1. Settings for photographing participant s hand. A digital camera with tripod, LED lights and photobox. (Figure 1). 어제혈은제 1 중수골중앙의적백육제 ( 赤白肉祭 ) 상에위치한혈자리로, 단모지외전근상의영역을본연구의관심영역 (regions of interest, ROIs) 으로설정하여실제측정면적은약 3cmⅹ5cm이었고, 대조를위해동일한손바닥내의비경혈부위 ( 제 2~5 중수수지관절부위로서어제혈촬영면적과동일한면적 ) 를함께비교분석하였다 (Figure 2). 촬영시어제혈하단에흰색의종이판을참조색으로위치시켜노출변이를보정하였다. 디지털이미지는해상도 4000ⅹ3000 픽셀로 JPEG 형태의파일로저장하였다. 2) L*, a*, b* 산출저장된이미지는 Capture NX (Nikon Co., Japan) 프로그램으로전송하여, 화이트밸런스도구를사용하여참조색 (white reference color) 을기준으로보정하였다. 참조색의평균 R, G, B값이 190 에서 210 사이의값으로되도록일정하게보정한이후 BMP 형태의파일로전환하여저장하였다. 변환된파일은 Picture Color Analyzer로전송되어관심영역의평 Fig. 2. Two regions of interest (ROIs) in this trial. The ROIs were cropped using Picture Color Analyzer software. A: LU10 region at the midpoint of the palmar border of the 1st metacarpal bone, B: Reference region, proximal to the heads of 2nd and 3rd metacarpal bone (no correlation with LU10). 균 R, G, B값을산출하는데사용되었다 13. 이때각각의이미지는일정한크기로크롭 (Crop) 작업을시행하였으며, 최종적으로 Adobe Photoshop (Adobe Systems Inc., USA) 을사용하여이전에산출한평균 R, G, B값을 L*, a*, b* 값으로변환하였다. 3) 설문지평가모든참가자들은어제혈촬영후총 7종의설문지를시행하였다. 소화불량증과관련된 6종의설문지 Gastrointestinal scale(gis) 14-16, 위장관증상척도설문지 (Gastrointestinal symptom rating scale, GSRS) 17, Nepean dyspepsia index-korean version(ndi-k) 18,19, Functional dyspepsia-related quality of life(fd-qol) 20, 소화불량증시각적상사척도 (Visual analogue scale for dyspeptic symptoms, VAS) 21, 식적설문지 (Food retention questionnaire, FRQ) 22 를시행하였고, 참가자의한열분포를평가하기위해한열변증설문지 (Cold heat questionnaire, CHQ) 23 를시행하였다. 3. 통계 수집된모든자료중연속형변수에대한측정치는 Mean±SD으로나타내었으며범주형자료의경우 29
(330) 는빈도 (n, %) 로표시하였고, 모든통계값은 P<0.05 수준에서유의성을판정하였다. 아울러, 통계분석법의선정시분석데이터의정규성을검토한후모수혹은비모수통계분석법을선정하여적용하였다. 두군의어제혈영역및비어제혈영역의 L*, a*, b* 값의평균비교는Mann-Whitney test를시행하였고. L*, a*, b* 값과설문점수와의상관성분석은 Pearson의상관분석을시행하여분석하였다. 본측정법의신뢰성평가는 2회측정한어제혈이미지의 L*, a*, b* 값간일치도를 test-retest reliability를통해분석하였다. 결과 1. 연구대상자의특징분석결과 1) 기본적특징분석결과본임상연구에참여한 41명의대상자중 2명이탈락되어최종적으로임상연구를완료한대상자는 39명 (FD 환자군 29명, 건강대조군 10명 ) 이었으며, 전체참가자중남자는 18명, 여자는 21명이었다. FD 환자군과건강대조군의 baseline 측정값을분석한결과각군의연령 (P<0.001), 체온 (P=0.005), 비처방약복용 (P=0.003) 부문에서유의한차이가있었다. 처방약복용에서는모든피험자가해당사항이없어분석이이루어지지않았다 (Table 1). 