내시경 점막 절제술

김광하,Kim, Gwang Ha 대한기관식도과학회 2011 大韓氣管食道科學會誌 Vol.17 No.1

Diagnosis of early esophageal cancer has become more frequent as a result of improved endoscopic technology, surveillance programmes, and increasing experience and awareness on the part of endoscopists. In early esophageal cancer, squamous cell carcinoma and early adenocarcinoma must be managed differently because they have different origins, pathogenesis. and clinical characteristics. The current treatment options vary widely, from extended resection with lymphadenectomy to endoscopic mucosal resection (EMR) or ablation. None of these treatment options can be recommended universally. Instead, an individualized strategy should be based on the depth of tumor infiltration into the mucosa or submucosa, the presence or absence of lymph node metastases, the multicentricity of tumor growth, the length of the segment of intestinal metaplasia, and comorbidities of the patient. EMR has become increasingly important, both as a diagnostic tool for the staging of esophageal carcinomas and as a method of carrying out definitive treatment when the cancer meets certain criteria in which the risk of lymph-node metastasis is negligible. EMR may be sufficient in a subset of patients who have m1 or m2 squamous cell carcinoma and in patients who have isolated foci of high-grade intraepithelial neoplasia or mucosal cancer.

미만성 및 분절성 호두까기 식도에서 임상양상 및 위식도역류

김광하 ( Gwang Ha Kim ),이동현 ( Dong Hyun Lee ),정우진 ( Woo Jin Jeong ),박원일 ( Won Il Park ),박진홍 ( Jin Hong Park ),김진선 ( Jin Seon Kim ),허정 ( Jeong Heo ),강대환 ( Dae Hwan Kang ),송근암 ( Geun Am Song ),조몽 ( Mong Ch 대한소화기기능성질환·운동학회 2004 Journal of Neurogastroenterology and Motility (JNM Vol.10 No.1

목적: 호두까기 식도는 정상연동운동을 보이나 하부식도 수축파의 진폭이 현저히 증가된 경우로, 두 군데 하부 식도에서의 평균 수축파의 진폭에 근거하여 정의하고 있다. 그러나 고압의 연동성 수축이 하부 식도의 한 부위에서만 나타날수 있으며, 이러한 분절성 운동이상은 미만성 호두까기 식도로 변화할 수 있다. 본 연구에서는 호두까기 식도를 미만성과 분절성으로 확장하여 정의하고 이 두 군 사이에 임상 양상과 위식도역류에 차이가 있는지 알아보고자 하였다. 대상및 방법: 비심인성 흉통, 연하곤란 및 인후 이물감 등을 주소로 2002년 7월부터 2003년 10월까지 본원 소화기 내과를 방문하여 표준 식도내압검사에서 호두까기 식도로 진단된 50명(남자 28명, 여자 22명, 평균 51.4세)을 대상으로 하였다. 이들 중 35명에서 보행성 식도산도검사를, 42명에서 상부위장관 내시경검사를 시행하였으며, 호두까기 식도는 식도내압소견에 따라 미만성 및 분절성 두 군으로 구분하였다. 결과: 1)미만성으로 진단된 경우가 24명, 분절성으로 진단된 경우가 26명이었으며, 두 군 간에 고혈압, 허혈성 심질환, 흉통, 연하곤란, 흉부 작열감, 위산의 역류, 인후 이물감, 후두증상, 쉰목소리의 빈도에 있어 유의한 차이는 없었다. 2) 전체 검사시간 중 pH 4 미만인 전체, 기립시 및 앙와위시 측정시간 백분율, pH 4 미만의 역류가 일어난 횟수, pH 4 미만의 역류가 5분 이상 일어난 횟수, DeMeester 종합점수 또한 두 군 간에 차이가 없었다. 보행성 식도산도검사에서 위식도역류질환으로 진단된 경우는 미만성 호두까기 식도군에서는 28.6%, 분절성 호두까기 식도군에서는 38.1%로 유의한 차이는 없었다. 3) 상부위장관 내시경검사상 역류성 식도염으로 진단된 경우는 각각 23.8%, 14.3%로, 두 군 간에 유의한 차이는 없었다. 4) 24시간 보행성 식도산도검사와 상부 위장관 내시경 검사를 종합하여 분석하였을 때, 위식도역류질환으로 진단된 경우는 각각 33.3%, 38.5%로, 역시 두 군 간에 유의한 차이는 없었다. 결론: 미만성 호두까기 식도군과 분절성 호두까기식도군 사이에 임상 양상 및 위식도역류의 정도에 차이는 없었다. 그러므로 분절성 호두까기 식도의 진단에 대한 관심과 함께 더 많은 환자를 대상으로 한 추적 식도내압검사 및 치료반응에 대한 추가적인 연구가 필요하리라 생각된다. Background/Aims: The most common esophageal motility abnormality in patients with noncardiac chest pain is nutcracker esophagus. Most investigators regard nutcracker esophagus as a diffuse process involving the distal esophagus. Others consider it a segmental disturbance affecting any level of the esophagus. This study compared the clinical characteristics and gastroesophageal reflux between two groups of nutcracker esophagus patients: diffuse and segmental. Methods: From July 2002 to October 2003, 50 patients were diagnosed as nutcracker esophagus and were grouped into diffuse type (24 patients) and segmental type (26 patients). Of them, 35 patients underwent 24-hour ambulatory pH monitoring and 42 underwent gastroscopy. Results: The groups did not differ significantly with respect to the clinical characteristics such as hypertension, ischemic heart disease, chest pain, dysphagia, heartburn, acid regurgitation, laryngitis, globus or hoarseness. They did not show any significant difference in gastroesophagea reflux parameters by 24-hour ambulatory pH monitoring and gastroscopic findings. Gastroesophageal reflux disease was diagnosed in 33.3% of diffuse types and in 38.5% of segmental types, which was not significantly different ( p=0.706). Conclusions: There was no significant difference in clinical characteristics or gastroesophageal reflux between the diffuse nutcracker esophagus group and the segmental nutcracker esophagus group.

