스테로이드 저항성 궤양성 대장염 환자에 대한 Cyclosporine A의 치료 효과

이대희(Dae Hee Lee),이준행(Jun Haeng Lee),박동영(Dong Young Park),김윤준(Yoon Jun Kim),황진혁(Jin Hyok Hwang),차성덕(Sung Duk Cha),정운태(Woon Tae Jeong),윤정환(Jung Hwan Yoon),이국래(Kook Lae Lee),이동호(Dong Ho Lee),정현채(Hyun Cha 대한소화기학회 1998 대한소화기학회지 Vol.30 No.1

N/A Background/Aims: In refractory severe ulcerative colitis patients who are resistant to intravenous corticosteroids and total parenteral nutrition, new medical therapeutic tools that induce rapid remission is required in order that the patients can avoid colectomy. Since 1990, several western groups reported in their well designed studies that cyclosporine A cou)d induce rapid remission at steroid resistant severe ulcerative colitis patients resulting avoidance of colectomy. We tested the effectiveness of intravenous cyclosporine A therapy at steroid resistant severe ulcerative colitis patients in Korea, which has little experiences in the management of steroid resistant severe ulcerative colitis. Methods: Seven patients were included who were refractory to intravenous corticosteroids and total parenteral nutrition of at least 4 weeks duration. Their liver function tests and creatinine clearance tests were all normal. Cyclosporine A were administered by continuous intravenous methods over 6 hours or 24 hours. The starting doses of cyclosporine A were 4 mg/kg. The blood level was monitored by radioimmunoassay with a monoclonal antibody. The doses were adjusted at blood level from 100 ng/ml to 400ng/ml. In one patient cyclosporine A was administered for only 4 days because of rapid aggravation and consequent emergency operation. In another 6 patients cyclosporine A were administered for 14 days. Results: Four patients revealed scores of less than 10 by clinical activity scores system. But, in spite of improvement by scores, 3 patients of above 4 responders exhibited persistent gross hematochezias at frequencies of more than 3 times a day. Therefore operations were recommended in 6 patients. But one patient refused operation and is under OPD follow up with oral cyclosporine A and corticosteroids medications but he exhibits persistent gross hematochezia at a frequency of 3 or 4 tirnes a day. Out of 5 patients who were operated, 4 patients were cured by operations but 1 patient died because of postoperational sepsis. Conclusions: We found that the intravenous cyclosporine A therapy produced some improvement by clinical activity scores in 4 patients out of 7 patients but induced clinical remission of gross hematochezia in only 1 patient. Therefore operation could be avoided in only 1 patient. This result suggests that the response of Korean patients to intravenous cyclosporine A therapy would be different from that of western people. However, many another studies, especially case control studies are required to clarify this possibility and to assign the proper role of intravenous cyclosporine A therapy in the manageent of patients with ulcerative colitis in Korea. (Korean J Gastroenterol 1997; 30:58-65)

위식도 역류질환 환자에서 Proton Pump Inhibitor 치료 후 재발률 및 증상개선에 관한 임상적 고찰

정유정 ( You Jeong Jeong ),이동호 ( Dong Ho Lee ),최태혁 ( Tae Hyuck Choi ),황태준 ( Tae Jun Hwang ),이병환 ( Byeong Hwan Lee ),나종천 ( Jong Chon Nah ),이상협 ( Sang Hyub Lee ),박영수 ( Young Soo Park ),황진혁 ( Jin Hyok Hwang 대한소화기학회 2010 대한소화기학회지 Vol.55 No.2