2) 설문점수 (GIS, GSRS, NDI-K, FD-QoL, CHQ, FRQ, VAS) 와 L*, a*, b* 측정값분석결과전체연구대상자의설문점수와어제혈영역의 L*, a*, b* 측정값은 Table 2에서제시한바와같고, Table 1. Baseline Characteristics of Participants Total (n=39) Mean±SD Range Age (yrs) 38.36±5.92 30.0-49.0 BMI (kg/m2) 22.47±3.27 17.4-31.0 SBP (mmhg) 121.54±14.41 95.0-167.0 DBP (mmhg) 76.79±9.77 61.0-106.0 Pulse (bpm) 76.15±9.73 59.0-96.0 BT( ) 36.23±0.33 35.2-36.8 Baseline Characteristics of Each Group FD (n=29) HC(n=10) P-value Age (yrs) * 40.34±5.18 32.60±3.86 <0.001 a BMI (kg/m 2 ) 22.57±3.27 22.18±3.42 0.752 a SBP (mmhg) 121.24±14.62 122.40±14.47 0.830 a DBP (mmhg) 76.86±9.67 76.60±10.58 0.943 a Pulse (bpm) 77.31±10.31 72.80±7.24 0.211 a BT( ) * 36.15±0.34 36.44±0.22 0.005 a Sex (M, %) 41.4 60.0 0.465 b P/H (%) 20.7 20.0 1.000 b Surgery (%) 13.8 20.0 0.636 b PD (%) 0 0 - NPD (%) * 0 40.0 0.003 b Drinking (%) 75.9 90.0 0.653 b Smoking (%) 20.7 0 0.308 b Coffee (%) 93.1 70.0 0.096 b Data shown are mean ± standard deviation unless otherwise indicated. FD: Functional Dyspepsia, HC: Healthy Control, SD: Standard Deviation, BMI: Body Mass Index, SBP: Systolic Blood Pressure, DBP: Diastolic Blood Pressure, BT: Body Temperature, P/H: Physical History, PD: Prescription Drug, NPD: Non-Prescription Drug, *P < 0.05 vs. Healthy Control. a. Two Sample t-test, b. Fisher's Exact Test. 30
기능성소화불량증환자와건강인의어제혈색택비교연구 (331) Table 2. Descriptive Characteristics of the Color Parameters of Regions of Interest (ROIs) and Questionnaire Scores. Total (n=39) Mean±SD Range Color Parameter Region L* 62.59±4.95 51-74 LU10 a* 14.69±3.06 8-22 b* 12.85±2.94 6-22 Reference Rregion L* 53.15±6.65 40-69 a* 17.69±2.99 12-24 b* 16.49±3.33 10-28 GIS 13.51±8.28 0-30 NDI-K 59.28±33.65 0-118 FD-QoL 24.00±15.56 1-54 GSRS 9.33±6.89 0-27 Cold Pattern 4.82±2.70 0-10 Heat Pattern 3.49±2.43 0-9 FRQ 65.21±19.21 20-98 VAS 45.03±18.08 2-70 Data shown are mean ± standard deviation. L*: Luminance, a*: Red(+)/Green(-) Balance, b*: Yellow(+)/Blue(-) Balance. GIS: Gastrointestinal Symptom Scale, NDI-K: Nepean Dyspepsia Index-Korean Version, FD-QoL: Functional Dyspepsia-related Quality of Life, GSRS: Gastrointestinal Symptom Rating Scale, Cold Pattern: Cold Subscale of the Cold-Heat Questionnaire, Heat Pattern: Heat Subscale of the Cold-Heat Questionnaire, FRQ: Food Retention Questionnaire, VAS: Visual Analogue Scale for Dyspeptic Symptoms. Table 3. Comparison of Questionnaire Scores between 