Analysis of Electronic Endoscopic Image of Intramucosal Gastric Carinoma by Using Homoglobin Index

김광하(Gwang-Ha Kim),임은경(Eun-Kyung Lim),김광백(Gwang-Baek Kim) 한국지능시스템학회 2005 한국지능시스템학회 학술발표 논문집 Vol.15 No.2

It has been suggested that the endoscopic color of intramucosal gastric carcinoma is correlated with mucosal vascularity within the carcinomatous tissue. The development of electronic endoscopy has made it possible to quantitatively measure the mucosal hemoglobin volume, using a hemoglobin index. The aim of this study was to make a software program to calculate the hemoglobin index (IHb) and then investigate whether the mucosal IHb determined from the electronic endoscopic data is a useful marker for evaluating the color of intramucosal gastric carcinoma, in particular wi th regard to its value for discriminating between the histologic type. The mean values of IHb for the carcinoma (IHb-C) and the mean values of IHb for the surrounding non-cancerous mucosa (IHb-N) were calculated in 75 intestinal-type and 34 diffuse-type gastric carcinomas. Then, we analyzed the ratio of the IHb-C to IHb-N. The mean IHb-C/IHb-N ratio in the intestinal-type carcinoma group was higher than that in the diffuse-type carcinoma group (1.28±0.19 vs. 0.81±0.18, respectively, p<0.001). When the cut-off point of the C/N ratio was set at 1.00, the accuracy rate, the sensitivity, the specificity, and the positive and negative predictive values of a C/N ratio below 1.00 for the differential diagnosis of diffuse-type carcinoma from intestinal-type carcinoma were 94.5%, 94.1%, 94.7%, 88.9% and 97.3%, respectively. IHb is useful for quantitative measurement of the endoscopic color in intramucosal gastric carcinoma and the IHb-C/IHb-N ratio would be helpful in distinguishing diffuse-type carcinoma from intestinal-type carcinoma.

