GI motility disorder Cecil chap 132(p694-702 )
1. Normal motility in stomach, small intestine and colon
1) smooth muscle
stomach¿¡¼ distal colon±îÁö luminal content°¡ À̵¿Çϱâ À§Çؼ´Â phasic & tonic
contractions & intrinsic stomach muscle toneÀÇ relaxation(peristaltic reflex)»çÀÌÀÇ Á¶È°¡
ÇÊ¿äÇÏ´Ù.
smooth muscle cellÀÇ slow wave frequency´Â cell¾È¿¡ ÀÖÀ¸³ª ÀÎÁ¢¼¼Æ÷ÀÇ activity¿¡ ÀÇÇØ
modifyµÉ ¼ö ÀÖ´Ù. pacemaker regionÀÌ GIT °¢ ºÎºÐÀÇ dominant frequency¸¦ Á¶ÀýÇÑ´Ù.
* interstitial cell of Cajal
: GITÀÇ ´Ù¸¥ ºÎºÐ¿¡ ´ëÇÑ pacemaker·Î ÀÛ¿ëÇϸç ÀÌ ¼¼Æ÷ÀÇ Á¸Àç´Â proto-oncogene c-ki
tÀÇ Á¸Àç·Î ¾Ë¼ö ÀÖ´Ù.
proto-oncogene c-kit´Â tyroine kinase receptor¸¦ codeÇÑ´Ù.
slow wave˂ progressive propagation˼ gastric smooth muscle cell˂ tight electrical
couplingÀ¸·Î ÀÌ·ç¾îÁö¸ç, higher contraction frequency´Â mean pressure¸¦ Áõ°¡½ÃÄÑ
intraluminal contents¸¦ lower pressure area ¹× distal·Î À̵¿½ÃŲ´Ù.
discending colon¿¡ intraluminal pressure°¡ ³ôÀ¸¸é intraluminal pressure¸¦ µÚ·Î´Â
transverese colonÀ¸·Î, ¾ÕÀ¸·Î´Â sigmoid colonÂÊÀ¸·Î À̵¿½ÃŲ´Ù.
±×·¯¹Ç·Î frequency gradientº¸´Ù´Â pressure amplitude gradient°¡ colonic transitÀ» °áÁ¤
ÇÑ´Ù.
colon¿¡¼ proximal descending colon & splenic flexure¿¡ ¼öÃàÀÌ ¿ì¼¼Çϸé Àå³» ³»¿ë¹°À»
¼¯´Â ÀÛ¿ëÀ» Çϰí, transverse colonÀº storage areaÀÇ ¿ªÇÒÀ» ÇÑ´Ù.
´Ù¸¥ motility patternÀÎ propagating contractionÀº neural controlÇÏ¿¡ ÀÌ·ç¾îÁö¸ç fecal
content¸¦ T-colon¿¡¼ distalÂÊÀ¸·Î propagationÇÏ¿© sigmoid colon¿¡ º¸´Ù ¸¹ÀÌ ÀúÀå
µÈ´Ù.
circular contractionÀº lumenÀ» ±¸È¹ÈÇÏ¿© Á¡¸·¿¡ ³ëÃâµÈ contents¸¦ ¼¯´Â ¿ªÇÒÀ» ÇÑ´Ù.
longitudinal muscleÀÌ Âª¾ÆÁ® luminal contents°¡ Àü¹æÀ¸·Î À̵¿ÇÑ´Ù.
sphincter contraction & relaxationÀº ÁÖÀ§ bowel pressure or physiologic stimuli¿¡ ¹ÝÀÀ
ÇÏ¿© enteric neurotransmitter or circulating peptide hormone¿¡ ÀÇÇØ Á¶ÀýµÈ´Ù. GI smooth
muscle contractionÀ» À§Çؼ´Â intracellular Ca³óµµÀÇ Áõ°¡°¡ ÇÊ¿äÇÏ´Ù.
