GERD --
1.
ĵ ȯ(gastroesophageal reflux disorder; GERD) ǥ ĵȯ θ ˷ , ſ 츮 ſ 幮 ȯ νĵǾ Դ. ĵ ȯ ־ , ɺ, ˾ ŭ̳ ʷ ִ ȯ, 翡 ϸ 40%̻ Ŵ GERD ǥ ۿ ȣϸ, 30% ̸ ݸ鿡 츮 2.4-2.7% ǰ ִ. ֱ ĻȰ ȭ Ҿ İ ǰ , α , Helicobacter pylori 츮 GERD þ ̸ ε ֱ Ⱓ ȯ GERD ȯڰ ĸ ްϰ ϴ ִ.
GERD 빰 Ư ĵ ν ϰų ĵ ջ , Ǵ ϴ ϰ ִ. ̿Ͱ κ ĵ ִ ݿ ð ˻ ĵ ջ ( ĵ; reflux esophagitis), ̻ ð Ұ ĵ ش(̶ GERD). ĵ ִٰ ؼ ϴ ƴϴ. ĵ ȯ δ ۿ(heartburn), Ư ġ ġо (acid regurgitation) ǥ 89%, 95% Ư̵ δ.6 ĵ δ ȣ ߰ Ǵ ħ, õ, , μ , ȭ ְ, ̺İ ̹, Ҹ ĵ, ĵο, ĵ, ĵξϱ ϸ, Ŀ, , -ȣ ְ, ܿ 强 , ġ, ϰ, , 谨 پϰ Ÿ ִ. ̿Ͱ ſ پϸ ϴٰ ؼ ݵ ϴٰų ĵ ջ ϴٰ .
2.
GERD ϴ ο ؼ Ȯ , ũ Ϻνĵ (lower esophageal sphincter: LES) ɺ, ĵ 츣Ͼ(Henia) , ĵ ûҴ , ĵ , ҵ ۿϴ Ѵ. LES з Ͼ , ̺ٴ ϰ Ϻνĵ ̿(transient lower esophageal sphincter relaxations: tLESRs) ߿ ̰ κ ̶ Ѵٰ ˷ ִ. tLESRs Ͽ LES з з ڱ âǾ ߵȴ. â tLESRs Ű ֱ ϸ ȭ(nitric oxide) к ؼ ݸ (cholinergic pathway) ϴ ˷ ־, ȭ ռȿ (nitric oxide synthase inhibitor) ݸ ӻ ̿ ɼ ûϳ ̵ ӻ ȿ뼺 δٴ . ̿Ͱ tLESRs ĵ ɼ ϴ ̰Եȴ.
ĵ 츣Ͼƿ GERD 迡 ؼ ź Ұ 踦 Ƿ Ѷ ū ٴ شDZ Ͽ ֱ ̿ ̷ ִ. ĵ ȯ ĵ 츣Ͼư õǾ ְ, Ⱦ渷 Ϻθ ̷ Ⱦ ĵ ϴµ, ĵ 츣Ͼƿ ݵ ĵ Ż Ǿٰ ĵ Ǵ ĵ ʷϰ ȴ. ĵ 츣Ͼ ũⰡ ũ LES з ٰ ˷ ִ.
ĵ ȯ ݼ ĵ ûҴ Ҹ ϰ ִ. ĵ ħ(Į) ߿ Ѵ. GERD ĵ ȭ Ѵٴ ־ , ̷ Ǽȯ ӵǹǷ ִ ġῡ ߿ϰڴ.
ĵ 꿡 ɷ ĵ ϰ Ǵµ, ̿Ͱ ĵ Ǽ pH ȵǴ , ĵ ϼ μ ź(bicarbonate) к ʴ 쿡 ְ, ĵ ȭ͵ ٰ ˷ ִ. ĵ , Į ִ Ե 쿡 ϰ Ѵٰ ˷ ִ.
3.
GERD ռ ӻ ſ پϹǷ 찡 ִ. ӻ ̿ ˻δ ĵ ð ˻, 24ð ༺ ĵ pH ˻, ߰˻, ĵ ˻, ĵ ˻, ĵ ûҴ ˻, ĵ а˻, ٷĵ, ˻ ְ ֱٿ Ǵ ˻ ߿ ִ.
1) ð ˻
ӻ GERD ǽɵ ð ϴ, proton pump inhibitor(PPI) õϴĿ ؼ , ¿Ǵ 츮 ̷ϰԵ ĵ ִ Ƿ 谨 ηؼ ǻ ȭϱ ð˻縦 ؾ ϴ , ð ˻ ĵ ̶ GERD PPI ϸ 谨 ϴ ó ִ.