한국인 담석증에 대한 임상적 고찰

김광하(Gwang Ha Kim),옥창민(Chang Min Ok),김병진(Byung Jin Kim),주형준(Hyung Jun Joo),송철수(Chul Soo Song),송근암(Guen Am Song),조몽(Mong Cho),양웅석(Ung Suk Yang) 대한소화기학회 1997 대한소화기학회지 Vol.29 No.3

N/A Background/Aitns: It has been reported frequently that clinical features of gallstone diseases in Koreans were different from those of Occidentals. These differences were thought to be due to inherent racial difference and acquired living habits. The purpose of this study is to evaluate whether the pattern of gallstone disease changes or not in Korea. Methods: We analyzed 5,488 cases of gallstone diseases which were reported in Korea frorn 1966 to 1994. We divided the period into 6 groups: the first period was 1,000 cases reported from 1966 to 1970, the second was 331 cases from 1971 to 1975, the third was 1,000 cases from 1976 to 1980, the fourth was 1,957 cases from 1981 to 1985, the fifth was 1,000 cases from 1986 to 1990, and the sixth was 200 cases from 1991 to 1993. Results: The age group of highest incidence was the fifth and sixth decade. The incidence below the third decade showed a decreasing tendency. In contrast, the incidence above sixth decade showed an increasing tendency. The male to female ratio was 1:1.25 to 1:1.71 and had no periological change. The duration of illness of highest frequency was below 6 months. In the case of duration above 5 years these was a decreasing tendency. The major complaints of biliary stone were right upper quadrant pain and tenderness. Nausea, vomiting, jaundice, and radiating pain showed a decreasing tendency. The major laboratory findings were leukocytosis, elevated SGOT and SGPT, elevated alkaline phosphatase, hyperbilirubinemia and hypoalbuminemia. Of these, only hypoalbuminernia had a decreasing tendency. By the second period, the main diagnostic procedures were oral cholecystogram and intravenous cholecysto- graphy. From the fourth period, ultrasonography, ERCP, CT and PTC were been used comrnonly. For the location of gallstone, the gallbladder stone revealed the only increasing tendency, the common bile duct stone had a decreasing tendency, and the intrahepatic duct stone had no periological change. From 1980, the cholesterol stone became the main composition of gallstones. But, there was no periological change between early and late 1980s. Positive bacterial culture rate was 57.0% and the most common microorganism was E. coli. Klebsiella and Enterobacter. Pseudomonas showed an increasing tendency. Of the diseases associated with gallstone, only diabetes had an increasing tendency. The frequency of residual stone had an increasing tendency. Conclusions: The age of peak incidence of gallstone diseases was the fifth and sixth decades and there was a little predominance in females. From 1980, the cholesterol stone becarne the main composition of gallstones. For the location of gallstone, the gallbladder stone showed an increasing tendency and the common bile duct stone revealed a decreasing tendency. These suggested clinical features of gallstone diseases in Koreans are somewhat similar to those of Occidentals. (Korean J Gastroenterol 1997;29:352 - 361)

Relationships Between the Expressions of CDX1 and CDX2 mRNA and Clinicopathologic Features in Colorectal Cancers

김광하 ( Gwang Ha Kim ),( Dong Hyun Lee ),( Hyung Wook Kim ),( Jong Yun Cheong ),( Soo Boon Seo ),( Jeong Heo ),( Dae Hwan Kang ),( Geun Am Song ),( Mong Cho ),( Ung Suk Yang ),( Do Youn Park ),( Mi Ae Y 대한내과학회 2005 The Korean Journal of Internal Medicine Vol.20 No.4

Background : CDX1 and CDX2 are members of the caudal-type homeobox gene family and control the proliferation and differentiation of intestinal mucosal cells. Their expressions are commonly reduced in colorectal cancer, but reports about the relationships between their expressions and clinicopathologic features are rare. The aim of this study was to examine the expressions of CDX1 and CDX2 mRNAs in colorectal cancers and to assess the relationships between their expressions and clinicopathologic features. Methods : CDX1 and CDX2 mRNA expressions were analyzed by real-time polymerase chain reaction in 48 colorectal cancers and in adjacent non-tumorous normal mucosal tissue. Results : CDX1 and CDX2 mRNA expressions were significantly reduced in colorectal cancer tissues versus normal mucosal tissues (p=0.001, p=0.042, respectively). As compared with paired normal mucosal tissues, colorectal tissues showed reduced CDX1 mRNA expression in 64.6% (31/48) and reduced CDX2 mRNA expression in 66.7% (32/48) of cases. A statistically significant positive correlation was found between the expressions of CDX1 mRNA and CDX2 mRNA in colorectal cancer (r=0.543, p<0.001). However, the expressions of CDX1 and CDX2 mRNAs were not related to age, sex, cancer location, differentiation, lymphatic or vascular invasion, lymph node metastasis, stage or serum carcinoembryonic antigen level. Conclusions : CDX1 and CDX2 mRNA expressions were found to be significantly reduced in colorectal cancers, but these expressional changes were not found to be related to clinicopathologic features.