GIT¸¦ ÅëÇÑ intraluminal content transport¿¡´Â smooth muscle relaxationµµ ¶È°°ÀÌ Áß¿ä
ÇÏ´Ù.
cAMP»ý»êÀº smooth m. cell membrane receptorÀÇ ligand activation¿¡ ÀÇÇØ ½ÃÀ۵ǰí SR
·Î CaÀÌ À̵¿ÇÔÀ¸·Î½á intraluminal Ca³óµµ°¡ °¨¼ÒÇÑ´Ù.
(1) enteric nervous system
enteric neuron¿¡´Â ¸¹Àº excitatory & inhibitory neurotransmitter°¡ ÇÔÀ¯µÇ¾î ÀÖ´Ù(Tab
132-1).
ÀϺΠneurotransmitters´Â stimulatory(¿¹, Ach)ÀÌ°í ´Ù¸¥ °ÍµéÀº inhibitory(¿¹, VIP)ÀÌÁö¸¸,
ÀϺΠneurotransmitter ´Â nerve¿Í muscle¿¡ ´Ù¸¥ ÀÛ¿ëÀ» ³ªÅ¸³¿À¸·Î½á motility patternÀ»
Á¶ÀýÇÑ´Ù.(¿¹, opiates´Â muscle¿¡´Â stimulation, Ach release´Â inhibition)
ȤÀº ´Ù¸¥ regional effect¸¦ ³ªÅ¸³»±âµµ ÇÑ´Ù(¿¹, neurotensinÀº gastric muscleÀº relax,
small intestinal & colon muscle˼ stimulation).
NO´Â myenteric neuron, smooth muscle cells & cells of Cajal¿¡¼ »ý»êµÇ¸ç, intracellular
cGMP¸¦ À¯µµÇÔÀ¸·Î½á GI smooth muscle relaxation½ÃŰ´Â final mediatorÀÌ´Ù.
intrinsic enteric neuronÀº ¼·Î ¿¬°áµÇ¾î ÀÖ´Ù(Fig 132-2).
(2) enteric peptide hormones
peptides´Â ½Ä»çÈÄ GI mucosa¿¡¼ Ç÷ÁßÀ¸·Î À¯¸®µÇ¾î hormoneó·³ ÀÛ¿ëÇÏ¿© gastric,
small intestinal, and colonic smooth muscle contraction¿¡ ¿µÇâÀ» ¹ÌÄ£´Ù.
enteric nervous systemó·³ stimulating peptides(gastrin, CCK, motilin)¿Í inhibitory
peptides(enteroglucagon & peptide YY)»çÀÌÀÇ counterbalance°¡ motility¸¦ Á¶ÀýÇÑ´Ù.
½Ä»çÈÄ 30-60ºÐ¿¡ ÃÖ°í Ç÷Á߳󵵿¡ µµ´ÞÇÑ´Ù.
(3) GI transit
¨ç stomach
liquid emptying(T12=15min)ÀÌ solid(T12=45-90min)º¸´Ù ºü¸£´Ù.
glucose solutionÀÇ gastric emptyingÀº 2 kcal/min·Î salineº¸´Ù ºü¸£´Ù.
fundus: liquid emptying
antrum: solid emptying
¨è small intestine
transit time: small intestine¿¡¼ cecum±îÁö 40-180min
* MMC(migrating motor complex)
°øº¹½Ã ¹ß»ýÇÏ¿© indigestible luminal content¸¦ Á¦°ÅÇÏ´Â ¿ªÇÒÀ» ÇÑ´Ù.
3 phases·Î ÀÌ·ç¾îÁö¸ç
phase 1 : inactivity period
phase 2 : intermittent phasic contractions
phase 3 : continous periods of contractions that propels the remaining intestinal
contents during fasting
phase 3 MMC´Â stomach(3 cycle/min)¿¡¼ duodenum(11 cycles/min)À¸·Î ÁøÇàÇÑ´Ù.
