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 Ŭ󸮽θ̽, 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 ö󰡹Ƿ ̷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.