대장암에서 CDX1 mRNA 및 CDX2 mRNA의 발현과 임상병리학적 인자와의 연관성

김광하 ( Gwang Ha Kim ),이동현 ( Dong Hyun Lee ),김형욱 ( Hyung Wook Kim ),정종윤 ( Jong Yun Cheong ),서수분 ( Soo Boon Seo ),허정 ( Jeong Heo ),강대환 ( Dae Hwan Kang ),송근암 ( Geun Am Song ),조몽 ( Mong Cho ),양웅석 ( Ung Suk 대한내과학회 2004 대한내과학회지 Vol.67 No.4

비효과적 식도운동 환자에서의 식도 산청소능

김광하(Gwang Ha Kim),배용목(Yong Mock Bae),정을조(Eul Jo Jeong),문재현(Jae Hyeon Moon),안진광(Jin Kwang An),김진선(Jin Seon Kim),허정(Jeong Heo),강대환(Dae Hwan Kang),송근암(Geun Am Song),조몽(Mong Cho),양웅석(Ung Suk Yang) 대한내과학회 2002 대한내과학회지 Vol.63 No.4

목적 : 저진폭 수축파와 연동운동 단절은 식도 내용물의 부적절한 배출과 역류와 연관성이 있어 기능적·임상적 중요성을 가진다. 이런 이유로 비특이성 식도운동장애(NEMD)에서 구분하여 비효율적 식도운동(IEM) 이라는 새로운 진단명이 제시되고 있다. 이에 저자들은 산역류가 있는 IEM 환자에서 식도 산청소능을 조사하고자 하였다. 방법 : 2001년 6월부터 2002년 5월까지 쉰 목소리, 인후 이물감, 흉통 등으로 식도운동검사와 보행성 식도산도검사를 시행 받은 252예 중에서 산역류를 보이는 정상식도운동군 51명(남:여 18:33, 평균 48.0세)과 IEM군 40명(남;여, 16:24, 평균 48.6세)을 대상으로 하여 식도운동검사와 보행성 식도산도검사 결과를 비교분석하였다. 적어도 wet swallow의 30% 이상에서 원위부 식도의 저수축 소견이 관찰되는 경우를 IEM으로 진단하였으며. 식도 산청소능은 원위부 식도 pH가 4 미만인 전체 시간(분)을 총 역류 횟수로 나눈 값으로 정의하여 양군 간에 결과를 비교분석하였다. 결과 : 1) IEM군에서 근위부 식도와 원위부 식도 수축파의 진폭, 하부식도괄약근압은 각각 47.3±21.9 mmHg, 60.0±27.5 mmHg, 18.0±6.7 mmHg로, 정상식도운동군(66.5±22.6 mmHg, 100.3±31.8 mmHg, 29.5±8.4 mmHg)보다 유의하게 낮았다(p<0.05). 2) IEM군에서 전체 검사시간 중, 기립시, 앙와위시 pH 4 미만인 전체 측정시간 백분율은 0.78±1.08%, 1.05±1.55%, 0.42±1.16%로, 정상식도운동군(각각 0.55±0.85%, 0.85±1.31%, 0.14±0.41%)과 유의한 차이는 없었다(p>0.05). 또한, 전체 측정시간 중 pH 4 미만의 역류가 일어난 횟수, 전체 측정시간 중 pH 4 미만의 역류가 5분 이상 일어난 횟수, Demeester 종합점수, 최장역류시간도 양군간에 유의한 차이는 없었다(p>0.05). 3) IEM군에서 앙와위시 식도 산청소능은 0.73±0.64분/회로, 정상식도운동군 0.31±0.29분/회보다 유의하게 증가되어 있었다(p=0.021). 하지만 기립시 식도 산청소능은 IEM군 0.51±0.42분/회, 정상식도운동군 0.41±0.40분/회으로 양군간에 유의한 차이는 없었다(p=0.096). 결론 : IEM군에서 정상식도운동군보다 앙와위시 유의한 식도 산청소능 증가가 관찰되었다. IEM이 위식도역류질환(GERD)에서 흔히 관찰되는 것을 고려한다면, IEM시 보다 더 적극적인 항역류 치료가 필요하며, 차후 GERD의 장기합병증과의 관련성에 대한 연구도 필요할 것으로 보인다. 이러한 상황을 고려해 볼 때 IEM은 NEMD에서 분리하여 독립된 운동질환으로 분류하는 것이 바람직하리라 사료된다. Background : Failed or hypotensive peristalsis, two of the diagnostic criteria for NEMD, correlates with impaired anterograde propulsion and retrograde escape of esophageal contents. The aim of this study was to evaluate esophageal acid clearance (EAC) in patients with ineffective esophageal motility (IEM). Methods : Of 252 patients performing esophageal manometry and ambulatory esophageal pH monitoring, 51 patients with normal motility and acid reflux and 40 patients with IEM and acid reflux were included. Results : The amplitude of peristaltic waves in the proximal and distal esophagus and lower esophageal sphincter pressure was lower significantly in patients with IEM than those with normal motility. Percentage of time of pH<4 in total, upright, and supine period and number of reflux episodes was not different in both. Supine EAC was significantly increased in patients with IEM when compared to those with normal motility. Upright EAC was not different in both. Conclusion : We concluded supine EAC is increased in patients with IEM. Since IEM is frequently associated with gastroesophageal reflux disease (GERD), a more intensive therapy must be needed. We propose IEM can be as a specific entity of primary esophageal motility disorder, especially in patients with GERD.(Korean J Med 63:386-393, 2002)

