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[Acid Pocket. »êÁÖ¸Ó´Ï]

1. ¼­·Ð

Çй®¿¡µµ À¯ÇàÀÌ ÀÖ½À´Ï´Ù. »õ·Î¿î °Ë»ç³ª ¾àÁ¦°¡ °³¹ßµÇ¸é ±×¿Í °ü·ÃµÈ Ãø¸éÀÌ ºÎ°¢µÇ°ï ÇÕ´Ï´Ù.À§½Äµµ¿ª·ùÁúȯÀº ´Ù¾çÇÑ º´Å»ý¸®¿Í Áõ»óÀ» º¸ÀÌ´Â ÁúȯÀÔ´Ï´Ù. À§»êºÐºñ¾ïÁ¦Á¦°¡ °³¹ßµÇ¾úÀ» ¶§¿¡´Â À§³» »êµµ¸¦ ÃøÁ¤ÇÏ´Â °ÍÀÌ À¯ÇàÀ̾ú½À´Ï´Ù. À§»ê¿ª·ù¸¦ 24½Ã°£ µ¿¾È ÃøÁ¤ÇÏ´Â ¹æ¹ýÀÌ °³¹ßµÇ¾úÀ» ¶§¿¡´Â ¸¹Àº ȯÀÚµéÀÌ ÄÚ¿¡ Ä«Å×Å͸¦ ²È°í ÀáÀ» ÀÚ¾ßÇÏ´Â °ï¿åÀ» Ä¡¸£±âµµ ÇÏ¿´½À´Ï´Ù. Ç÷¾×³» ¹Ý°¨±â°¡ ±ä PPI°¡ ³ª¿À¸é¼­ ¾àÁ¦ º¹¿ë ½ÃÁ¡°ú ¾ß°£Áõ»ó¿¡ ´ëÇÑ ³íÀÇ°¡ È°¹ßÇØÁö±âµµ ÇÏ¿´½À´Ï´Ù. ÃÖ±Ù »êÁÖ¸Ó´Ï(acid pocket)¶ó´Â Çö»óÀÌ ¹ß°ßµÇ¸é¼­, ½Äµµ¿­°øÅ»Àå°ú ½ÄÈÄ Áõ»óÀÌ »õ·Ó°Ô Á¶¸í¹Þ°í ÀÖ½À´Ï´Ù. »ç½Ç ´ë À¯ÇàÀÔ´Ï´Ù.

½ÄµµÀ§Á¢Çպδ ÇϺνĵµÁ¶ÀÓ±Ù, Ⱦ°æ¸·, ±×¸®°í Ⱦ°æ¸·½ÄµµÀδë(phrenoesophageal ligament)µîÀ¸·Î ±¸¼ºµÇ¾î ÀÖ½À´Ï´Ù. ÀÌ Áß ÇϺνĵµÁ¶ÀÓ±ÙÀº (1) one way valve·Î¼­ ¿¬ÇÏÀÛ¿ë ½Ã À½½Ä¹°ÀÌ Åë°úµÇµµ·Ï À̿ϵǰí, (2) À§³»¿ë¹°ÀÇ ¿ª·ù¸¦ ¸·°í, (3) ÀÏ°ú¼º ÇϺνĵµÁ¶ÀÓ±Ù ÀÌ¿Ï(transient lower esophageal sphincter relaxation, TLESR)À» ÅëÇÏ¿© À§³» °ø±âÀÇ ¸ö¹Û ¹èÃâÀ» Çã¿ëÇÏ´Â ±â´ÉÀ» ÇÕ´Ï´Ù.


2. ÀÏ°ú¼º ÇϺνĵµÁ¶ÀÓ±Ù ÀÌ¿Ï(TLESR)

TLESRÀº Á¶±Ý ´õ ¾ð±ÞÇÒ ÇÊ¿ä°¡ ÀÖ½À´Ï´Ù. ÇϺνĵµÁ¶ÀÓ±ÙÀº º¸Åë À½½Ä¹°À» »ïÅ°´Â ¸¶Áö¸· °úÁ¤¿¡ À̿ϵ˴ϴÙ. ±×·±µ¥, À½½Ä¹°À» »ïÅ°Áö ¾Ê°íµµ ÇϺνĵµÁ¶ÀÓ±ÙÀÌ À̿ϵǴ Çö»óÀÌ ¹ß°ßµÇ¾ú½À´Ï´Ù (¡°TLESR¡±). »ïÅ´°ú °ü·ÃµÈ ÇϺνĵµÁ¶ÀÓ±Ù ÀÌ¿Ï¿¡´Â ¾ïÁ¦¼º ¹× Àڱؼº ½Å°æ °æ·Î°¡ ¸ðµÎ °ü¿©ÇÏÁö¸¸, TLESR¿¡¼­´Â ¿ÀÁ÷ ¾ïÁ¦¼º °æ·Î¸¸ÀÌ ¿µÇâÀ» ¹ÌĨ´Ï´Ù.

TLESR¿¡´Â ÇϺνĵµ°ý¾à±Ù ÀÌ¿Ï°ú ÇÔ²² ½Äµµ Á¾ÁÖ±Ù(longitudinal muscle)ÀÌ ¼öÃàµÇ¾î ½Äµµ°¡ ª¾ÆÁö´Â Çö»óÀÌ µ¿¹ÝµË´Ï´Ù. ±× °á°ú TLESR µ¿¾È ½ÄµµÀ§Á¢Çպΰ¡ »ó¹æÀ¸·Î À̵¿ÇÏ¿© Ⱦ°æ¸·°ú ½ÄµµÀ§Á¢Çպΰ¡ °ø°£ÀûÀ¸·Î ºÐ¸®(¡°spatial separation¡±)µË´Ï´Ù. À̴ Ⱦ°æ¸·¿¡ ÀÇÇÑ ¿ª·ù¾ïÁ¦±â´ÉÀÌ ¾àÈ­µÇ´Â °á°ú¸¦ ³º½À´Ï´Ù. ¿äÄÁµ¥ TLESRÀº (1) ÇϺνĵµÁ¶ÀÓ±Ù ¾Ð·ÂÀ» ³·Ãß°í, (2) Ⱦ°æ¸·¿¡ ÀÇÇÑ ¿ª·ù¾ïÁ¦±â´ÉÀ» ¾àÈ­½ÃÄÑ À§³»¿ë¹°ÀÌ ½Äµµ·Î ¿ª·ùÇϱ⠽¬¿î Á¶°ÇÀÌ µË´Ï´Ù.