ð ˻ ĵ պ ִ ˻ ĵ Ұ ٷ ġḦ ϰ ȴ. ĵ з Modified Savary & Miller з, ν з(LA classification), Ϻĵȯ ȸ з з ̿ LAз ˻ڰ ġ ſ , ̳ ġϿ ֱ ȣǰ ִ(Table 1). Ϻ ȭ, , ҽ ̼Һȭ(minimal change: grade MN) ߿Ͽ ð ĵ з ̸ Խų ϰ ̿ ʿ ̴.
GERD ϰ ǽɵ ð ˻ Ұ 쿡 ˻縦 ְ, َĵ Ǽ 糪 , ȭ ư ִ ĵ ˻翡 ̿ȴ.
2) 24ð ༺ ĵ pH ˻
˻ GERD Ȳݷ(gold standrad) ˻ ˷ ִ. ڹ ĵ ƴ϶ ĵ 꿡 ְ, Ļ, , ħ ִ. к ĵ -̿ϰ õ 48ð ̻ Ų (PPI 72ð̻ ), ¿ pH ־ ĵ LES 5 cm ġŲ. pH 迡 Ǿ 踦 ϰ 24ð ϻȰ ϸ鼭 ĵ pH ϰ ȴ. pH 4ϸ ϰ , ü ð ð (%), Ƚ, 5̻ Ⱓ Ƚ, Ǿ ð õ ִ. ְ ð濡 ĵ ܵǸ ˻縦 ݵ ʿ , , ġῡ ҷ , 찡 ȴ. ΰ 79-95%, Ư̵ 87-100% ϰ ִ.
3) ˻
˻ Ű ִ ߽Ų ̿ ϴ ̴. LES 5 cm pH ġ Ų 15 3ȸ ٸ ø ϰ, ٽ 15 3ȸ (valsalva) ϰ, 3ȸ (deep sniffs) ϰ, 뿡 ⸦ Ͽ й 15ʰ 3ȸ Ѵ. δ 0.1 N HCL ְ pH LES 10 cm ġ 5 ٸ ٽ 3ȸ ߰˻縦 Ѵ. 24ð ༺ ĵ pH ˻ 80% GERD ִ ȯڰ 缺 Ÿ ־ٰ Ѵ.
4) ĵ ˻
GERD ƴ Į ؼ Ͼ, ĵ ִ ߵǾ ̿ǰ ִ. ̴ 460nm ְ Ÿ б Ư ̿ pH ʾ Ȯ ϴ.
5) ˻
1958 ̿Ǿ ˻ ĵ ˾ƺ ˻, Bernstein ˻ ˷ ִ. 0.1 N HCL Ŀ ĵ Ű鼭 ߽۵ ˻ð ª ε Ư̵ .
6) ĵ ûҴ ˻
кҿ հ ٴ ð и ̰ ִ. ĵ ӹ ð ĵ ջ ߿ ϰԵǸ, ̿Ͱ ĵ óϿ ٽ ų Ÿ ȭ ִ ð ɸ ϴ ûҴɰ˻̴. 15 ml 0.1 N HCL ĵ LES 5 cm 濡 ġ pH ؿ ĵ pH 4.0 ̻ ö ɸ ð, ûҽð ĵ Ǵ ϴµ ɸ ð , ûҽð ̿Ͽ Ѵ.
7) ĵ ˻
LES Ӹ ƴ϶ ĵ ü Ͽ ûҴ ִ.
8) ٷĵ
ٷ ĵ ε ĵ, ĵ, ĵ ˾ Ӹ ƴ϶ ĵ 츣Ͼ ũ ĵ̸ ϴµ ϴ. ˻ ٷ ĵ 빰 ĵ Ǵ ˻ ε Ư̵ ʹ ʴ.
4. ġ
GERD ġ ǥ ȣ, ĵ (ĵ) ȸ, պ , ǥ ϸ, ġ , ߵ ̻ ȣϴ Ÿ(H2) ü ϰų Ѵ. ̷ ġῡ ȣ 뷮 H2 ü Ǵ PPI ̿ϰ Ǹ, ġ ܰ Ѵ.
1) Ȱ
ϻȰ ִ ġ ⺻ ſ ߿ѵ, ĻȰ â ϹǷ ̸ ϵ ϰ, Ļ ٷ 巯 ϹǷ ϵ Ѵ. ̳ ﰡ, LES з ҽŰ Ͻ ϰ ǹǷ ϴ . ݸ, , , LES з ߹Ƿ ϴ , к Ű , Ŀ ̸, ü 꼺 ĵ ڱϴ 꽺, 꽺, Ÿ , ź ϴ . üδ Ű ü ؾ ϴµ, ̴ , ϻ Ȱ θ ൿ ϴ , ü ٿ Ѵ. ؾ δ LES з ߰ų ĵ ϽŰ ε, õľ, ݸ , Į , ȯ , , Ÿ, Ӿ , ̵ ٸ ȯ ؾ Ѵ. Ư ߰ ȯڳ ĵ ְ ִ ħ ü κп 2 (6-8 inch) ȴ. ַ µȰ ϴ 츮 ȯڵ ϱ Ǽδ ü ̴ ſ Ӹ Ը 찡 ִµ ̴ ʴ´.
