Esophagus ´ëÀå°æ Á¤¸®
1. UES´Â excitary innervation¸¸ ¹Þ°í
LES´Â excitary & inhibitory innervationµÑ´Ù ¹Þ´Â´Ù.
2. manometryµµÁß ½Äµµ³»¾Ð¿¡ ¿µÇâÀ» ÁÙ¼ö ÀÖ´Â ÀÎÀÚ
: »ïŰ´Â ½Ã°£°£°Ý, »ïŰ´Â ¹°Áú, º¹¾ÐÁ¤µµ, ȯÀÚ ÀÚ¼¼, ÁøÁ¤Á¦ »ç¿ë
osmolality¿Í temperature´Â °Ç°Àο¡¼ peristalsis¿¡ °ÅÀÇ ¿µÇâÀÌ ¾ø´Ù.
3. LES pressure¡é(¾Ï±â)
3S-C2°¡ ÀåÂøµÈ doni-VAN¥â´Â LES¾Ð·ÂÀ» ³·Ãá´Ù.
3S : secretin, serotonin, somatostatin
C2 : CCK, calcium channel blocker
do : dopamine
ni : nicotine, smoking
V : VIP
A : adenosine, aminophylline
N : nitric oxide, nitrates
¥â : ¥â-agonist
±× ¿Ü high xanthine(tea, coffee, cola), fatty mealÀº »ý°¢ÇØ º¸¸é LES pr¡éµÊÀ» ¾Ë¼ö ÀÖÁã..
4. LES pressure¡è(¾Ï±â)
BPH´Â motilium-M, Gastrin-P°¡ ¾Ð·ÂÀ» ³ôÀδÙ.
B : Bombesin
P : protein meal
H : histamine
M : motilin, metoclopramide, domperidone
M : muscarinic M2 receptor agonist
Gastrin
P : substance P, PGF2¥á
±× ¿Ü> antacidµµ LES pressure¸¦ Áõ°¡½ÃŲ´Ù.
5. LES¸¦ À̿ϽÃŰ´Â ½Å°æÀü´Þ ¹°Áú: VIP, nitric oxide
LES¸¦ ¼öÃà½ÃŰ´Â ½Å°æÀü´Þ ¹°Áú: acetylcholine
6. pseudoachalasia(=secondary achalasia) ±âÀü
i) tumor mass°¡ distal esophagus¸¦ encircle or compression
ii) malignant cellÀÌ esophageal neural plexus¿¡ infiltrationÇÏ¿©
postganglionic LES innervation¿¡ Àå¾ÖÃÊ·¡
7. Achalasia Ä¡·á
1) medical: NTG, nitrate, CCB
2) botulinum toxin
3) Balloon dilatation: 85%¿¡¼ È¿°úÀû
4) Heller's extramucosal myotomy
5) laparoscopic myotomy
8. achalasiaÀÇ Æ¯Â¡Àû manometry¼Ò°ß
i) LES incomplete relaxation
ii) bodyÀÇ simultaneous onset contraction
9. achalasiaÀÇ ¿øÀÎ: VIP¿Í NO synthase¸¦ ÇÔÀ¯ÇÏ´Â inhibitory neuron°á¼ÕÀÌ ¿øÀÎ
10. achalasia¿¡¼ Åë»óÀûÀÎ ÆòȰ±Ù ÀÌ¿ÏÁ¦(calcium channel blocker)´Â È¿°ú°¡ ºü¸¥ ÀåÁ¡ÀÌ
ÀÖÀ¸³ª ¹ÝÀÀ·ü(response)´Â 50-70%Á¤µµÀÌ´Ù.
11. achalasiaÀÇ surgical txÀûÀÀÁõ
i) dilatation fail
ii) perforation risk¿¡ ³ëÃâµÇ±â¸¦ ¹Ù¶óÁö ¾ÊÀ» ¶§
12. achalasia - nerve cell body degeneration
diffuse esophageal spasm - nerve processÀÇ degeneration
13. diffuse esophageal spasmÀÇ manometry¼Ò°ß
i) prolonged large amplitude
ii) repetitive contraction of simultaneous onset in lower esophagus
14. diffuse esophageal spasm À¯¹ß°Ë»ç
i) edrophonium & solid bolus : pain & motor abnormalityÀ¯¹ßÇÏÁö¸¸ pain°ú motor change
»çÀÌÀÇ correlationÀº ¾àÇÏ´Ù.
ii) cold swallow: chest painÀ» ÀÏÀ¸Å°Áö¸¸ manometry»ó spasmÀº ÀÏÀ¸Å°Áö ¾Ê´Â´Ù.
