변비의 치료

박무인 ( Moo In Park ) 대한내과학회 2011 대한내과학회지 Vol.80 No.5

Constipation is a common gastrointestinal disease affecting approximately 16.5% of the population in Korea. Systemic diseases such as hypothyroidism or colon cancer and drugs can cause constipation in some patients with constipation, there is no obstructive mucosal or structural cause in the vast majority of patients with constipation. Evaluation for secondary causes of constipation is needed to provide appropriate management. Once secondary causes have been excluded, constipation may be classified into normal or slow transit constipation, evacuation disorder of the spastic or flaccid varieties, or both. Treatment of chronic constipation based on the underlying pathophysiology is generally successful. The aims of this review are to discuss the management of functional constipation based on guidelines for the treatment of constipation published in Korean Journal of gastroenterology in 2011: lifestyle changes; bulking agents and stool softeners; osmotic agents; stimulant laxatives; prokinetics; biofeedback and surgical treatments. Exercise and dietary fiber are helpful in some patients with constipation. Laxatives including bulking agents, stool softeners, osmotic agents, stimulant laxatives have been found to be more effective than placebo at relieving symptoms of constipation. New enterokinetic agents such as 5-hydroxytryptamine-4 receptor agonists, intestinal secretagogues, and peripheral opioid antagonists could be effective in patients with constipation who cannotget adequate relief from current laxatives. Biofeedback could relieve symptoms in selected patients with constipation due to pelvic floor dyssynergia. Surgical treatments can be helpful in some patients with refractory constipation.

관해 상태인 크론병 환자에서 Saccharomyces Boulardii 복용 후 Crohn's Disease Activity Index의 변화: 단일 기관 후향적 연구

오규만 ( Gyu Man Oh ),문원 ( Won Moon ),서광일 ( Kwang Il Seo ),정경원 ( Kyoungwon Jung ),김재현 ( Jae Hyun Kim ),김성은 ( Sung Eun Kim ),박무인 ( Moo In Park ),박선자 ( Seun Ja Park ) 대한소화기학회 2020 대한소화기학회지 Vol.76 No.6

Background/Aims: Crohn’s disease (CD) is characterized by uncontrolled inflammation of the intestine. Saccharomyces boulardii (S. boulardii), a probiotic, stabilizes the intestinal wall. This study examined the changes in the CD activity index (CDAI) after taking S. boulardii in patients with CD in clinical remission. Methods: In this single hospital-based retrospective cohort study, the medical records of CD patients in clinical remission, who had received S. boulardii for more than 6 months, were reviewed. The CDAI, BMI, and serum levels of hemoglobin (Hb), ferritin, iron, vitamin B12, folate, total protein, albumin, total cholesterol, CRP, and fecal calprotectin (FC) between the initiation and the 6th month were compared. The timing and reasons for the discontinuation were also investigated. Results: One hundred and fifty-four patients were included, and 92 patients, who received for more than 6 months, were analyzed. The changes in CDAI, BMI, Hb, and total cholesterol were significant as follows: CDAI from 38.52 to 30.53 (p<0.01), BMI (kg/m²) from 23.38 to 23.97 (p<0.01), Hb (g/dL) from 13.73 to 14.03 (p<0.01), and total cholesterol (mg/dL) from 154.9 to 161.5 (p<0.01). On the other hand, the changes in FC, CRP, ferritin, vitamin B12, folate, total protein, and albumin were not statistically significant. Only one patient stopped due to a flare-up, but this was not believed to be related to the drug. Conclusions: In patients with CD in remission, S. boulardii appears to improve the CDAI, BMI, serum Hb, and total cholesterol level without safety issues. Further randomized controlled studies will be needed. (Korean J Gastroenterol 2020;76:314-321)

위암 날문부 폐쇄 환자에게 시행한 치료의 비교고찰: 위-공장 우회술과 금속성 자가팽창성 스텐트 삽입술

조성진,윤기영,최경현,박무인,박선자,고지호,이상호,Jo, Seung-Jin,Yoon, Ki-Young,Choi, Kyung-Hyun,Park, Moo-In,Park, Seun-Ja,Ko, Ji-Ho,Lee, Sang-Ho 대한위암학회 2007 대한위암학회지 Vol.7 No.2