목적: 위 식도 역류질환은 치료 후 증상 호전 및 식도염이 치유되더라도 약 복용을 중단하면 1년 이내에 50-80%에서 재발하는 만성적인 경과를 갖는 것으로 알려져 있다. 이에 저자들은 위 식도 역류질환 환자들에서 양자펌프 억제제 투여 후 재발률과 치료에 대한 반응을 비교하였다. 대상 및 방법: 2008년 7월부터 2009년 1월까지 분당서울대학교병원 소화기내과 외래를 방문했던 식도염 증상을 호소하는 총 207명의 역류성 식도염 환자에서 위 내시경 검사를 시행 후 비미란성 역류성 식도염과 미란성 역류성 식도염 두 군으로 나누었고 비미란성 식도염군은 란소프라졸 15 mg, 미란성 식도염군은 란소프라졸 30mg을 각각 8주간 투여하였다. 상부위장관 내시경 검사 시 H. pylori 감염 여부를 확인하였으며 가슴 쓰림, 역류, 소화장애 및 비전형적인 증상의 4가지 증상항목을 치료 전과 8주간 치료 후에 조사하였다. 투약에 따른 치료반응이 있었던 환자들에서 전화 설문이나 외래 방문을 통하여 치료 중단 후 증상 재발에 대해 평가하였다. 결과:평균 추적 관찰 기간은 24.4주로 시험을 완료한 총 207명의 위 식도 역류질환 환자에서 전체 재발률은 40%였으며 NERD군 94명, ERD군 113명으로 나눈 두 군에서의 재발률은 각각 43.8%, 35.1%였고 두 군 간 차이는 없었다. 평균 재발 시기는 NERD군은 10.1주, ERD군은 10.6주였으며, 8주간 투약 후 증상 개선율은 전체 위 식도 역류질환 환자에서 89.4%였고 NERD군은 85.1%, ERD군은 92.9%로 재발시기와 증상 개선율 모두 두 군 간 차이를 보이지 않았다. 식도염의 4가지 증상에 대해 치료 전후 비교한 점수는 두 군 모두 유의한 감소가 있었으며(p< 0.001), H. pylori 감염률은 NERD군에 비해 ERD군에서 유의하게 낮은 결과를 나타내었다(34.3% vs. 20.0%, p=0.036). 결론: 위 식도 역류질환 환자에서 8주간 PPI 치료 후 6개월 이내 재발률은 40%였으며 절반용량을 투여한 비미란성 식도염군과 표준용량을 투여한 미란성 식도염군에서 재발률, 재발시기 및 증상 개선율은 두군 간 차이가 없었고, 역류성 식도염의 재발을 예방하기 위해 양자펌프 억제제의 필요 시 투여 혹은 지속적 투여를 고려해야 될 것으로 생각한다. Background/Aims: Gastro-esophageal reflux disease (GERD) is a chronic condition, with 50-80% of patients experiencing recurrence within one year following completion of initial treatment. The present study aimed to estimate recurrence rate and treatment response in GERD patients treated with proton pump inhibitor. Methods: A total of 207 symptomatic GERD patients, which were confirmed by endoscopy from July 2008 till January 2009, were enrolled. They were divided into non-erosive reflux disease (NERD) group and erosive reflux disease (ERD) group by endoscopic findings. Patients were treated with lansoprazole 15 mg (NERD group) or 30 mg (ERD group) once daily for 8 weeks. The presence of symptoms was assessed in each patient at baseline and post-treatment using a questionnaire. Subsequent symptomatic recurrence on the cessation of therapy in each improved patients was checked by telephone survey or outpatient interview. Results: Ninety-four patients and 113 patients were first diagnosed with NERD and ERD, respectively. The mean post-treatment follow-up period was 24.4±8.5 weeks. Recurrence rate was 40.0% (NERD, 43.8%; ERD, 37.1% (p=0.224)). Recurrence time was 10.1±5.8 weeks (NERD 9.6 weeks; ERD, 10.6 weeks (p=0.444)). Regarding the symptom improvement after 8 week therapy with lansoprazole, 89.4% (NERD, 85.1%; ERD, 92.9% (p=0.056)) of total patients were symptomatically improved. Conclusions: Forty percentage of GERD patients recurred within 6 months following the completion of 8 week therapy with lansoprazole. Recurrence rate, recurrence time, and rate of symptom improvement were not significantly different between NERD group treated with half dose and ERD group treated with full dose lansoprazole. (Korean J Gastroenterol 2010;55:100-108)

유당흡수장애자 및 염증성 장질환 환자에서의 우유섭취량에 따른 유당흡수능과 유당불내성 증상의 발현양상

송인성(In Sung Song),정현채(Hyun Chae Jung),김정룡(Chung Yong Kim),문선희(Sun Hi Moon),황진혁(Jin Hyok Hwang) 대한내과학회 1999 대한내과학회지 Vol.56 No.5