TLESRÀº ½ÄÈÄ¿¡ ÀÚÁÖ ¹ß»ýÇÕ´Ï´Ù. ÀÌ´Â TLESRÀ» ÀÏÀ¸Å°´Â °¡Àå Áß¿äÇÑ ÀÚ±ØÀÌ ºÐ¹®ºÎ ½ÅÀå¼ö¿ëü(stretch receptor)ÀÇ È°¼ºÈ­À̱⠶§¹®ÀÔ´Ï´Ù. TLESRÀÇ ºóµµ´Â ½ÄÈÄ¿¡ ³ô¾ÆÁö¹Ç·Î, À§½Äµµ¿ª·ùȯÀÚ¿¡¼­ ½ÄÈÄ Áõ»ó¹ß»ýÀÇ Áß¿äÇÑ ¿øÀÎÀ¸·Î Áö¸ñµÇ¾ú½À´Ï´Ù. ´ç¿¬È÷ Á¤»óÀο¡ ºñÇÏ¿© À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ TLESRÀÇ ºóµµ°¡ ³ôÀ» °ÍÀ¸·Î ÃßÁ¤µÇ¾ú½À´Ï´Ù. ±×·±µ¥, ½ÇÁ¦ ¿¬±¸¿¡¼­´Â Á¤»óÀΰú À§½Äµµ¿ª·ùÁúȯ ȯÀÚ´Â TLESRÀÇ ºóµµ¿¡ Â÷ÀÌ°¡ ¾ø¾ú½À´Ï´Ù. ÀÌ´Â ¸Å¿ì Áß¿äÇÑ ¼Ò°ßÀÔ´Ï´Ù. À§½Äµµ¿ª·ùÁúȯ¿¡¼­ ½ÄÈÄ Áõ»óÀÌ ¹ß»ýÇÏ´Â ¿øÀÎÀ¸·Î TLESR¿¡ ÀÇÇÑ ¾Ð·ÂÀÇ º¯È­ ÀÌ¿ÜÀÇ ¹º°¡°¡ ÀÖ´Ù´Â °ÍÀ» ÃßÁ¤ÄÉ Çϱ⠶§¹®ÀÔ´Ï´Ù.

Á¤»óÀΰú À§½Äµµ¿ª·ùÁúȯ ȯÀÚÀÇ TLESR ºóµµ´Â ºñ½ÁÇÏÁö¸¸, ±× °á°ú´Â »ó´çÈ÷ ´Ù¸¨´Ï´Ù. °¡Àå Áß¿äÇÑ °ÍÀº TLESR¿¡ À§»ê¿ª·ù°¡ µ¿¹ÝµÇ´Â ºóµµ°¡ ´Ù¸£´Ù´Â Á¡ÀÔ´Ï´Ù. Á¤»óÀο¡ ºñÇÏ¿© À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ TLESR¿¡ À§»ê¿ª·ù°¡ µ¿¹ÝµÇ´Â ºóµµ°¡ µÎ¹è ÀÌ»ó ³ô½À´Ï´Ù. ÀÓÇÇ´ø½º °Ë»ç¿¡¼­´Â Á¤»óÀο¡¼­ TLESR µ¿¾È ¾×ü¿Í °¡½ºÀÇ È¥ÇÕ¿ª·ù°¡ ¸¹Àº ¹Ý¸é, À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­´Â ¾×ü¸¸ ¿ª·ùµÈ´Ù°í ÇÕ´Ï´Ù. ½ÄµµÀ§Á¢ÇÕºÎÀÇ Á÷°æÀÌ Áõ°¡ÇÑ °æ¿ì¿¡ ¾×ü¿ª·ù°¡ ¸¹´Ù´Â ¿¬±¸µµ ÀÖ½À´Ï´Ù. ÀÌ·¯ÇÑ °üÂûµéÀº À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ (1) ½ÄÈÄ ½Å°æ °æ·Î¿¡ ÀÇÇÑ TLESRÀÇ ºóµµ´Â Á¤»óÀΰú Â÷ÀÌ°¡ ¾øÁö¸¸, (2) ¹º°¡ÀÇ ÇغÎÇÐÀû ÀÌ»ó¿¡ ÀÇÇÏ¿© TLESRÀÇ °á°ú(Áï, À§»ê ¿ª·ù)´Â ´Þ¶óÁø´Ù´Â °á·Ð¿¡ µµ´ÞÇÏ°Ô ÇÕ´Ï´Ù. ±×·¸´Ù¸é ¹«½¼ ÇغÎÇÐÀû Â÷ÀÌ°¡ ÀÖ´Â °ÍÀϱî¿ä? Á¤´äÀº ½Äµµ¿­°øÅ»ÀåÀÔ´Ï´Ù.


3. ½Äµµ¿­°øÅ»ÀåÀÇ ÅðÃâ°ú º¹±Í

À§½Äµµ¿ª·ùÁúȯ ȯÀÚ´Â ³»½Ã°æ ¼Ò°ß¿¡ µû¶ó Á¡¸·»óÇØ(mucosal break)°¡ ÀÖ´Â ¹Ì¶õ¼º ½Äµµ¿°(erosive esophagitis) ȯÀÚ¿Í Á¡¸·»óÇØ°¡ ¾ø´Â ºñ¹Ì¶õ¼º¿ª·ùÁúȯ (NERD) ȯÀÚ·Î ³ª´©¾îÁý´Ï´Ù. ¿©±â±îÁö´Â ´©±¸³ª µ¿ÀÇÇÒ ¼ö ÀÖ½À´Ï´Ù. ±×·±µ¥ À§½Äµµ¿ª·ùÁúȯ¿¡ ÈçÈ÷ µ¿¹ÝµÇ´Â ½Äµµ¿­°øÅ»Àå¿¡ ÀÇÇÑ À§½Äµµ¿ª·ùÁúȯÀÇ ºÐ·ù°¡ ¾ø´Ù´Â °ÍÀº ¹«Ã´ ÀÌ»óÇÑ ÀÏÀÔ´Ï´Ù. LA group C³ª D, ȤÀº ÀåºÐÀý ¹Ù·¿½Äµµ ȯÀÚ¿¡¼­´Â ´ëºÎºÐ ÇöÀúÇÑ ½Äµµ¿­°øÅ»ÀåÀÌ µ¿¹ÝµÇ´Âµ¥ ¸»ÀÔ´Ï´Ù. ³»½Ã°æ ÀÇ»çÀÇ °æÇè°ú À§½Äµµ¿ª·ùÁúȯ ¿¬±¸ÀÚµéÀÇ ¼³¸íÀÌ ¹Ì¹¦ÇÏ°Ô ¾î±ß³ª´Â ºÎºÐÀÔ´Ï´Ù. À̸¦ ¾î¶»°Ô ÀÌÇØÇÏ¿©¾ß ÇÒ±î¿ä?

1971³â Cohen ¹Ú»ç´Â New England Journal of Medicine¿¡ ÇÑ ³í¹®À» ¹ßÇ¥ÇÏ¿´½À´Ï´Ù (1971;281:1053-1056). ÇÙ½ÉÀûÀÎ ³»¿ëÀº ÇϺνĵµ°ý¾à±Ù ¾Ð·ÂÀÌ (1) ½Äµµ¿­°øÅ»Àå À¯¹«¿Í °ü·ÃÀÌ ¾øÁö¸¸, (2) À§»ê¿ª·ùÁõ»óÀÌ Àִ ȯÀÚ¿Í ¾ø´Â ȯÀÚ¿¡¼­´Â ÇöÀúÈ÷ Â÷ÀÌ°¡ ÀÖ´Ù´Â °ÍÀ̾ú½À´Ï´Ù. ÀÌ´Â ½Äµµ¿­°øÅ»ÀåÀº À§½Äµµ¿ª·ùÁúȯ°ú »ó°üÀÌ ¾ø´Ù´Â °ÍÀ» ÀǹÌÇÏ´Â °ÍÀ¸·Î Çؼ®µÇ¾ú½À´Ï´Ù.