2 Groups. FD (n=29) HC (n=10) P-value GIS * 17.24±5.87 2.70±2.79 <0.001 a NDI-K * 73.90±25.12 16.90±11.52 <0.001 a FD-QoL * 28.66±14.71 10.50±8.73 <0.001 b GSRS * 11.97±5.86 1.70±2.58 <0.001 b Cold Pattern * 5.93±1.98 1.60±1.78 <0.001 b Heat Pattern * 4.14±2.23 1.60±2.01 0.005 b FRQ * 72.45±13.85 44.20±17.36 <0.001 a VAS * 53.10±9.86 21.60±16.08 <0.001 b Data shown are mean ± standard deviation. GIS: Gastrointestinal Symptom Scale, NDI-K: Nepean Dyspepsia Index-Korean Version, FD-QoL: Functional Dyspepsia-related Quality of Life, GSRS: Gastrointestinal Symptom Rating Scale, Cold Pattern: Cold Subscale of the Cold-Heat Questionnaire, Heat Pattern: Heat Subscale of the Cold-Heat Questionnaire, FRQ: Food Retention Questionnaire, VAS: Visual Analogue Scale for Dyspeptic Symptoms, *P < 0.05 vs. Healthy Control. a. Two Sample t-test, b. Mann-Whitney U Test. 어제혈의평균 L* 값은 62.59±4.95, a* 값은 14.69±3.06, b* 값은 12.85±2.94으로나타났다. 모든설문점수에서 FD 환자군이건강대조군보다통계적으로유의하게높은점수를나타내었다 (Table 3). 2. L*, a*, b* 측정값분석 1) FD 환자군과건강대조군의 L*, a*, b* 측정값 비교분석 FD 환자군에서정상대조군보다어제혈부위의 L* 값이통계적으로유의하게높았고 (P=0.037), a*, b* 값에서는통계적으로유의한차이는없었다 (Table 4). 반면비어제혈영역에서는마찬가지로 FD 환자군의 L* 값이정상대조군보다높은경향을나타내었지만통계적인유의성은없었고, a*, b* 값에서도통 31
(332) Table 4. Comparison of L*, a* and b* Values between 2 Groups. Color parameter FD (n=29) HC (n=10) P-value Region LU 10 L* 63.41±5.10 60.20±3.73 0.037 a a* 14.79±3.19 14.40±2.80 0.731 b b* 13.03±3.26 12.30±1.77 0.672 a Reference Point L* 54.00±6.94 50.70±5.29 0.179 b a* 17.69±3.13 17.70±2.71 0.993 b b* 16.55±3.63 16.30±2.41 0.922 a Data shown are mean ± standard deviation. FD: Functional Dyspepsia, HC: Healthy Control, L*: Luminance, a*: Red(+)/Green(-) Balance, b*: Yellow(+)/Blue(-) Balance. a. Mann-Whitney U Test, b. Two Sample t-test Bold values indicate significant P-values. Table 5. Comparison of L*, a* and b* Values in Each Group. Group Color Parameter LU10 Reference Point P-value FD (n=29) L* 63.41±5.10 54.00±6.94 <0.001 a a* 14.79±3.19 17.69±3.13 0.001 b b* 13.03±3.26 16.55±3.63 <0.001 a HC (n=10) L* 60.20±3.73 50.70±5.29 0.018 a a* 14.40±2.80 17.70±2.71 0.297 a b* 12.30±1.77 16.30±2.41 0.389 a Data shown are mean ± standard deviation. FD: Functional Dyspepsia, HC: Healthy Control, L*: Luminance, a*: Red(+)/Green(-) Balance, b*: Yellow(+)/Blue(-) Balance. a. Two Sample t-test, b. Mann-Whitney U Test. Bold values indicate significant P-values. 