목적: 위암에 의한 위출구 폐쇄는 다양한 소화기 증상과 영양 실조를 야기하며, 따라서 삶의 질을 떨어뜨리고 생명을 단축시킨다. 이처럼 위날문부 폐쇄 환자에게 시행하는 스텐트삽입 시술은 위 공장 우회술에 비교하여 덜 침습적이고 효과적인 시술로 알려져 있다. 그러나, 위암에서의 스텐트 시술의 효과와 위공장 우회술의 효과에 대한 비교연구는 찾아볼 수 없다. 대상 및 방법: 2000년 1월부터 2006년 8월까지 고신대학교 복음병원에서 내시경 및 위장관 조영술을 이용하여 위암으로 인한 위 날문부 폐쇄를 진단 받고, 위 날문부 스텐트 삽입시술을 받은 환자군과 위공장 우회술을 받은 환자군 간의 데이터 통계를 1개월에서 46개월까지 추적 관찰한 외래 차트를 바탕으로 후향적으로 비교하였다. 이 중 위암의 재발로 인해 시술을 받은 환자와 이중암(double cancer)으로 진단을 받은 환자는 제외하였다. 결과: 100명의 환자가 스텐트 삽입을 시행받았고, 31명의 환자가 위 공장 우회술을 시행받았다. 두 그룹 간 남녀 성별 비는 통계적인 의미가 없었으나(스텐트 M : F 2 : 1, 우회술 M : F 2 : 1, P=0.637) 연령은 스텐트군은 $67{\pm}10$, 우회술군은 $57{\pm}10$ (P<0.001)으로 통계적인 의미가 있었다. 스텐트 삽입군에서 수술을 못한 이유는 60%의 경우 암진행, 34%의 경우는 고령, 6%의 경우는 동반질환의 중중도에 의하였고, 스텐트 시술 후 가장 gms한 합병증은 스텐트내 종양성장, 다음으로 스텐트 이동이었고 시술의 실패는 3%였다. 두 군 간 시술 후 유동식까지 걸린 시간은 스텐트군 $3{\pm}2$ (일), 우회술군은 $6{\pm}2$ (일)(P=0.003) 그리고 시술 후 입원기간은 스텐트군 $5{\pm}2$ (일), 우회술군 $15{\pm}6$ (일)(P<0.001)로 모두 통계적으로 유의한 결과가 나왔다. 결론: 위암의 날문부 폐쇄 환자에게 시행한 자가팽창 금속성 스텐트 시술은 위장 우회술에 비하여 빠른 식 사진행과 짧은 입원기간으로 효과적인 시술일 수 있지만, 스텐트가 움직이거나 종양의 재성장으로 인해 스텐트를 다시 시술해야하근 불편함이 있는 등 스텐트로 인한 환자의 불편함이 많아서 향후 더욱 많은 연구가 필요할 것이다. Purpose: In gastric cancer patients with gastric outlet obstruction, there are several complications such as malnutrition and vomiting. Palliative enteral stenting is a less invasive procedure as compared with a gastrojejunostomy. The aim of this study was to determine whether there was a significant difference between patients that undergone palliative enteral slanting and patients that had received a bypass gastrojejunostomy. Materials and Methods: One hundred patients underwent palliative entering stenting and 3f patients were subjected to a surgical bypass gastrojejunostomy. We reviewed the medical records of the patients with gastric outlet obstruction secondary to far advanced gastric cancer that were diagnosed using a gastrofibroscope, UGI and abdominal CT, and were admitted to our institution between January 2000 and August 2006. The outcome of stent placement for gastric outlet obstruction was compared with palliative gastrojejunostomy during the same period. We excluded patients with recurrent gastric cancer and double cancer from this study. Results: There were significant differences between the group of patients that underwent slanting and the group of patients that received a gastrojejunostomy regarding the age of patients ($67{\pm}12$ vs. $57{\pm}9$, P<0.001) but not between the sex of the patients (M : F, 2 : 1 vs. 2 :1, P=0.637). The most common complication of stenting was tumor ingrowth (16/100, 16%) and the second most common complication was stent migration (14/100). Failure of the procedure occurred in only three patients. Twenty-three patients underwent re-slanting and one patient required open conversion with a gastrojejunostomy. The median time to the first meal was $4{\pm}2$ days in the stent group of patients and $6{\pm}2$ days in the gastrojejunostomy group of patients (P=0.001). The median postoperative hospital stays were 9 days in the stent group of patients and 15 days in the gastrojejunostomy group of patients (P=0.003). The mean survival periods were 11 months in the stent group of patients and 10 months in the gastrojejunostomy group of patients (P=0.937). Conclusion: There were no significant differences In the mean survival rates. An earlier first meal and a shorter hospitalization stay were found in the slanting group of patients compared to the bypass gastrojejunostomy group of patients. However, re-slanting was a concern due to tumor ingrowth and stent migration.