1980³â Dent ¹Ú»ç´Â perfused sleeve sensor¸¦ ÀÌ¿ëÇÏ¿© TLESR Çö»óÀ» ¹ß°ßÇÑ °Íµµ À§½Äµµ¿ª·ùÁúȯÀÇ º´Å»ý¸®¿¡¼­ ¾Ð·ÂÀÇ º¯È­°¡ Áß¿äÇÑ °ÍÀÌÁö, ½Äµµ¿­°øÅ»ÀåÀ̶ó´Â ÇغÎÇÐÀû ÀÌ»óÀº Áß¿äÇÏÁö ¾Ê´Ù´Â °ÍÀ¸·Î Çؼ®µÇ¾ú½À´Ï´Ù.

ÀÌ·¯ÇÑ À¯¸íÇÑ ¿¬±¸µé¿¡ ÀÇÇÏ¿© ½Äµµ¿­°øÅ»ÀåÀº À§½Äµµ¿ª·ùÁúȯ º´Å»ý¸®¿¡¼­ °ü½É¹ÛÀ¸·Î ¹Ð·Á³µ½À´Ï´Ù. ÀÌ¿Í °°Àº ¾îó±¸´Ï ¾ø´Â »óȲÀº 2001³â ¿µ±¹ Glasgow Áö¿ª¿¡¼­ Fletcher¿Í McColl µîÀÌ acid pocket Çö»óÀ» ¹ß°ßÇϱâ±îÁö °è¼ÓµÇ¾ú½À´Ï´Ù. ¹«·Á 30³â µ¿¾È ½Äµµ¿­°øÅ»ÀåÀÌ ºÎÀûÀýÇÑ ´ëÁ¢À» ¹ÞÀº ¼ÀÀÔ´Ï´Ù.

½Äµµ¿­°øÅ»ÀåÀÌ ¾ï¿ïÇÏ°Ô ÅðÃâ´çÇß´ø ÀÌÀ¯ Áß Çϳª°¡ ½Äµµ¿­°øÅ»ÀåÀ» Á¤È®È÷ Á¤ÀÇÇϱ⠾î·Æ´Ù´Â °ÍÀÔ´Ï´Ù. ¹Ù·ý»çÁø¿¡¼­ 2 cm ÀÌ»óÀÇ °íÁ¤µÈ Å»ÀåÀÌ ÀÖÀ» ¶§¿¡¸¸ ½Äµµ¿­°øÅ»ÀåÀ¸·Î Á¤ÀÇÇÑ °ÍÀº specificity¸¦ ³ôÀ̱â À§ÇÏ¿© sensitivity¸¦ Èñ»ýÇÑ ¼±ÅÃÀ̾ú½À´Ï´Ù. 2 cm ÀÌÇÏÀÇ Å»ÀåÀ̳ª °íÁ¤µÇÁö ¾Ê°í ÀϽÃÀûÀ¸·Î ¹ß»ýÇÏ¿´´Ù À̳» ȯ¿øµÇ´Â °¡º­¿î Å»ÀåÀº ¹«½ÃµÇ¾ú½À´Ï´Ù. ½ÇÁ¦·Î´Â 2 cm ÀÌ»óÀÇ °íÁ¤µÈ Å»À庸´Ù´Â °æ¹ÌÇÑ Å»ÀåÀÌ ÈξÀ ¸¹½À´Ï´Ù. °¡º­¿î Å»ÀåÀ» ¹«½ÃÇÑ °üÇàÀÌ ¡°Å»Àå°ú À§½Äµµ¿ª·ùÁúȯÀº °ü·ÃÀÌ ¾ø´Ù¡±´Â À߸øµÈ °á·ÐÀ» À̲ø¾ú´ø °ÍÀÔ´Ï´Ù.

»ç½Ç °¡º­¿î Å»ÀåÀÇ ÀÓ»óÀû ÀÇÀǸ¦ ½Ã»çÇÏ´Â ¼Ò°ßµéÀº ÀûÁö ¾Ê¾Ò½À´Ï´Ù. (1) 1996³â Hill ¹Ú»ç²²¼­ Á¦¾ÈÇÑ flap valveÀÇ Hill grading systemÀº grade IV¶ó´Â ÀüÇüÀûÀÌ°í °íÁ¤µÈ Å»ÀåÀÌ »Ó¸¸ ¾Æ´Ï¶ó grade II ȤÀº IIIÀÇ °¡º­¿î ¼Ò°ßµµ À§½Äµµ¿ª·ùÁúȯÀÇ ¹ß»ý°ú °ü·ÃÀÌ ÀÖÀ½À» º¸¿©ÁÖ¾ú½À´Ï´Ù. (2) 2010³â °í·Á´ëÇб³ÀÇ ¹Ú¿µÅ ¹Ú»ç²²¼­´Â ³»½Ã°æ¿¡¼­ °üÂûµÇ´Â short segment hiatal hernia°¡ À§½Äµµ¿ª·ùÁúȯÀÇ Áß¿ä ¼Ò°ßÀÓÀ» Á¦½ÃÇÏ¿´½À´Ï´Ù. (3) 2006³â Bredenoor µîÀº Gastroenterology¿¡ ÇϺνĵµ°ý¾à±ÙÀÌ ÀϽÃÀûÀ¸·Î µÑ·Î ³ª´©¾îÁö´Â Çö»óÀ» °íÇØ»óµµ ½Äµµ³»¾Ð°Ë»ç »çÁøÀ¸·Î ¼±¸íÇÏ°Ô º¸¿©ÁÖ¾ú½À´Ï´Ù. ½Äµµ¿­°øÅ»ÀåÀÌ È¯¿øµÇÁö ¾ÊÀº »óÅÂ(unreduced state)¿Í ȯ¿øµÈ »óÅÂ(reduced state)¿¡¼­ ¿ª·ùÀÇ ºóµµ°¡ ÇöÀúÈ÷ ´Þ¶ú½À´Ï´Ù. (4) 2012³â Curic µîÀº À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ ½Äµµ°¡ À§¿Í ¸¸³ª´Â °¢µµ¿Í À§Ä¡°¡ Á¤»óÀΰú ´Ù¸£´Ù´Â Á¡À» DDW¿¡¼­ ¹ßÇ¥Çϱ⵵ ÇÏ¿´½À´Ï´Ù. ÀÌ»óÀÇ ¼Ò°ßÀ» Á¾ÇÕÇÒ ¶§, ½Äµµ¿­°øÅ»ÀåÀº µðÁöÅÐÀûÀ¸·Î 'ÀÖ´Ù/¾ø´Ù¡¯·Î ³ª´­ ¼ö ¾ø´Â »óÅÂÀÔ´Ï´Ù. ¿ÀÈ÷·Á 2 cm ÀÌ»óÀÇ °íÁ¤µÈ ÇöÀúÇÑ Å»ÀåºÎÅÍ ÀϽÃÀûÀ¸·Î ³ªÅ¸³ª´Â °¡º­¿î Å»Àå±îÁö ¸ðµÎ °¡´ÉÇÑ ¾Æ³ª·Î±×ÀûÀÎ ½ºÆåÆ®·³À¸·Î ÀÌÇØÇÏ´Â °ÍÀÌ Å¸´çÇÕ´Ï´Ù.