2. GI motility disorder
1) delayed gastric emptying Tab 132-3
typical sx: early satiety, nausea, vomiting
¿¹> postvagotomy, DM, viral infections, reflux esophagitis, brain stem lesions,
anorexia nervosa, tachygastria
¨ç diabetic gastroparesis
diabetic hyperglycemia or ketoacidosis¿¡ ÇÕº´µÇ¾î ³ªÅ¸³ª´Â delayed gastric emptyingÀº
´ë»ç»óŰ¡ È£ÀüµÇ¸é ȸº¹µÈ´Ù. ±×·¯³ª ¶§·Î´Â À§°¡ ½ÉÇÏ°Ô ÆØ¸¸Çϰí Á¡¸·ÃâÇ÷À» º¸¿© NG
tube decompressionÀÌ ÇÊ¿äÇÒ¼öµµ ÀÖ´Ù.
chronic delayed gastric emptyingÀº long-standing IDDM°ú µ¿¹ÝµÇ¸ç ÀÓ»óÀû ¹®Á¦°¡ Å©´Ù.
±×·± ȯÀÚµéÀº ¹Ýº¹ÇÏ¿© nausea, vomitingÀ» º¸À̰í À½½Ä¼·ÃëÀÇ Àå¾Ö ¹× insulin¿ä±¸¸¦
º¹ÀâÇÏ°Ô ÇÑ´Ù.
retinopathy, nephropathy, peripheral neuropathy ¹× ´Ù¸¥ ÇÕº´ÁõÀÌ ÈçÈ÷ Á¸ÀçÇÑ´Ù.
1mmÀÌ»óÀÇ non-digestible materialÀÇ emptying¿¡ ÇÊ¿äÇÑ MMC°¡ ¾ø¾î¼ diabetic patient
´Â bezoar°¡ Àß »ý±ä´Ù.
autonomic neuropathy°¡ Ç×»ó Á¸ÀçÇÏ´Â °ÍÀº ¾Æ´ÏÁö¸¸ vagal neuropathy´Â DM¿¡¼
gastric stasis¸¦ ÀÏÀ¸Å°´Â º´ÀÎÀ¸·Î »ý°¢µÈ´Ù.
metoclopramide°¡ gastric emptyingÀ» ÃËÁø½Ã۰í, nausea and distension¿¡ ´ëÇÑ CNS
recognitionÀ» °¨¼Ò½ÃÅ´À¸·Î½á Áõ»óÀ» È£Àü½ÃŲ´Ù. Bethanechol¶ÇÇÑ gastric motility¸¦
Áõ°¡½Ã۰í, diabetic gastric stasisȯÀÚÀÇ Áõ»óÀ» È£Àü½ÃŲ´Ù.
erythromycinÀº antral contraction°ú fundal toneÀ» Áõ°¡½ÃÅ´À¸·Î½á gastroparesisÁõ»óÀ»
È£Àü½ÃŲ´Ù. clonidineµµ gastric emptying & sxÀ» È£Àü½Ãų¼ö ÀÖ´Ù.
¨è anorexia nervosa
anorexia nervosaȯÀÚ¿¡¼ liquid°¡ ¾Æ´Ñ solid gastric emptying°¡ Áö¿¬µÇ´Â °ÍÀÌ °üÂû
µÈ´Ù.
À̰ÍÀÌ bulimia ȯÀÚ¿¡¼´Â °üÂûµÇÁö ¾Ê´Â´Ù.
delayed gastric emptying˼ antral dysrhythmia, fundal hypotonia, decreased
postprandial plasma concentrations of norepinephrine and neurotensin and impaired
autonomic function(decreased resting diastolic blood pressure and skin conductance)
°ú °ü·ÃÀÖ´Ù.
underlying psychiatric disturbance reversalÀÌ complete sx resolution¿¡ ÇÊ¿äÇÏ´Ù.
2) rapid gastric emptying
¿¹> dumping syndrome, pancreatic insufficiency, celiac sprue,
Zollinger-Ellison syndrome, duodenal ulcer