계적으로유의한차이를보이지않았다 (Table 4). 2) 각군의어제혈과비어제혈영역의 L*, a*, b* 측정값비교분석 FD 환자들의어제혈은비어제혈영역보다 L* 값이유의하게높았고, a* 와 b* 값은통계적으로유의하게낮은경향을보였다 (Table 5). 건강대조군에서는어제혈이비어제혈영역보다 L* 값이유의하게높았으나, a* 와 b* 값에서는유의한차이를보이지않았다 (Table 5). 3) 설문점수 (GIS, GSRS, NDI-K, FD-QoL, CHQ, FRQ, VAS) 와 L*, a*, b* 측정값의상관성분석연구대상자전체의설문점수와어제혈영역의 L*, a*, b* 측정값의상관성을분석한결과 GIS 설문점수와 L* 값에서상관계수 (r) 0.351로통계적으로유의한양의상관관계를보였다 (P=0.028, Table 6). 또한 NDI-K 증상점수표의하위항목인소화불량증상의괴로운정도를평가하는설문항목과 L* 값에서도상관계수 (r) 0.365로통계적으로유의한양의상관관계를보였다 (P=0.022, Table 6). 반면 L*, a*, b* 값과한증설문점수에서는각각의상관계수 (r) 가순서대로 0.266, 0.063, 0.208이었고, 열증설문점수와의상관계수 (r) 는 0.175, 0.010, 0.062로써모두낮은양의상관관계를나타내었고, 통계적유의성도없었다 (Table 6). 3. 신뢰도평가반복측정한어제혈영역의 L*, a*, b* 값의일치도는모두통계적으로매우유의한양의상관관계를나타내었다 (Table 7). 32
기능성소화불량증환자와건강인의어제혈색택비교연구 (333) Table 6. Pearson's Correlations between Color Parameters of LU10 and Questionnaire Scores Questionnaire GIS NDI-K Total Score Frequency Intensity Bothersomeness FD-QoL GSRS Cold Pattern Heat Pattern FRQ VAS Pearson's Correlation(r) Region L* a* b* r 0.351 0.067 0.246 P-value 0.028 0.687 0.131 r 0.235-0.021 0.029 P-value 0.149 0.899 0.859 r 0.020 0.154 0.061 P-value 0.902 0.349 0.713 r 0.277-0.081 0.064 P-value 0.088 0.625 0.699 r 0.365-0.123 0.074 P-value 0.022 0.454 0.653 r 0.225 0.006 0.151 P-value 0.168 0.973 0.358 r 0.207-0.025-0.036 P-value 0.206 0.880 0.826 r 0.266 0.063 0.208 P-value 0.102 0.703 0.204 r 0.175 0.010 0.062 P-value 0.287 0.951 0.706 r 0.182-0.012 0.101 P-value 0.267 0.941 0.540 r 0.274 0.122 0.157 P-value 0.091 0.460 0.339 L*: Luminance, a*: Red(+)/Green(-) Balance, b*: Yellow(+)/Blue(-) Balance, GIS: Gastrointestinal Symptom Scale, NDI-K: Nepean Dyspepsia Index-Korean Version, FD-QoL: Functional Dyspepsia-related Quality of Life, GSRS: Gastrointestinal Symptom Rating Scale, Cold Pattern: Cold Subscale of the Cold-Heat Questionnaire, Heat Pattern: Heat Subscale of the Cold-Heat Questionnaire, FRQ: Food Retention Questionnaire, VAS: Visual Analogue Scale for Dyspeptic Symptoms. Bold values indicate significant P-values and Pearson's correlations at the significant P-values. Table 7. Test-retest Reliability of L*, a* and b* Values on LU10 Color Parameter Coefficient of Correlation P-value L* 0.871 <0.001 a* 0.945 <0.001 b* 0.936 <0.001 L*: Luminance, a*: Red(+)/Green(-) Balance, b*: Yellow(+)/Blue(-) Balance Analyzed by Pearson's r. P-value<0.05 is considered as statistically significance. 