4. ½Äµµ¿­°øÅ»Àå°ú TLESR

½Äµµ¿­°øÅ»ÀåÀº TLESR°ú µÎ °¡Áö Ãø¸é¿¡¼­ Èï¹Ì·Î¿î »ó°ü°ü°è°¡ ÀÖ½À´Ï´Ù. ¸ÕÀú ÇغÎÇÐÀû ÀÌ»óÀÔ´Ï´Ù. ¾Õ¼­ TLESR¿¡¼­ ÇϺνĵµ°ý¾à±Ù ÀÌ¿Ï°ú ÇÔ²² ½Äµµ Á¾ÁÖ±ÙÀÌ ¼öÃàµÇ¾î ½Äµµ°¡ ª¾ÆÁö¸é¼­ ½ÄµµÀ§Á¢Çպΰ¡ À§·Î ¿Ã¶ó°¡´Â Çö»óÀ» ¼³¸íÇÏ¿´½À´Ï´Ù. ±×·±µ¥ TLESR °ü·Ã ½ÄµµÀ§Á¢ÇպΠ»ó½ÂÀº ½Äµµ¿­°øÅ»ÀåÀÇ À¯¹«¿¡ µû¶ó Å« Â÷ÀÌ°¡ ÀÖ½À´Ï´Ù. Á¤»óÀΰú ½Äµµ¿­°øÅ»Àå ȯÀÚ¿¡¼­ TLESR¿¡ ÀÇÇÑ À§½ÄµµÁ¢ÇÕºÎÀÇ »ó½ÂÀÌ °¢°¢ 2.4 cm¿Í 1.2 cm·Î ¼­·Î ´Þ¶ú½À´Ï´Ù. º¸´Ù Áß¿äÇÑ ¼Ò°ßÀº TLESR¿¡¼­ À§½ÄµµÁ¢ÇպΠ³»°­ÀÇ ÃÖ´ë Á÷°æÀÌ Á¤»óÀο¡¼­ 1.8 cm, ½Äµµ¿­°øÅ»Àå ȯÀÚ¿¡¼­ 3.0 cm·Î Å« Â÷ÀÌ°¡ ÀÖ´Ù´Â Á¡ÀÔ´Ï´Ù. ½Äµµ¿­°øÅ»ÀåÀÌ ÀÖÀ¸¸é TLESR¿¡¼­ À§½ÄµµÁ¢Çպΰ¡ ³Ð°Ô ¿­·Á¼­ À§³»¿ë¹°ÀÌ ¿ª·ùÇϱ⠽¬¿î »óÅ°¡ µÈ´Ù´Â ÀǹÌÀÔ´Ï´Ù.

±â´ÉÀû Ãø¸éµµ Èï¹Ì·Ó½À´Ï´Ù. °°Àº TLESRÀÌ¶óµµ À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ »ê¿ª·ù°¡ µ¿¹ÝµÉ È®·üÀÌ ³ôÀ½Àº ¾Õ¼­ ¼³¸íÇÑ ¹Ù ÀÖ½À´Ï´Ù. ´Ù¸¥ Ãø¸é¿¡¼­ »ìÆ캸¸é, À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ ½Äµµ¿­°øÅ»ÀåÀÌ ¾ø´Â °æ¿ì »ê¿ª·ù ±âÀüÀº ´ëºÎºÐ TLESRÀÔ´Ï´Ù. ±×·¯³ª ½Äµµ¿­°øÅ»ÀåÀÌ ÀÖ´Â À§½Äµµ¿ª·ùÁúȯ ȯÀÚÀÇ »ê¿ª·ù ±âÀüÀº TLESRÀÌ Àý¹Ý Á¤µµÀÏ »ÓÀ̸ç, ³ª¸ÓÁö ´Ù¾çÇÑ ±âÀüÀÌ Àý¹ÝÀÔ´Ï´Ù.


5. »êÁÖ¸Ó´Ï (acid pocket)

À§½Äµµ¿ª·ùÁúȯ¿¡¼­ »ê¿ª·ù Áõ»óÀº ½ÄÈÄ¿¡ °¡Àå ÇöÀúÇÕ´Ï´Ù. ±×·±µ¥ ½ÄÈÄ¿¡´Â À½½Ä¹°¿¡ ÀÇÇÏ¿© À§»êÀÌ ÁßÈ­µÇ±â ¶§¹®¿¡ À§³» pH°¡ °¡Àå ³ôÀº »óÅ°¡ µË´Ï´Ù. pH°¡ °¡Àå ³ôÀº »óÅÂ, Áï À§°¡ »ê¼ºÀÌ ¾Æ´Ñ »óÅ¿¡¼­ À§»ê¿ª·ù°¡ ¸¹´Ù´Â °ÍÀº ¸ð¼øÀÔ´Ï´Ù. ¶ÇÇÑ ½Äµµ¿Í À§¿¡ pH probe¸¦ À§Ä¡½ÃÅ°°í ÃøÁ¤Çϸé À§³» pHº¸´Ù ½Äµµ pH°¡ ³·Àº °æ¿ì°¡ ÀÖ½À´Ï´Ù. ½ÄÈÄ À§³» pH´Â 5 Á¤µµÀÔ´Ï´Ù. ±×·±µ¥ ¿ª·ù¿¡ ÀÇÇÑ ½Äµµ pH°¡ 2±îÁö ³»·Á°£´Ù´Â Á¡Àº ÀÌÇØÇϱ⠾î·Á¿î ¸ð¼øÀÌ ¾Æ´Ò ¼ö ¾ø½À´Ï´Ù. ¾î¶»°Ô ÀÌ·¯ÇÑ Çö»óÀÌ °¡´ÉÇÒ±î¿ä? ÀÌ¿¡ ´ëÇÑ ¼³¸íÀº 1997³â PennsylvaniaÀÇ Fisher¿Í 2001³â GlasgowÀÇ Fletcher¿¡ ÀÇÇÏ¿© ´Ü¼­°¡ ¸¶·ÃµÇ¾ú½À´Ï´Ù. Fisher´Â ½ÄÈÄ À§³» pH°¡ À§Ä¡¿¡ µû¶ó Â÷ÀÌ°¡ ÀÖ´Ù´Â Á¡("regional difference")À», Fletcher´Â ½ÄÈÄ À§½ÄµµÁ¢ÇպΠÀαٿ¡ pH°¡ ³·Àº ¿µ¿ª("acid pocket¡±)ÀÌ Á¸ÀçÇÔÀ» º¸¿©ÁÖ¾ú±â ¶§¹®ÀÔ´Ï´Ù.