N/A Objective : To define whether lactase-deficient subjects are intolerable to even a pack of milk(200ml) and whether milk intolerance in the patients with IBD is only due to lactose malabsorption, we performed this study. Methods : We evaluated 32 healthy adults and 12 patients with active stage of inflammatory bowel disease(IBD) who had not received antibiotics therapy within the previous 3 weeks. Thirty-two healthy adults underwent H2-breath test with 200, 400, 600 and 800ml of milk at 1st, 2nd, 3rd and 4th day of study, respectively. We measured their end-expiratory hydrogen concentrations and asked them to record the gastrointestinal symptoms. Twelve patients with IBD were tested only with 200ml of milk. Lactose malabsorption was defined as the increase of 20ppm over basal H2 concentration and lactose intolerance as having two or more of the following symptoms; abdominal pain, diarrhea, borborygmus and flatus. Results : The prevalence of lactase deficiency was 72%(23 of 32 subjects) at 800ml of milk(lactose 40g). Among the lactase-deficient subjects, lactose intolerance at 200ml of milk(lactose 10g) was noticed only in 13%(3 of 23 subjects). In the patients with active stage of IBD, the frequency of milk intolerance at 200ml of milk was 50%(6 of 12 subjects), which was higher than in the healthy adults(9%). But the prevalence of lactose malabsorber in the patients with IBD at 200ml of milk(17%) was not higher than in the healthy adults(16%). Conclusion : Most of lactase-deficient subjects(87%) can ingest one pack of milk without lactose intolerance. The increased prevalence of lactose intolerance in the patients with IBD at 200ml of milk is not originated from lactose malabsorption, but probably from incomplete colonic compensation salvage.

식도 조직 검사상 우연히 발견된 호산구 식도염의 임상적 의의

정연무 ( Youn Mu Jung ),이혜승 ( Hye Seung Lee ),이동호 ( Dong Ho Lee ),정유정 ( You Jeong Jeong ),최태혁 ( Tae Hyuck Choi ),이상협 ( Sang Hyub Lee ),박영수 ( Young Soo Park ),황진혁 ( Jin Hyok Hwang ),김진욱 ( Jin Wook Kim ),정 대한소화기학회 2010 대한소화기학회지 Vol.55 No.3

목적: 호산구 식도염은 식도에 호산구가 심하게 침윤하여 삼킴 곤란이나 음식 막힘 등의 증상을 일으키는 만성적인 질환이다. 이에 저자들은 우리나라 식도 조직 검사상 호산구 식도염의 발견율과 임상 특징을 알아 보고자 하였다. 대상 및 방법: 분당서울대병원에서 2006년 1월부터 2008년 8월까지 식도 생검을 받은 환자들의 조직소견을 후향 분석하여 고배율에서 20개 이상의 호산구가 관찰될 때 호산구 식도염이라 정하였고 각 환자들의 임상 특징과 내시경 소견을 조사하였다. 결과: 2년 8개월간 내시경 식도 점막 이상으로 식도 생검을 받은 환자 1,609명 중 7명(0.4%)에서 고배율당 20개 이상의 호산구 침윤이 관찰되었으며 이들은 심와부 동통, 역류증세 및 소화장애 등의 비특이적인 소화기 증상과 백색 삼출과 백색 결절, 식도 용종 및 식도 비후증 등의 내시경 소견을 보였다. 결론: 생검을 시행한 환자들의 후향적인 식도 조직 재검토 결과 0.4%에서 호산구 식도염이 발견되었고, 임상 양상과 내시경 소견은 비특이적이었다. 전 세계적으로 호산구 식도염의 유병률이 빠르게 증가하는 것을 볼 때 만성적인 삼킴 곤란 증상이 있거나 특히 산 억제제 치료에 반응하지 않는 역류성 식도염 환자에서 호산구 식도염의 가능성을 고려하여 세심한 진단 접근 및 식도 생검이 요구되며 이에 대한 향후 대규모 전향 연구가 필요할 것으로 생각한다. Background/Aims: Eosinophilic esophagitis (EE) is a chronic inflammatory disorder characterized by abnormal dense eosinophilic infiltration of esophageal mucosa and results in dysphasia and food impaction. EE is being increasingly recognized in adults. The prevalence is largely unknown. This study was performed to evaluate the detection rate of EE diagnosed based on pathologic criteria and to define the clinical characteristics of EE in Korea. Methods: We reviewed biopsy specimen of the 1,609 patients who underwent esophageal biopsy from January 2006 till August 2008. The presence of more than 20 eosinophils per high power field in biopsy specimens was considered cases of EE. Clinical information and endoscopic findings were obtained. Results: 7 (0.4%) patients were diagnosed as EE based on pathologic criteria retrospectively. Clinical symptoms were epigastric pain (43%), regurgitation (29%), dyspepsia (14%), and no symptom (14%). Endoscopic findings were whitish exudates or granules (57%), esophageal polyp (29%), and hyperemic change (14%). Two patients received treatment. One patient with bronchial asthma improved after treatment with inhaled corticosteroid, and one patient improved after 8 week proton pump inhibitor therapy. Conclusions: Eosinophilic esophagitis was found in 0.4% of the total esophageal biopsied cases. Our results suggest that Korean patients with eosinophilic esophagitis showed symptoms mimicking gastroesophageal reflux disease and atypical endoscopic findings. Therefore, regardless of the gross appearance of the mucosa, meticulous diagnostic approaches are needed for patients with swallowing difficulty and lack of response to proton pump inhibitor. (Korean J Gastroenterol 2010;55:162-168)