고찰망진은환자의주관적인호소가들어가지않고, 의사의기준으로진단하므로비교적일관되어환자의상태와병리의파악에상대적으로신뢰성을가지고있다 2. 그럼에도장상론 ( 臟象論 ) 과경락학설등의기초이론체계를바탕으로하는한의진단법은주 관적이고종합적인인식체계로인해 26, 진단분야에서유효성검증및객관화와정량화는현대를살아가는한의사들에게늘미완의과제로남겨져왔고, 한의학이론에근거한현대적이면서도체계적인진단법의개발이지속적으로요구되고있는상황이다. 한편본연구의적응증인기능성소화불량증은기질적인원인이없이상복부의통증혹은불쾌감이 33
(334) 만성적으로반복되는질환으로, 아시아인의유병률은대략 8-23% 정도로보고되고있다 27. 기능성소화불량증은치명적이지않지만, 지속적으로삶의질을저하시켜사회경제적부담이큰질환중의하나로 28, 실제한방치료의수요가높고외래를찾는그빈도가높아한방치료의유효성을입증하는연구는전세계적으로활발히진행되고있다 29. 그러나기능성소화불량증과관련된한방진단지표개발에관한연구는현재부족한실정이다. 최근양도락을활용한경락기능연구및통각계를이용한복부압통진단등의연구가이루어졌음에도 30,31, 실제진료환경에즉각적용될수있는신뢰성과실용성을겸비한진단법개발의필요성은지속적으로대두되고있다 32. 어제 ( 魚際 ) 혈은수태음폐경의영혈 ( 營穴 ) 로서, 청폐열 ( 淸肺熱 ), 리인후 ( 利咽喉 ) 의작용을가지며, 주로후비 ( 喉痺 ), 해수 ( 咳嗽 ), 편도선염등호흡기질환을치료하는데다용되어왔다 33. 靈樞經脈篇 에서 위중 ( 胃中 ) 이한 ( 寒 ) 하면어제의락 ( 絡 ) 이푸르고, 위중이열 ( 熱 ) 하면어제의락이붉고, 그것이검은것은오랫동안앓고있다는증거이다 라고하였고, 대체적으로모지구 ( 拇指球 ) 의경맥이푸를때는하리 ( 下痢 ) 증상이있으며, 위장의상태가좋지않을때는이푸른맥이확실하게나타난다고하였다 34. 또한楊 6 은 鍼灸經穴學 에서어제가위한 ( 胃寒 ) 과위열 ( 胃熱 ) 을진단하는데효과적이며, 변비환자의어제혈부위는붉고, 대변이묽은환자는암청색을나타내며, 심한설사와장염의경우청근 ( 靑筋 ) 형태가관찰된다고하여위염이나만성설사등을치료하는데어제혈이효과가있음을주장하며, 수태음폐경이중초 ( 中焦 ) 에서기시 ( 起始 ) 하여대장에하락 ( 下絡 ) 하는점이진단적, 치료적효과의근거라고제시하였다. 여러문헌적근거들을토대로어제혈망진법이임상진료환경에서환자의한열분포및소화기능과내장의기능상태를간접적으로평가하는진단지표로활용되고있지만, 실제그진단적유효성을검증한임상연구는진행되지않아본연구에서어제 혈망진법의유효성을검증하기위하여 Seo 10 등이제시한방법을응용하여어제혈색택분석을시행하였다. 본연구에서사용한 L*, a*, b* 표색계는 1976년국제조명위원회 (Commission Internationale del Eclairage, CIE) 에의해규격화된표색계로서 L* 값은명도를의미하는지표로서피부의밝기를의미하며, 0에서 100사이의값을가지고 0은검은색을 100은흰색을의미하게된다 35. a* 값은적-녹색의정도를의미하는것으로 +60에서 -60사이의값을가지며, 양의값에서그절대값이커질수록적색의정도가강한것을의미한다 35. b* 값은황-청색의정도를나타내는지표이며마찬가지로 +60에서 -60 사이의분포를가지고, 양의값에서절대값이커질수록황색의정도가강한것을의미하게된다 35. 본연구에서분석한 FD 환자군의어제혈영역의평균 L* 값은건강대조군보다통계적으로유의하게높은값을나타내었고, a*, b* 값에서는유의한차이를보이지않았다 (Table 4). 반면, 비어제혈영역에서는 FD 환자군의 L* 값은높았지만통계적인유의성은보이지않았고, a*, b* 값에서는두군에서유의한차이를보이지않았다 (Table 4). 이는기능성소화불량증환자들이소화불량증상이없는건강대조군보다어제혈부위가창백한것을의미하게된다. 또한본연구는소화기증상과관련된어제혈의진단특이성을확인하기위해동일한이미지에서경혈점이아닌동일한영역의 L*, a*, b* 값을산출하였고, 비어제혈영역에서는색변수간유의한군간차이가없는것을확인하였다. 한편, 각군의어제혈영역과비어제혈영역의 L*, a*, b* 값을분석한결과, FD 환자군은비어제혈영역이어제혈영역보다통계적으로유의하게 L* 값이낮고, a* 값과 b* 값은높아더어둡고, 붉고, 푸른경향을나타내었다 (Table 5). 건강대조군에서는비어제혈영역의 L* 값이통계적으로유의하게낮았으나, FD 환자군과달리 a*, b* 값에서영역간통계적으로유의한차이를보이진않았다 (Table 5). 이는연구대상자전체의어제혈의 L* 값이비어제혈영역 34