GlasgowÀÇ Fletcher¿Í McColl µîÀº pH probe pull-through techniqueÀ» ÀÌ¿ëÇÏ¿© ½ÄÈÄ À§ÀÇ Àü¹ÝÀûÀÎ pH°¡ 4.7±îÁö ³ô¾ÆÁöÁö¸¸, À§½ÄµµÁ¢ÇպΠÁ÷ÇϺο¡ ¾à 2 cm Á¤µµ´Â pH°¡ 1.6Á¤µµ·Î ³·°Ô À¯ÁöµÇ´Â ºÎÀ§°¡ ÀÖ´Ù°í º¸°íÇϸ鼭 À̸¦ acid pocketÀ¸·Î ¸í¸íÇÏ¿´½À´Ï´Ù. ÀÌÈÄ °°Àº ¿¬±¸ÀÚµéÀº high resoluation pH-meter¸¦ ÀÌ¿ëÇÏ¿© acid pocketÀÌ ½ÄÈÄ 14ºÐ ºÎÅÍ °üÂûµÇ±â ½ÃÀÛÇÏ¿© ¾à 90ºÐ Á¤µµ Áö¼ÓµÊÀ» º¸¿©ÁÖ¾ú½À´Ï´Ù. ½ÄÈÄ À§½ÄµµÁ¢ÇպΠÁ÷ÇϺο¡ pH°¡ ³·Àº ¾×ü°¡ ¸ð¿©Àֱ⠶§¹®¿¡ TLESRÀº »ê¿ª·ù¸¦ ÀÏÀ¸Å³ ¼ö ÀÖ´Â °ÍÀÔ´Ï´Ù.

À̷μ­ ½ÄÈÄ À§³» pH´Â 5Àε¥ ¿ª·ù¿¡ ÀÇÇÑ ½Äµµ pH°¡ 2±îÁö ³»·Á°¡´Â ¸ð¼øÀº ÇØ°áµÇ¾ú½À´Ï´Ù. ´Ù¸¸ acid pocket°ú TLESRÀº À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­¸¸ °üÂûµÇ´Â Ưº°ÇÑ ¼Ò°ßÀÌ ¾Æ´Ï¶ó´Â Á¡À» °í·ÁÇØ¾ß ÇÕ´Ï´Ù. µû¶ó¼­ acid pocket°ú TLESR ÀÌ¿Ü¿¡ ¹º°¡ÀÇ Á¶°ÇÀÌ ÀÖ¾î¾ß¸¸ À§½Äµµ¿ª·ùÁúȯÀÌ µÈ´Ù°í »ý°¢ÇÒ ¼ö ÀÖ½À´Ï´Ù. ¹Ù·Î ÀÌ°÷¿¡¼­ ½Äµµ¿­°øÇã´Ï¾Æ¿Í acid pocketÀÌ ¸¸³ª°Ô µË´Ï´Ù.


6. À§½Äµµ¿ª·ùÁúȯ ȯÀÚÀÇ acid pocket

Á¤»óÀΰú À§½Äµµ¿ª·ùÁúȯ ȯÀÚÀÇ acid pocketÀº Å©±â¿Í À§Ä¡¿¡ ¾à°£ Â÷ÀÌ°¡ ÀÖ½À´Ï´Ù. ÀϹÝÀûÀ¸·Î À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­ acid pocketÀº ±æ°í º¸´Ù À§ÂÊ¿¡ ÀÚ¸®Àâ°í ÀÖ½À´Ï´Ù. ƯÈ÷ ½Äµµ¿­°øÇã´Ï¾Æ°¡ Àִ ȯÀÚ¿¡¼­ acid pocketÀº Ⱦ°æ¸·º¸´Ù À§ÂÊ¿¡ À§Ä¡ÇÕ´Ï´Ù. Beaumant µî¿¡ ÀÇÇϸé acid pocketÀÌ È¾°æ¸·º¸´Ù ¾Æ·¡ÂÊ¿¡ À§Ä¡ÇÑ °æ¿ì TLESRÀÇ 10%¿¡¼­ »ê¿ª·ù°¡ ÀϾÁö¸¸, acid pocketÀÌ È¾°æ¸·º¸´Ù À§ÂÊ¿¡ À§Ä¡ÇÑ °æ¿ì TLESRÀÇ 80%¿¡¼­ »ê¿ª·ù°¡ ÀϾ´Ï´Ù.


7. °á·Ð - Unifying hypothesis

À§½Äµµ¿ª·ùÁúȯ ȯÀÚ´Â ½ÄµµÀ§Á¢ÇÕºÎÀÇ ±â´ÉÀû ¹× ÇغÎÇÐÀû ÀÌ»óÀ» °¡Áö°í ÀÖ½À´Ï´Ù. ÇغÎÇÐÀû ÀÌ»óÀÌ ÀüÇô ¾ø´Â ±â´ÉÀû ÀÌ»ó¸¸À¸·Î À§½Äµµ¿ª·ùÁúȯÀÌ ¹ß»ýÇÏ´ÂÁö´Â ¹ÌÁö¼öÀÔ´Ï´Ù. ½ÄÈÄ »ê¿ª·ùÀÇ °¡Àå Áß¿äÇÑ À¯¹ßÀÎÀÚÀÎ TLESR Á¶Â÷ ½Äµµ¿­°øÅ»Àå ¿©ºÎ¿¡ µû¶ó »ê¿ª·ùÀÇ ºóµµ°¡ Å©°Ô ´Þ¶óÁý´Ï´Ù. µû¶ó¼­ À§½Äµµ¿ª·ùÁúȯ¿¡¼­ ±â´ÉÀû ÀÌ»óÀº ÇغÎÇÐÀû ÀÌ»ó°ú ±ä¹ÐÇÏ°Ô ¿¬°áµÇ¾î ÀÖ½À´Ï´Ù. ´Ù¸¸ ±â´ÉÀû ÀÌ»óÀÌ ¸ÕÀúÀÎÁö ÇغÎÇÐÀû ÀÌ»óÀÌ ¸ÕÀúÀÎÁö ¸íÈ®ÇÏÁö ¾Ê½À´Ï´Ù.

½Äµµ¿­°øÅ»ÀåÀº ¾Æ³ª·Î±× Çö»óÀÔ´Ï´Ù. ¿ì¸®°¡ ½Äµµ¿­°øÅ»ÀåÀÌ ¾ø´Ù°í ÆÇ´ÜÇÏ´Â °ÍÀº À§½ÄµµÁ¢Çպο¡ ÇغÎÇÐÀû ÀÌ»óÀÌ ¾ø´Ù´Â ¶æÀº ¾Æ´Õ´Ï´Ù. °æ¹ÌÇÑ º¯È­´Â ÇöÀçÀÇ Áø´Ü±âÁØÀ¸·Î Àâ¾Æ³¾ ¼ö ¾øÀ» »ÓÀÔ´Ï´Ù.

ÀÌ ¸ðµç °ÍÀ» ¿ä¾àÇϸé ÇϳªÀÇ ÅëÇÕÀÌ·ÐÀÌ ³ª¿É´Ï´Ù. °æ¹ÌÇÑ ½Äµµ¿­°øÅ»ÀåÀ» Æ÷ÇÔÇÑ ¹º°¡ÀÇ ÇغÎÇÐÀû ÀÌ»óÀÌ ÀÖÀ» ¶§, acid pocketÀÇ Å©±â³ª À§Ä¡°¡ ´Þ¶óÁö°í, TLESR¿¡ ÀÇÇÑ »ê¿ª·ùÀÇ ºóµµ°¡ ¸¹¾ÆÁö¸é¼­ ½ÄÈÄ »ê¿ª·ùÁõ»óÀÌ ¹ß»ýÇÏ´Â °ÍÀÔ´Ï´Ù. ÀÌ ¼¼°¡Áö ¿ä¼Ò´Â »óÈ£ ¿¬°üµÇ¾î ÀÖ½À´Ï´Ù. ´Ù¸¸ ¾î´À °ÍÀÌ ÀÏÂ÷ÀûÀÎ ¿øÀÎÀÎÁö´Â ¾ÆÁ÷ ¸íÈ®ÇÏÁö ¾Ê½À´Ï´Ù. Àú´Â degenerative change¿¡ ÀÇÇÑ ÇغÎÇÐÀû ÀÌ»óÀÌ Ã¹ Çö»óÀÏ °ÍÀ¸·Î »ý°¢ÇÏ°í ÀÖ½À´Ï´Ù.