15. diffuse esophageal spasmÀÇ Ä¡·á
i) anticholinergics: limited value
ii) NG, nitrate, nifedipine : helpful
iii) reassurance & tranquilizer
16. noncardiogenic chest pain°ú °¨º°µÇ¾î¾ß ÇÒ ½Äµµ¿îµ¿Áúȯ 2°¡Áö
diffuse esophageal spasm, nutcracker esophagus
17. nutcracker esophagusÀÇ manometry¼Ò°ß
normal peristalsis & high-amplitude, long duration contraction in distal
esophagus(>180mmHg)
18. esophagitis¸¦ À¯¹ßÇÏ´Â reflux material: gastric acid, pepsin, bile salt, pancreatic
enzyme
19. ÈäÅëÀ¸·Î ³»¿ø½Ã °ü»óµ¿¸ÆÁúȯ°Ë»ç¿¡¼ À½¼ºÀ» º¸ÀÌ°í ³»½Ã°æ¿¡¼ Á¤»óÀ» º¸Àδٸé
´ÙÀ½À¸·Î ÇØ¾ß ÇÒ °Ë»ç?
i) esophageal manometry with Bernstein test
ii) 24hr ambulatory pH monitoring
20. ¿ª·ùÀ¯¹«È®ÀÎ: barium swallow, 99mTc-sulfur colloid scan, 24hr pH monitoring
¿ª·ù¿Í Áõ»ó°úÀÇ °ü°èÈ®ÀÎ: Bernstein test, 24hr pH monitoring
** 24hr pH monitoringÀº ¿ª·ùÀ¯¹« ¹× ¿ª·ù¿Í Áõ»ó°úÀÇ °ü°è¸¦ µ¿½Ã¿¡ È®ÀÎÇÒ¼ö ÀÖ´Ù.
21. GERD¿¡´Â Bernstein test°¡, incomplete vagotomyÀÇ Áø´Ü¿¡´Â Sham feeding test°¡
pyloric stenosis¿¡´Â saline loading test°¡ ÁÖ·Î ÀÌ¿ëµÈ´Ù.
22. reflux esophagitisÀÇ ³»½Ã°æÀ» ÀÌ¿ëÇÑ Á¡¸·»ý°Ë½Ã ÃÖ¼ÒÇÑ ÇϺΠ½Äµµ ÇùºÎ »ó¹æ 5cm À§
ÀÌ»óÀÇ ºÎÀ§¿¡¼ ÇØ¾ß ÇÑ´Ù. (5cm¹Ì¸¸¿¡¼´Â Á¤»óÀο¡¼µµ mucosal change°¡ ¸ÅÈÄ ÈçÈ÷
°üÂûµÇ¹Ç·Î)
23. GERD¿¡¼ anticholinergics´Â ±Ý±âÀÌ´Ù. ±× ÀÌÀ¯?
LES pressure¸¦ ³·Ãß°í, esophageal emptyingÀ» Áö¿¬½ÃŲ´Ù.
alkaline salivaÀÇ ºÐºñ¸¦ °¨¼Ò½ÃŲ´Ù.
24. reflux esophagitisÀÇ ÇÕº´Áõ:
esophageal stricture, Barrett's esophagus, pulmonary aspiration, esophageal
adenocarcinoma
25. Barrett's esophagusÀÇ Ä¡·á¹æÄ§
1) no dysplasia: 12-18°³¿ù¸¶´Ù F/U
2) low grade dysplasia: 3°³¿ù vigorous txÈÄ Á¶Á÷°Ë»ç, 6-12°³¿ù¸¶´Ù F/U
3) high grade dysplasia: esophagectomy½ÃÇà
26. Barrett's esophagusȯÀÚ¿¡¼ Àû±ØÀûÀÎ antireflux therapy°¡ ÇÊ¿äÇÑ ÀÌÀ¯?
i) malignancy risk°¡ ³ô´Ù.
ii) Á¤»ó squamous epitheliumÀ¸·Î reversionµÉ °¡´É¼ºÀÌ ÀÖ´Ù.
27. radiation esophagitis
indomethacinÀº radiation damage¸¦ °¨¼Ò½Ãų¼ö ÀÖ´Ù.
28. esophageal ca¿¡¼ÀÇ hypercalcemia: PTHrP secretion¶§¹®
29. Zenker's diverticulum¼ö¼ú
: cricopharyngeal myotomy c/s diverticulectomy