건강 검진자에서의 미란성 및 비미란성 위식도역류질환의 임상적 특성 및 위험인자

김현영 ( Hyun Young Kim ),김나영 ( Na Young Kim ),김선미 ( Sun Mi Kim ),서지현 ( Ji Hyun Seo ),박영수 ( Young Soo Park ),황진혁 ( Jin Hyok Hwang ),김진욱 ( Jin Wook Kim ),정숙향 ( Sook Hyang Jung ),이동호 ( Dong Ho Lee ) 대한내과학회 2006 대한내과학회지 Vol.71 No.5

목적: 우리나라에서 미란성 위식도역류와 비미란성 위식도역류에 대한 전향적인 조사연구는 거의 없었다. 본 연구는 건강검진자에서의 미란성 위식도역류와 비미란성 위식도역류 유병률을 알아보고 이에 대한 위험요인과 임상 특성에 대해서 알아보고자 하였다. 방법: 2005년 1월부터 5월까지 분당서울대학교병원 건강증진센터를 방문한 수진자 752명을 대상으로 위내시경 및 위식도역류 증상설문지를 시행하였다. 위식도역류질환의 위험요인들은 각각 성별, 흡연, 알콜, 운동, 체질량지수, 콜레스테롤, 공복혈당, 중성지방과 H. pylori IgG에 대해서 로지스틱 회귀 분석을 시행하였다. 비미란성 위식도역류 진단은 가슴쓰림 그리고/또는 산역류 증상이 일주일에 1회 이상 있는 경우 내지 내시경적 미세변화로 정의하였다. 미란성 위식도역류는 미세변화를 제외한 LA 분류법을 기준으로 하였다. 결과: 1) 752명을 세 군으로 나누어보면, 미란성 위식도역류군이 65명(8.6%), 비미란성 위식도역류군이 66명(8.8%), 정상군 621명(82.6%)으로 위식도역류질환 유병률은 17.4%였다. 2) 65명의 미란성 위식도역류군에서 일주일에 1회 이상의 가슴쓰림 그리고/또는 산 역류 증상이 있었던 경우가 19명(29.2%), 역류증상 빈도가 낮거나 비전형적인 역류증상이 있었던 경우가 38명(58.5%), 무증상인 경우가 8명(12.3%)이었다. 3) 65명의 미란성 위식도역류군에서 LA 분류법에 기초로 해서 A도가 48명(73.8%), B도가 11명(17%), C도가 6명(9.2%)이었는데 각 군에서 증상과 역류 증상 정도는 상관관계가 없었다. 4) 정상군과 비미란성 위식도역류질환에서 H. pylori 혈청학적 유병률은 65.3%, 60%로 차이가 없는 반면 미란성 위식도역류질환에서는 36.4%로 의미있게 낮아(p<0.0001) H. pylori 감염 음성일 때 미란성 위식도역류가 발생할 상대적 위험도는 5.079배(95% 신뢰도구간: 1.907-13.530)이었다. 6) 단변량분석에서 남자에서 역류성 식도염이 발병률이 높은 반면 여자에서는 비미란성 위식도역류질환 발병률이 높았고, 그 외 나이, 흡연, 알콜, 체질량지수, 콜레스테롤, 공복혈당, 중성지방은 의미있는 차이가 없었다. 결론: 이상의 결과에서 볼 때 우리나라 건강검진자에서의 위식도역류질환 유병률은 19.3%였고, 미란성 식도염 정도와 역류 증상은 일치하지 않았으며 미란성 위식도역류질환은 H. pylori 감염군에서 의미있게 낮았다. Background: This study was prospectively performed to evaluate the clinical spectrum and risk factors of gastroesophageal reflux disease (GERD) in health check-up subjects. Methods: A prospective survey was performed for 752 subjects, aged 18-79 years, who visited the health promotion center. The subjects were asked to complete a questionnaire, and the risk of GERD was calculated by logistic regression analysis with regard to several variables, including smoking, alcohol, exercise, body mass index, fasting glucose, cholesterol, triglyceride and anti-H. pylori immunoglobulin G (IgG). Non-erosive reflux disease (NERD) was defined as the presence of heartburn and/or acid regurgitation for at least once per week. Results: 752 subjects were classified into three groups: 65 erosive reflux disease (ERD) subjects (8.6%), 66 NERD subjects (8.8%) and 621 control group subjects (82.6%). For the 65 ERD subjects, typical reflux symptoms were found in 19 (29.2%), less frequent reflux or atypical symptoms were found in 38 (58.5%) and no symptoms were found in 8 (12.3%). A Los Angeles grade A score was noted in 48 subjects (73.8%), a B score was noted in 11 (17.0%), and a C score was noted in 6 (9.2%). There was no correlation between the grade of reflux esophagitis and the severity of symptoms. The positive rate of H. pylori IgG in the ERD was 36.4%, and this was significantly lower than the rates for the NERD (60%) and control groups (65.3%); this resulted in the odds ratio of ERD in the absence of H. pylori infection to be 5.079 (95% CI: 1.907-13.530). Conclusions: The prevalence rate of GERD in health check-up subjects was 17.4%. There was no correlation between the grade of ERD and the severity of the reflux symptoms. The relative risk of GERD in Koreans was significantly low in the H. pylori IgG positive subjects.(Korean J Med 71:491-500, 2006)