기능성소화불량증환자와건강인의어제혈색택비교연구 (335) 보다높은경향을나타내는것을고려하였을때, 관찰되는일반적인특성으로보여지며 (Table 3), 본연구에참가한건강대조군참가자수는 10명으로분석대상자수가충분하지않아, 보다적절한대조점을설정하여향후추가분석이필요할것으로판단된다. L*, a*, b* 값과설문점수와의상관성분석에서는 L* 값과 GIS, NDI-K 증상점수표의하위항목인소화불량의괴로운정도를평가하는설문항목에서통계적으로유의한양의상관관계를나타내었다 (Table 6). 이때 Pearson의상관계수 (r) 는각각 0.351, 0.365, 설명력 (r 2 ) 은 12.3%, 13.3% 로높은값을나타내지는못하였다 (Table 6). 또한, 당초한열변증설문점수와 L*, a*, b* 값간관련성이있을것으로생각하여, 한증설문점수와 L* 값은양의상관관계를 b* 값과는음의상관관계를나타내고, 열증설문점수와 L* 값은음의상관관계를 a* 값과는양의상관관계를나타낼것으로예상하였지만, 모두낮은양의상관관계를나타내었을뿐통계적유의성은보이지않았다. 이는예비연구의성격을지닌본연구의특성상, 군당분석대상자수가충분하지않았고, 본연구에서사용한한열변증설문지의문항자체가평소한열기호나체질적인요소를고려하지않고병증으로발생한한열증상만을평가하여건강상의불편함을호소하지않는대조군의한열분포를평가하는데부적합하였기때문으로사료되며, 후속연구에서는반드시보완되어야할부분으로여겨진다. 선행연구에의하면피부색을결정짓는요소는멜라닌과, 모세혈관속헤모글로빈이며, 이중멜라닌은인종과같은유전적요인에의해영향을받고, 헤모글로빈이피부의혈색과창백함을결정짓는요소로밝혀져있다 36. Ishiwata 37 는피부가창백해지는것은모세혈관속헤모글로빈양의감소와저관류현상이관련이있음을보고하였고, Takiwaki 38 는 L*, a* 값은피부의홍반, 혈류량, 색소침착을대변할수있다고하였다. 본연구의 FD 환자군이건강대조군에비해 L* 값이높아어제혈부위가창백한것은, 말초로의혈류량이적어발생하는것으로, 한의학적으로기능성소화불량증은비기허약 ( 脾氣虛弱 ) 이주가 되는질환이므로 39, 면색위황 ( 面色萎黃 ), 사지무력 ( 四肢無力 ) 하는비기허 ( 脾氣虛 ) 증상과의관련성을배제할수없기때문으로사료된다. 또한이러한비기허가만성적으로진행되면비양허 ( 脾陽虛 ) 하여형한지냉 ( 形寒肢冷 ) 하게되므로 39, 결국본연구에서와같은특징적인차이를보이게되었을것으로판단된다. 실제한증설문지의 4번문항인 손발이잘시리거나차가운편입니다. 에서 FD환자군은전체 29명중 19명이 그렇다 고응답하였고, 건강대조군에서는전체 10명중 3명만 그렇다 고응답하여말초에서자각적으로느끼는냉온감각에군간차이가존재하는것으로나타났다. 비록한열변증설문점수와 L*, a*, b* 측정값의상관성이규명되지않은것은본연구가가지는제한점이지만, 비기허를평가할수있는설문지를추가로시행하고, 어제혈부위의피부온도측정, 초음파를활용한요골동맥의혈류량측정등의추가연구를통해추후검증이필요하다고생각된다. 한편, 본연구의 L*, a*, b* 측정값간일치도는세측정값의 Pearson 상관계수 (r) 가각각 0.871, 0.945, 0.936으로써통계적으로매우유의하게높은수준의상관성을나타내며본측정법의높은신뢰성을나타내었다 (Table 7). 본연구대상자의기본적특성분석에서연령, 체온, 비처방약복용부문에서유의한차이가발견되었는데 (Table 1), 본연구의연구참여기준연령이만 30-49세의중장년층으로범위가제한되어있으므로, 연령의차이가결과에영향을미쳤을것이라고단정짓기는힘들며, 향후다양한연령대를대상으로한추가적인분석이이루어져야할것으로판단된다. 한편, 체온에서보이는두군의차이는, 본연구에참가한전체대상자의수가충분하지않아발생하는편차로보여지고, 비처방약의복용부문역시일회적인건강기능식품의복용이었으므로, 본연구의분석결과와는무관한차이로보여지는바이다. 연구수행결과, 디지털카메라를이용하여어제혈색택분석을시행하여, FD 환자군과건강대조군 35