위 생검조직에서 PCR 을 사용한 Helicobacter pylori 검출

김광하(Gwang Ha Kim),옥창민(Chang Min Ok),유영일(Young Il Yu),허정(Jung Huh),최성호(Seong Ho Choi),송철수(Chul Soo Song),송근암(Geun Am Song),조몽(Mong Cho),양웅석(Ung Suk Yang),문한규(Han Kyu Moon) 대한내과학회 1997 대한내과학회지 Vol.52 No.5

N/A Objective: Helicobacter pylori (H. pylori) has been implicated in the pathogenesis of chronic gastritis, gastric ulcer, duodenal ulcer and gastric cancer. Histological examination and culture are considered to be the most specific tests, and rapid urease test and serological test are rapid but less specific tests. 'I he aim of this study was to investigate the efficiency of the polymerase chain reaction (PCR) assay as a procedure for the diagnosis of H, pylori infection in gastric biopsy specimens. Methods: Biopsy specimens were obtained from the gastric antrum within 2cm from the pyloric channel of 42 patients during endoscopy and submitted for the histological examination, CLO test, and PCR assay. At the same time, another biopsy specimens were obtained from the lesion for the diagnosis of the diseases. Also, blood was sampled for the measure of the value of IgM and IgG. Results: As the result of the histopathological examination, chronic gastritis was diagnosed in 13 patients, gastric ulcer in 11, duodenal ulcer in H, and gastric cancer in 10. By the histological examination of the antrum, H, pylori were found in 77% of chronic gastritis, 55% of gastric ulcer, 75% of duodenal ulcer, and 40% of gastric cancer. As a whole, the bacteria was identified in 62%, 60%, 88%, 90%, 69% of patients by histological test, CLD test, IgM, IgG, and P(;R respectively. The gold standard we used for the presence of bacteria was histological examination. Sensitivity, specificity, positive predictive value, ancl negative predictive value for PCR assay were 92%, 69%, 83% and 85% respectively. The results of other test were as follows. CLO test: 89%, 88%, 92%, 82%, IgM:92%, 19%, 65%, 60%, IgG:100%, 25%, 68%, 100%, Conclusion: CR is a very sensitive but some- what less specific test for the detection of H. pylori. This is mainly due to the contamination of H. pylori during endoscopy and biopsy. So, minimization of the contamination would make PCR clinically useful test.