위식도역류질환 진단 및 임상양상에 있어서 내시경, 24시간 식도 산도검사, Bernstein 검사의 역할 및 증상과의 관계

이경수 ( Kyoung Soo Lee ),김나영 ( Na Young Kim ),박란영 ( Ran Young Park ),김충현 ( Chung Hyun Kim ),김현영 ( Hyun Young Kim ),박영수 ( Young Soo Park ),황진혁 ( Jin Hyok Hwang ),김진욱 ( Jin Wook Kim ),이동호 ( Dong Ho Lee ) 대한내과학회 2006 대한내과학회지 Vol.70 No.2

성인의 환상췌장 1예

김유선,장윤석,김지원,김찬규,정준오,황진혁,정현채,송인성,이건욱,김정룡 대한내과학회 1997 대한내과학회지 Vol.53 No.3S

성인에서의 환상췌장은 소화성 궤양이나 췌장염, 또는 간외담관 폐쇄등의 합병증이 없을 경우 대부분 무증상인 경우가 많은 매우 드문 성천성 기형이다. 저자들은 환자가 어렸을 때 바둑알을 먹음으로써 환상췌장에 의한 십이지장의 불완전 폐색을 더욱 심화시켜 비교적 일찍 환상췌장을 진단하고 우회술을 시행한 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Annular pancreas is a very rare congenital anomaly which consists of a ring of normal pancreatic tissue around the second portion of the duodenum. The majority of annular pancreas in adults are asymptomatic. The symptoms in adults are due to chronic partial duodenal obstruction. We experienced a case of annular pancreas detected in 22-year old male patient who has complained postprandial abdominal pain with fullness, nausea and vomiting for a long time. We suspected upper gastrointestinal partial obstruction and diagnosed as annular pancreas by radiologic and endoscopic findings. After surgical removal of partial obstruction, patient's nutritional status was much improved. Charicteristically, the coin shaped stone in the second portion of the duodenum which was swallowed in the childhood had aggravated duodenal obstruction. Therefore, we could diagnose this case as annular pancreas preoperatively. We report it with review of the literature.