[References]

1) EndoTODAY Hiatal hernia

2) 2014³â 1¿ù 25ÀÏ ´ëÇÑ»óºÎÀ§Àå°üÇ︮ÄÚ¹ÚÅÍÇÐȸ °³¿øÀÇ ½ÉÆ÷Áö¾ö¿¡¼­ ÀÌÇõ ±³¼ö°¡ acid pocket¿¡ ´ëÇÏ¿© Àß Á¤¸®ÇÑ °ÍÀ» º¸¾Ò½À´Ï´Ù. ¿Å±é´Ï´Ù.

À§½Äµµ¿ª·ùÁúȯ¿¡¼­ À§»ê ¿ª·ù´Â ´ëºÎºÐ ½ÄÈÄ¿¡ ºó¹øÇÏ°Ô ¹ß»ýÇÑ´Ù. ±×·¯³ª ½ÇÁ¦·Î ½ÄÈÄ¿¡´Â À½½ÄÀ¸·Î ÀÎÇÑ ¿ÏÃæÀÛ¿ë ¶§¹®¿¡ À§»ê Á¤µµ°¡ ¾àÇØÁö´Â °ÍÀÌ ÀϹÝÀûÀÎ Çö»óÀÌ´Ù. µû¶ó¼­ ½ÄÈÄ À§»ê »óÅÂ¿Í ½ÄÈÄ Áõ»ó°úÀÇ ±«¸®°¡ ¼³¸íÀÌ µÇÁö ¾Ê¾Ò´Âµ¥ ÀÌ·¯ÇÑ ¹®Á¦´Â Fletcher µî¿¡ ÀÇÇÑ ¿¬±¸¿¡¼­ ÀÌÀ¯°¡ óÀ½À¸·Î º¸°í°¡ µÇ¾ú´Ù. ÀÌ ¿¬±¸¿¡¼­´Â À§ÀÇ ºÐ¹®ºÎ´Â ½ÄÈÄ ¿ÏÃæ ÀÛ¿ëÀ» ¹ÞÁö ¸øÇÏ´Â ºÎºÐÀ¸·Î È®ÀÎÀÌ µÇ¾ú°í ÀÌ°ÍÀÌ ½ÄÈÄ À§»ê ¿ª·ùÀÇ Áß¿äÇÑ ¿øÀÎÀ̶ó´Â °ÍÀÌ´Ù. ÀÌó·³ ½ÄÈÄ¿¡ À§ ±ÙÀ§ºÎÀÇ ³ôÀº »ê¼ºÀÎ ÀÛÀº ±¸¿ªÀ» »êÁÖ¸Ó´Ï (acid pocket) ¶ó°í ºÎ¸£°í ÀÖ´Ù.

ÀÌ·¯ÇÑ »êÁÖ¸Ó´ÏÀÇ Á¸Àç´Â ±× ÈÄ ¸¹Àº ¿¬±¸Àڵ鿡 ÀÇÇؼ­ ÇغÎÇÐÀûÀ¸·Î ȤÀº »ý¸®ÇÐÀûÀ¸·Î Áõ¸íÀÌ µÇ¾ú´Âµ¥ pull-through »ê ÃøÁ¤ ¹æ¹ý, ´Ùä³Î »ê ÃøÁ¤¹ý, single photon emission CT (SPECT) µîÀÇ ¹æ¹ýÀ» ÀÌ¿ëÇؼ­ ¸¹Àº ¿¬±¸°¡ ÁøÇàµÇ¾ú´Ù. »ç½Ç À§ ±ÙÀ§ºÎ°¡ À½½Ä¿¡ ÀÇÇÑ ¿ÏÃæ È¿°ú¸¦ ¹ÞÁö ¸øÇÏ´Â ±âÀüÀº ¿©ÀüÈ÷ ºÒºÐ¸íÇÏ´Ù. ½ÄÈÄ À§»ê ºÐºñ°¡ µÇ¸é À§°­ÀÇ º¯¿¬ºÎ´Â ½ÉÇÑ »ê¼ºÀ¸·Î º¯ÇÏ´Â ¹Ý¸é À§°­ Á߾Ӻδ À½½Ä¿¡ ÀÇÇؼ­ »êµµ°¡ ¾àÇØÁö´Âµ¥ À̶§ À½½ÄÀ̳ª ºÐºñµÈ ¹°ÁúÀÌ À§ÀÇ ÁÖ¸§À» ÆØâ½ÃÅ°Áö¸¸ À§ ºÐ¹®ºÎ¿¡¼­´Â Ⱦ°Ý¸·°ú ÇϺΠ½Äµµ Á¶ÀÓ±ÙÀ¸·Î ÀÎÇؼ­ ÀÌ·¯ÇÑ ÆØâ È¿°ú°¡ ³ªÅ¸³ªÁö ¾Ê¾Æ¼­ ±ÙÀ§ºÎÀÇ ³»°­ ¿ëÀû¿¡ ¿µÇâÀ» ¹ÞÁö ¾Ê°í »ê¼ºµµ°¡ ³ô¾ÆÁö´Â °ÍÀ¸·Î ÀÌÇصǰí ÀÖ´Ù.

°¡Àå Å« °ü½ÉÀº À§½Äµµ¿ª·ùÁúȯ¿¡¼­ »êÁÖ¸Ó´ÏÀÇ ÀÓ»óÀûÀÎ ¿ªÇÒÀÌ´Ù. ¸î ¸î ¿¬±¸¿¡ ÀÇÇϸé ÇϺνĵµÁ¶ÀÓ±ÙÀÇ ÀÌ¿ÏÀ¸·Î ÀÎÇؼ­ »êÁÖ¸Ó´Ï°¡ À§½ÄµµÁ¢ÇպΠ°¡±îÀÌ¿¡, ȤÀº ½ÉÁö¾î´Â À̸¦ ³Ñ¾î ÇϺΠ½Äµµ¿¡±îÁö ¿µÇâÀ» ¹ÌÄ¡´Â °ÍÀ¸·Î ¾Ë·ÁÁ® Àִµ¥ ÀÌ·¯ÇÑ °úÁ¤ÀÌ À§½ÄµµÁ¢ÇÕºÎÀÇ ¿°Áõ°ú Àå»óÇÇ È­»ýÀ» À¯¹ßÇÏ´Â °ÍÀ¸·Î ÃßÁ¤µÇ°í ÀÖ´Ù. ƯÈ÷ À§½Äµµ¿ª·ùÁúȯ°ú »êÁÖ¸Ó´ÏÀÇ ÀÓ»óÀûÀÎ °ü·Ã¼º¿¡¼­´Â »êÁÖ¸Ó´ÏÀÇ Å©±â¿Í À§Ä¡°¡ Áß¿äÇÑ ¿äÀÎÀ¸·Î ¾Ë·ÁÁ® Àִµ¥ °Ç°­´ëÁ¶±º¿¡ ºñÇÏ¿© À§½Äµµ¿ª·ùÁúȯ ȯÀÚ¿¡¼­´Â ´õ ±ä »êÁÖ¸Ó´Ï°¡ È®ÀεǾú°í ÀÌ´Â À§½ÄµµÁ¢ÇÕºÎÀÇ ±ÙÀ§ºÎ·ÎÀÇ À̵¿À¸·Î ÀÎÇÑ °á°ú·Î ¼³¸íÀÌ µÇ°í ÀÖ´Ù. ÀÌ·¯ÇÑ ¿¬±¸ °á°ú·ÎºÎÅÍ µ¿¹ÝµÇ¾î ÀÖ´Â ½Äµµ¿­°øÅ»Àå ¼Ò°ßÀÌ ±ÙÀ§ºÎ »êÁָӴϸ¦ Å©°Ô Çϰųª ±æ°Ô ÇÏ´Â È¿°ú°¡ ÀÖ´Â °ÍÀ¸·Î »ý°¢µÈ´Ù.