비만이 일시적인 하부식도괄약근 이완의 증가와 연관이 있다

김광하 ( Gwang Ha Kim ) 대한소화기기능성질환·운동학회 2007 Journal of Neurogastroenterology and Motility (JNM Vol.13 No.1

요약 : 비만은 위식도역류질환(GERD) 및 그 합병증과 관계가 있으나, 그 기전에 대해선 아직 명확하지 않다. 저자들은 GERD가 없는 사람에서 비만과 하부식도괄약근(LES) 기능의 연관성에 대해서 조사하였다. 전향적으로 체중감량 시술을 받기 위해서 내원한 연속적인 비만(BMI>30)인 환자를 대상으로 하고, 연령과 나이가 유사한 과체중(BMI 25-30) 및 정상체중인(20≤BMI<25) 사람을 대조군으로 하였다. 식도염, 역류증상, 양자펌프 수용체 사용자, 틈새헤르니아 >2 cm, 미세혈관 합병증이 있는 당뇨환자는 제외하였다. 모든 참가자에서 표준검사식이 2시간 뒤 식후 식도내압검사와 산도검사를 시행하고, 이후 24시간 보행성 산도검사를 시행하였다. 총 84명(비만 28명, 과체중 28명, 정상체중 28명)이 포함되었다. 세 군 사이에 평균 LES 압, LES 길이, 연동운동은 유사하였다. 식후 2시간 동안 비만군과 과체중군에서 일시적인 하부식도괄약근 이완(transient LES relaxation, TLESR)수의 의미 있는 증가(정상체중: 2.1±1.2, 과체중: 3.8±1.6, 비만: 7.3±2.0, p<0.001), 산역류와 관련된 TLESR 비율의 의미 있는 증가(정상체중: 17.6%±22.0%, 과체중: 51.8%±22.5%, 비만 63.5%±21.7%, p<0.001), 위식도 압력 차이의 의미 있는 증가(정상체중: 4.5±1.2 mmHg, 과체중: 7.1±1.4 mmHg, 비만: 10.0±1.5 mmHg, p<0.001)가 관찰되었다. 다변량회귀분석 후 BMI (r2:0.70, B: 0.28, 95% CI: 0.24-0.33, p<0.001)와 허리둘레(r2:0.65, B: 0.10, 95% CI: 0.08-0.11, p<0.001)는 TLESR과 유의한 상관관계가 있었다. 결론적으로 GERD가 없는 사람에서 비만은 식후기간중의 TLESR과 산역류 증가와 상관관계가 있었다. 식후 LES의 비정상적인 기능은 비만과 관련된 GERD의 병인에서 초기에 관찰되는 소견일 것이다.

위식도역류질환의 식도 외 증상

김광하 ( Gwang Ha Kim ) 대한소화기학회 2008 대한소화기학회지 Vol.52 No.2

Gastroesophageal reflux disease (GERD) often presents as typical symptoms such as heartburn or acid regurgitation. However, a subgroup of patients presents a collection of symptoms and signs that are not directly related to esophageal damage. These are known collectively as the extraesophageal manifestations of GERD, such as non-cardiac chest pain, laryngitis, chronic cough, hoarseness, asthma or dental erosion. They have a common pathophysiology, involving microaspiration of acid into the larynx and pharynx, and vagally mediated bronchospasm and laryngospasm. The role of extraesophageal reflux in such disorders is underestimated due to often silent symptoms and difficult confirmation of diagnosis. Endoscopy and pH monitoring are insensitive and therefore not useful in many patients as diagnostic modalities. Thus, anti-secretory therapy by proton pump inhibitor is used as both a diagnostic trial and as a therapy in the majority. Attention to optimizing therapy and judicious use of endoscopy and reflux monitoring are needed to maximize treatment success. (Korean J Gastroenterol 2008;52:69-79)