크론병에서 발생한 급성 골수성 백혈병 1예

김지원,김유선,송인성,정현채,최규완,우광훈,차성덕,황진혁,변정식,김점룡 대한소화기학회 1998 대한소화기학회지 Vol.31 No.2

Various hematological disorders, including iron deficency anemia and thrombocytosis, are known as extraintestinal rnanifestations of Crohns disease (CD). In addition, recent studies suggest that incidence of leukemia is higher in patients with CD than in the normal population. In the literature review, thirteen cases of leukemia associated with CD have been described since 1980. The etiology of leukemia in CD seems to be multifactorial and may involve immunologic abnormalities associated with CD, exposure to diagnostic radiation or side-effects of immuno- suppressants. A thirty-one year old female patient was diagnosed to have CD in 1991 and treated with sulfasalazine, corticosteroid, azathioprine and metronidazole, and then developed leukocytosis, severe anemia and marked thrombocytopenia. A diagnosis of acute myelomonocytic leukemia was established by bone marrow cytology and biopsy. Chromosomal analysis of bone marrow aspirate revealed t (8:21) with loss of sex chromosome. In conclusion when the patients with CD develop leukocytosis, marked anemia and thrombocytopenia, we should consider the, possibility of leukemia.

크론병으로 인한 대장협착의 내시경적 풍선확장술 1예

김지원,송인성,정현채,최규완,박민정,김정룡,김진,문선희,차성덕,황진혁,김찬규 대한소화기내시경학회 1997 Clinical Endoscopy Vol.17 No.5

Chronic idiopathic inflamatory bowel disease, espcaially Crohn's disease, is frequently complicated with low gastrointestinal stricture. Besides medical treatment of active inflammation, there is no specific, conservative approach to this complication, Repetitive surgery with extensive resections, leading to short bowel syndrome, is often necessary. Balloons have been used for a variety of gastrointestinal stenoses including esophageal, small intestinal, and colonic stricture. Balloon dilation offers many theoretical advantages (safety, and patient comfort) over dilation with bougies. Especially, the availability of large diameter balloon dilators, which pass through the biopsy channel of standard endoscopes (through-the scope balloon or TTS balloon), has promised efficient direct-vision dilatation of strictures without the need of guide wires or fluoroscope. We report a case of colonic Crohn's stricture dilated successfully using TTS balloon catheter.

비스테로이드성 소염제의 장기 복용후 생긴 교원성 대장염 1 예

이동호,김유선,송인성,정현채,정운태,박동영,최규완,김정룡,김병관,문선희,황진혁,정준오,김찬규,김선미 대한내과학회 1997 대한내과학회지 Vol.53 No.4

Collagenous colitis is characterized clinically by chronic watery diarrhea and pathologically by increased subepithelial collagen deposition associated with an inflammatory infiltrate in the lamina propria. Its etiology is still unclear, although a variety of associated diseases such as rheumatic syndromes, scleroderma, and thyroid diseases have been reported. We report a case of collagenous colitis following the prolonged use of NSAIDs. A 72-year-old woman who has taken NSAIDs for many years due to some dermatologic problems was admitted to the hospital because of chronic watery diarrhea and colicky abdominal pain of 3 months duration. There was no abnormal physical finding except cachectic appearance due to weight loss of 10㎏ during 3 months. Stool examination for ova and parasites and fat was negative, and stool culture for bacterial pathogens was negative. In complete blood count, there were relative eosinophila and mild anemia. Total serum protein and albumin was low, and thyroid function, RA factor, FANA were all normal. Results of upper and lower gastrointestinal contrast radiographs were normal. Sigmoidoscopy revealed normal colonic mucosa but she had a thick subepithelial collagenous deposit and chronic inflammation in lamina propria on colonic biopsy. Based on the above findings, she was diagnosed as collagenous colitis. Diarrhea improved after withdrawing NSAIDs and the treatment with oral prednisolone. In the post-treatment biopsy, the thickness of the collagen hand was diminished. Collagenous colitis is now recognized as one of the common causes of chronic diarrhea of obscure origin and NSAIDs may play an etiological role in some patient with collagenous colitis.