À§½Äµµ¿ª·ùÁúȯ°ú °Ç°­´ëÁ¶±º »çÀÌÀÇ »êÁָӴϸ¦ ºñ±³ÇÑ ¿¬±¸¿¡¼­ ÀÏ°ú¼º ÇϺνĵµÁ¶ÀÓ±Ù ÀÌ¿Ï (transient lower esophageal relaxation, TLESR)ÀÇ ºóµµ´Â À¯»çÇÏ¿´´Ù. ÀÌ ¿¬±¸¿¡¼­ »êÁÖ¸Ó´ÏÀÇ Å©±â¿Í À§Ä¡¸¦ ºÐ¼®Çϱâ À§Çؼ­ SPECT¸¦ »ç¿ëÇÏ¿´´Âµ¥ »êÁÖ¸Ó´Ï°¡ À§½Äµµ¿ª·ùÁúȯ¿¡¼­ ´õ ±æ´Ù´Â »ç½ÇÀ» È®ÀÎÇßÀ» »Ó¸¸ ¾Æ´Ï¶ó »êÁÖ¸Ó´ÏÀÇ À§Ä¡¿¡ °üÇÏ¿© TLESR Á÷Àü¿¡ ½Äµµ¿­°øÅ»Àå ³»¿¡ ȤÀº Ⱦ°Ý¸· À§¿¡ »êÁÖ¸Ó´Ï°¡ ºó¹øÇÏ°Ô À§Ä¡ÇÏ°í ÀÖ´Ù´Â °ÍÀ» Á¦½ÃÇÏ¿´´Ù. °á·ÐÀûÀ¸·Î À¯»çÇÑ TLESR ºóµµ¿¡µµ °Ç°­´ëÁ¶±ºº¸´Ù À§½Äµµ¿ª·ùÁúȯ¿¡¼­ ´õ ½ÉÇÑ »ê ¿ª·ù°¡ ¹ß»ýÇÏ´Â ±âÀüÀº »êÁÖ¸Ó´ÏÀÇ Å©±â¿Í À§Ä¡¿¡ ÀÇÇÑ °ÍÀ¸·Î ÆÇ´ÜÇϸç ÀÌ´Â ¹Ù·Î ½Äµµ¿­°øÅ»ÀåÀÇ À¯¹«¿Í ¹ÐÁ¢ÇÑ °ü·ÃÀÌ ÀÖ´Ù°í º¸°í ÀÖ´Ù. ÀÌ´Â ½Äµµ¿­°øÅ»Àå ȯÀÚ¿¡¼­ »êÁÖ¸Ó´Ï°¡ Á¸ÀçÇÏ°Ô µÇ¸é ÇϺνĵµÁ¶ÀÓ±ÙÀÌ ÀÌ¿ÏµÉ ¶§¸¶´Ù ½Äµµ·ÎÀÇ ¿ª·ù °¡´ÉÇÑ »êÀÇ ÀúÀå¼Ò·ÎÀÇ Áß¿äÇÑ ¿ªÇÒÀ» ÇÏ°Ô µÇ´Âµ¥ ¹Ù·Î ÀÓ»óÀûÀÎ Àǹ̰¡ ÀÖ´Â °ÍÀÌ´Ù.

3) 2014³â 1¿ù 23ÀÏ ÇÑ Çмú¸ðÀÓ¿¡¼­ acid pocket¿¡ ´ëÇÑ ³íÀǸ¦ ÇÏ¿´½À´Ï´Ù. ÀÌ·± Àú·± »ý°¢ÀÌ µé¾î¼­ ¸î ±ÛÀÚ ½á º¸¾Ò½À´Ï´Ù.

GERD ȯÀÚ¿Í Á¤»óÀÎ ¸ðµÎ »êÁָӴϸ¦ °¡Áö°í ÀÖ½À´Ï´Ù. »êÁÖ¸Ó´Ï°¡ ÀÓ»óÀû ÀÇÀǸ¦ °®´Â°¡´Â À¯¹«ÀÇ ¹®Á¦°¡ ¾Æ´Ï°í Å©±â³ª À§Ä¡ÀÇ ¹®Á¦ÀÎ °Í °°½À´Ï´Ù. »êÁÖ¸Ó´ÏÀÇ Å©±â¿Í À§Ä¡°¡ ´Þ¶óÁö´Â °ÍÀº ¾î¶² ¿¬À¯Àϱî¿ä? Hiatal hernia°¡ ¶Ñ·ÇÇÑ È¯ÀÚ¿¡¼­ »êÁÖ¸Ó´ÏÀÇ Å©±â¿Í À§Ä¡°¡ ¶Ñ·ÇÇÏ°Ô ´Þ¶óÁø´Ù°í ÇÕ´Ï´Ù. À̸¦ extrapolationÇغ¸¸é fixed hiatal hernia »Ó¸¸ ¾Æ´Ï¶ó transient hiatal herniaµµ »êÁÖ¸Ó´ÏÀÇ À§Ä¡¿Í Å©±â¿¡ ¿µÇâÀ» ÁÙ °ÍÀÔ´Ï´Ù.

Ȥ½Ã GERD ȯÀÚ¸¦ µÑ·Î ³ª´©¸é fixed hiatal hernia ±º°ú transient hiatal hernia ±ºÀÌ µÇ´Â ¼À ¾Æ´Ò±î¿ä? Áï hiatal hernia´Â GERDÀÇ ÇÊ¿äÁ¶°ÇÀÎ °Í ¾Æ´Ò±î¿ä? °á±¹ GERD´Â motility ÁúȯÀÌ ¾Æ´Ï¶ó hiatal hernia¿Í °ü·ÃµÈ anatomy ÁúȯÀÎ °Í ¾Æ´Ò±î¿ä?