2) ġ
ġ , H2 ü , PPI ַ ̿ϸ, ϴ ؼ ִ. PPI H2 ü ȿ ִ -ȿ 鿡 ٸ ̴. ġ Ŀ step-up ġ step-down ġ ִµ ڴ Ȱ ʿ信 ϰ, ̿ ȿ ܰ Ǵ H2 ü ϸ PPI ʱġῡ ȯڵ ܵδ ġ̰, ڴ ó PPI Ͽ ҽǵǰ ĵ ġǸ, ܰ Ǵ H2 ü ٲپ Ⱓ Ȱ س ġ ռ ġ ̶ ϰڴ.14 翡 ϸ պ GERD step-up , ̶ ĵ ִ step-down -ȿ 鿡 ϴٰ Ѵ.
ٷ ȭų ְ ۿð ª 1ð ħ ϰ ִ. ٷ ߵ alginic acid ÷ alginic acid ſ ϰ ٴϹǷ ĵ ̵Ű ĵ ۿѴ. Sucralfate ܹ Ͽ Ȯ(back diffusion) ϰ ع ̸ Ű ϰ μ νŸ۶ кѴ.
LES з ϰ, ĵ Ͽ ٷ ϸ, Ŵν Ĺ̳ к ĵ ȸ Ѵ. û̵尡 ǥ ̿Ǿ QT Ⱓ ν ɽǼ , ɽǼ, torsades de pointes ɰ ϹǷν FDA ġ Ǿ. 츮 , ˻ ̻ ٴ Ȯ Ŀ ϵ ϰ ִ. Ư Ŭθ̽, θ̽Ű , , Ÿ cytochrome P-450 縦 Ű û̵ ǹǷ ɰ ۿ뿡 ̸ ִ.
H2 ü GERD ϴ ν к ϰ ȴ. 60% ȯڿ ۿ ȭŰ, ĵ ȯ 50% ȿ δ. øƼ(800 mg q.i.d.), Ƽ(150mg b.i.d.), ĸƼ(20 mg b.i.d.), Ƽ(150 mg b.i.d.) ǰ , ĵ Ϲݿ뷮 ȿ 뷮 2踦 ̿ϴ 뷮 ̳ տ Ǵ PPI ܵ(PPI տ PPI ܵ ٴ ٰŰ öǷ ̷Դ ) ϰ ȴ.
PPI ȸ 뷮 24ð к 90% ϴ , ̿ȴ. ĵ 쿡 8 ġ 80%̻ ġȴ. 10% 뷮 PPI ġῡ ̴ Į ߰ к( pH < 4) 1ð̻ ӵǴ ''breakthrough'' ϸ Ѵ. Į ǽɵ , breakthrough ǽɵ PPI 뷮 ø⺸ٴ ħ Ƽ ϴ ȴ. ſ 迡 ǰϿ ̳ ũģȭ Ͽ Ⱓ ֱٿ ȮεǸ鼭 ο θ ̿ǰ ִ.
Ϲ ġ 2-3 ȿ , ĵ ġߴ 1̳ 50-80% ߷ ֹǷ 4-6 ϰ ȴ. Ŀ ߴϵ ϴ on-demand ԵǴµ ȿ ֱٿ PPI Ѵ.
3) ġ
ġ GERD ȯڿ ϴ δ Nissen պ ߺ(fundoplication), Hill posterior (gastropexy), Belsey Mark IV ִ. ġῡ ȣ ʴ 缺 ĵ, ĵ˾ ְ ġ , ̶ ĵ ȯ, , μ õ ȣ ġ ġῡ ȣ ʴ ̴. ֱٿ ̿ ϰ ȿ θ ̿DZ , ð ռ ̿ ð ߵǾ ̿DZ Ͽ. PPI ȣ ϱ ݵ ȯڰ GERD Ÿ Ȯؾ ϸ, ̸ ؼ PPI ״ ϸ鼭 24ð ༺ ĵ pH ˻縦 Ͽ 꿪 ȿ ȮϿ Ѵ.
5.
GERD 빰 Ư ĵ ν ϰų ջ , Ǵ ϴ ϰ ִ. ֱ 츮 GERD ϰ ־ ̿ ġ ӻ ǻ鿡 ʼ̴.
GERD ۿ, Ư ȣ⳪ ̺İ Ư ĵ ִ. ܹδ ð˻, 24ð ༺ ĵ pH ˻, ĵ ˻, ˻, ĵ ûҴ ˻, ĵ ˻, ٷĵ, ˻ ִ. ġ Ȱ , Ƽ, PPI, ̿ , , ϹǷ ʱ Ⱓ ؾ Ѵ.