(336) 의유의한차이를보았고, 소화기증상의정도를평가하는설문점수와측정된어제혈색변수간의유의한상관성도확인하여어제혈망진법의유효성을검증하여기능성소화불량증과관련된새로운한방진단지표로서의가능성을시사하였다. 결론본연구에서는기능성소화불량증환자들과건강대조군을상대로소화관혹은내장의기능상태를간접적으로반영한다고알려져있는어제혈의색택변화를비교분석함으로써, 어제혈색택분석의진단적유용성을확인해보고자하였다. 기능성소화불량증환자군에서건강대조군과비교하여어제혈의피부의명도 (L*) 값이높아창백한경향을나타내었고, 이는소화불량의정도와도유의한상관성을보여향후한방진단시어제혈부위의색택분석을활용하는것이유용할것으로판단된다. 다만, 다양한연령분포및다각적인변증유형분석을포함한대규모후속연구가필요할것으로보인다. 참고문헌 1. Lee BK, Park YB, Kim JH. Diagnosis in Korean Medicine [Ⅰ]; Four Diagnoses. 1st ed. Seoul: Sungbosa. 1986:41-2. 2. Jang JY, Kang JS, Kim BS. The importance of nose, eye, and In-dang( 印堂 ) region in inspecting color diagnosis. J Resear Cent Korean Med Daejeon Univ. 2010;19(1):87-98. 3. Hebei Medical University. Translation of Yongchukyung. 1st ed. Beijing: RenminWeisheng Publication. 1982:70. 4. Lee BK, Park YB, Kim JH. Diagnosis in Korean Medicine [Ⅰ]; Four Diagnoses. 1st ed. Seoul: Sungbosa. 1986:96-7. 5. Gwak AC. Translation of Hwangjenaegyeong Somun. 1st ed. Seoul: Euisungdang. 1993:14-28. 6. Yang YG. Meridian Points in Acupucnture and Moxibustion. 1st ed. Seoul: Iljongsa. 1992:145-7. 7. Kim JS, Han GJ, Choi BH, Park JW, Park KM, Yeo IK, et al. Development of differential criteria on tongue coating thickness in tongue diagnosis. Complement Ther Med. 2012;20(5): 316-22. 8. Park HH, Chung CU. Sasang Constitutional Diagnosis by Iridology: Comparative Study with QSCCII Questionaaire. Kor J Orient Preventive Med Soc. 2008;12(2):131-43. 9. Do JH, Kim JY. The diagnostic method using facial information in Sasang Constitutional diagnosis. Magazine of the IEEK. 2010;37(7): 53-61. 10. Seo JH, Park YB, Park YJ. Reliable facial color analysis a digital camera and its relationship with pathological patterns: A pilot study. EUJIM. 2014;6(3):322-7. 11. Drossman DA, Dumitrascu DL. Rome III: New standard for functional gastrointestinal disorders. J Gastrointestin Liver Dis. 2006;15:237-24. 12. Tack J, Talley NJ, Camilleri M, Holtmann G, Hu P, Malagelada JR, et al. Functional gastroduodenal disorders. Gastroenterology. 2006;130(5):1466-79. 13. Otaka I. Picture color analyzer, 2014; http://www.isao.com/pica.html. Accessed February 15, 2014 14. Madisch A, Holtmann G, Mayr G, Vinson B, Hotz J. Treatment of Functional Dyspepsia with a Herbal Preparation: A Double-Blind, Randomized, Placebo-Controlled, Multicenter Trial. Digestion. 2004;69(1):45-52. 15. Holtmann G, Gschossmann J, Mayr P, Talley NJ. A randomized placebo-controlled trial of simethicone and cisapride for the treatment of patients with functional dyspepsia. Aliment 36
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