»êÁÖ¸Ó´Ï °³³äÀÌ µµÀԵǸ鼭 »õ·Ó°Ô Ç®¸®´Â ¼ö¼ö²²³¢µéÀÌ ÀÖ½À´Ï´Ù. Prokinetics°¡ ÀϺΠGERD ȯÀÚ¿¡¼­ µµ¿òÀÌ µÇ´Âµ¥ ±× ±âÀüÀÌ ¸íȮġ ¾Ê¾Ò½À´Ï´Ù. ÃÖ±Ù small hiatal hernia°¡ ÀÖ´Â »ç¶÷¿¡¼­ erythromycinÀÌ »êÁÖ¸Ó´Ï À§Ä¡¸¦ Á¶Àý(¾Æ·¡·Î ³»¸²)ÇÏ´Â °ÍÀÌ Áõ»ó°³¼±¿¡ µµ¿òÀ» ÁÖ´Â ±âÀüÀ̶ó´Â ¿¬±¸¸¦ º¸¾Ò½À´Ï´Ù. Èï¹Ì·ÓÁö ¾Ê½À´Ï±î? »êÁÖ¸Ó´Ï´Â °ü½ÉÀ» °¡Áö°í ÁöÄѺ¼¸¸ÇÑ ÁÖÁ¦ÀÔ´Ï´Ù.

4) 2014³â 2¿ù 7ÀÏ. µ¥Àϸ®¸Þµð ±â°í - À§½Äµµ¿ª·ùÁúȯ Áõ»ó¹ß»ý±âÀü¿¡ ´ëÇÑ »õ·Î¿î ÀÌÇØ: Acid Pocket (Text, PDF 0.1 M)

5) 2014³â 4¿ù 18ÀÏ. ´ëÇÑ»óºÎÀ§Àå°üÇ︮ÄÚ¹ÚÅÍÇÐȸ. ÀÌÁØÇà °­¿¬ ¿ø°í

The physiological roles of esophageal gastric juction (EGJ) are (1) to allow food passage during swallowing as an one-way valve, (2) to prevent reflux, and (3) to a allow venting of air (not fluid) during transient lower esophageal sphincter relaxations (TLESRs). Traditionally, gastroesophageal reflux disease (GERD) is considered as a functional disease related with the dysfunction of EGJ. The existence of nonerosive reflux disease (NERD) have been used as a strong evidence of the functional disease concept. Anatomical factors such as hiatal hernia, relaxation of phrenoesophageal ligament, and shortened esophagus have been disregarded. A famous, but not accurate, study by doctor Cohen published in a very famous journal (NEJM) contributed this misconception. However, endoscopists knows there is something wrong around the GEJ in patients with NERD. It has been named as minimal change. But, there is no clear definition of minimal change.

Heartburn due to postprandial acid reflux is the most typical symptom of gastroesophageal reflux disease (GERD). However, gastric pH after a meal is high due to the buffering effect of food. It is quiete paradoxical that most acid reflux episodes develop when the stomach is least acidic. Using a a stepwise pull-through method with a pH electrode, Fletcher and colleges found an area of unbuffered, highly acidic, gastric juice at the esophagogastric junction (EGJ) in the postprandial period. They named it the "acid pocket". Intragastric pH increased from pH 1.4 in the fasting state to pH 4.7 after the meal, but remained at pH 1.6 in the acid pocket. Acid pocket develops 17 minutes after a meal and persists about one and half hour.

The frequency of TLESR is not different between GERD patients and controls. However the percentage of TLESRs accompanying acid reflux is high in GERD patients. This interesting finding leads to interesting findings that the size and location of acid pocket in GERD patients are different from controls. The acid pocket in GERD patients is longer and is located in the more proximal position. It is due to the existence of fixed or non-fixed hiatal hernia. Chances are high that many NERD patients are actually patients with non-fixed hiatal hernia.

2014³â 4¿ù 18ÀÏ´ëÇÑ»óºÎÀ§Àå°üÇ︮ÄÚ¹ÚÅÍ ½ÉÆ÷Áö¾öÀÇ acid pocket¿¡ ´ëÇÑ °­ÀÇ ÈÄ ¾î¶² Áú¹®¿¡ ´ëÇÏ¿© Áõ»óÀÌ ÀÖÀ¸¸é ¹°, ¿ìÀ¯, antacid, GavisconÀ» µå½Ãµµ·Ï ÇÑ´Ù°í ¸»Çß½À´Ï´Ù. ±×·±µ¥ ÄÝ·Òºñ¾Æ¿¡¼­ Âü¼®ÇØ ÁֽŠ¼±»ý´Ô²²¼­ '¿ìÀ¯'¿¡ ´ëÇÏ¿© ÀÌÀǸ¦ Á¦±âÇÏ¿´½À´Ï´Ù. ¿ìÀ¯´Â ÀÚü´Â ¾ËÄ®¸®Áö¸¸ ÀÎü¿¡¼­ À§»êÀ» ³»µµ·Ï Çϱ⠶§¹®¿¡ ÇÇÇϵµ·Ï ±ÇÇÑ´Ù°í ÇÕ´Ï´Ù. ¹Ý¸é ¿ä±¸¸£Æ®´Â ÁÁ´Ù°í ÇÏ¿´½À´Ï´Ù. °ü·Ã ÀڷḦ ¼Ò°³ÇÕ´Ï´Ù. ±ÞÈ÷ ÀÎÅͳݿ¡¼­ ÆÛ¿Â °ÍÀÔ´Ï´Ù.

Question: Can milk soothe acid reflux?

Answer: While drinking a glass of milk to relieve heartburn may initially ease the discomfort of acid reflux or gastroesophageal reflux disease (GERD), it may also have a rebound affect later when the same milk triggers the production of stomach acid later.

Milk has a soothing effect on the stomach and throat that can provide temporary relief but in the long run tends to encourage acid secretion. Sometimes this response is most pronounced when one drinks a glass of whole milk just before bedtime to treat heartburn and induce sleep, as ritual and old wives' tales have suggested.

Whole milk and dairy products may worsen acid reflux of GERD because of the fat contained in those food products. Foods containing saturated fats are known to relax the esophageal sphincter, a muscle in your lower esophagus that normally protects against reflux, opening for passage of food and drink and then closing and contracting for digestion.

Other foods that can trigger relaxation of this muscle include fried foods, tomato-based products, caffeine, alcohol, chocolate, citrus fruit, carbonated beverages, desserts, ice cream and yogurt. Skim milk and low-fat or non-fat yogurt may however provide quick relief of symptoms, but lifestyle changes may have the most benefit. They include weight loss, smoking cessation, decreasing alcohol intake, eating a healthy diet, eating smaller meals, elevating the head of your bed, and avoiding tight-fitting clothing.

There are also alternative herbal remedies, which include ingestion of licorice, slippery elm, and chamomile, as well as, relaxation techniques to reduce stress and anxiety and acupuncture, per one study. Nevertheless, you should always clear these remedies with your physician because of the possibility of drug interactions with medications you are already taking or prior diagnoses.

6) 2014³â 8¿ù 1ÀÏ. Dr Kahrilas's comment (AGA News)

How important is some intragastric acidity in the abscence of intragastric volume? Except in the most unususal of circumstances, acid reflux requires both. Clearly, administration after the acid pocket has already formed is too late... unless there is lingering effect from the prior PPI dose. This consideration speaks to the clinical utiligy of long half-life PPIs, administration of short half-life PPIs prior to meals for optimal effect, and the usd of on-demand medications for breakthrough symptoms that directly target the acid pocket once it has already formed, such as alginates. *(Kahrilas. AGA News 2014 June)



© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.