¼±Åà - È­»ìǥŰ/¿£ÅÍŰ ´Ý±â - ESC

 

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