위암환자의 혈청 CEA , CA19 - 9 및 AFP 에 관한 연구

최환준(Hwan Jun Choi),이신호(Shin Ho Lee),박무인(Moo In Park),우인기(In Ki Woo),김병립(Byung Lip Kim),최종수(Jong Soo Choi),지상근(Sang Geun Ghi),구자영(Ja Young Koo),정숙금(Sook Kum Jeong),허만하(Man Ha Huh) 대한내과학회 1994 대한내과학회지 Vol.47 No.5

N/A Objectives: For the diagnosis and evaluation of gastric cancer, various methods including upper GI series, endoscopy, ultrasound, CAT scan are used with serum tumor markers, especially CEA, CA19-9 and AFP. Although many studies were done to evaluate the clinical usefulness of serum tumor markers for the diagnosis and management of gastrointestinal cancer, the studies which was done in depth on gastric cancer alone were few. In this study we, therefore, evaluated clinical significance of serum CEA, CA19-9 and AFP of 712 gastric cancer patients for the diagnosis and management of gastric cancer. Methods: Serum levels of CEA, CA19-9 and AFP were measured in 712 eases of gastric cancer including 346 operative cases to evaluate the clinical usefulness of these markers for the diagnosis and management of gastric cancer. The cutoff level of serum CEA, CA19-9 and AFP were 10 ng/ml, 37 U/ml and 20 ng/ml, respectively. The serum levels were correlated with the stage, the location, the gross type, the depth of invasion, the nodal and distant metastasis. AFP-positive cases were analysed seperately and immunohistochemical staining was done to asses the presence of AFP, EGF and TGF β in the cancer tissue. Results: 1) Overall positivity of CEA, CA19-9 and AFP was 27.8% (198 cases), 32.7%; (233 cases) and 5.6% (30 cases/540 cases), respectively. 2) There was no difference in the positivity of serum CEA and CA19-9 according to locations and gross types of the cancer, but significant (p<0.05) difference in the positivity of serum CEA and CA19-9 was noted between cases of early gastric cancer (3.0% and 0.0%) and advanced gastric cancer (19.2% and 30.4%). 3) The positivity of serum CEA of stage IV (35.5%) was significantly (p<0.05) higher than that of stage II (4.4%), stage IIIA (10.2%) and stage IIIB (15.1%). Furthermore, 70.4% of the cases of positive serum CEA belonged to stage IV. On the other hand, serum CA19-9 positivity was 6.7%, 23.7%, 34.0% and 45.5% for the stage II, stage IIIA, stage IIIB and stage IU, respectively, showing significant difference between stage II and stage IIIA, IIIB, IV and between stage IIIA and stage IV (p<0.05). 4) The cases with perigastric tissue invasion (T₄) marked highest positivity (26.6%) of serum CEA level, but there was no correlation between positivity of serum CEA and depth of invasion. In the case of CA19-9, serum positivity v as 2.9%, l.5%, 29.3% and 39.8% for T₁, T₂, T₃, and T₄, respectively, showing relatively good correlation between CA19-9 positivity and depth of invasion. 5) The positivity of serum CEA and CA19-9 of NO group (3.0% and 9.9%, respectively) was significantly (p<0.05) lower than those of N2 group (15.7% and 24.5%, respectively). The positivity of N2 group (29.4% and 42.4%, respectively) was significantly higher than that of NO group and N2 gorup (p<0.05). 6) In the cases of metastasis present, CEA and CA19-9 positivity was 42.5% and 49.3%, respectively, which was significantly (p<0.05) higher than that of metastasis-negative cases (7.6g and 17.39, respectively). Between sites of metastasis, there was no difference in the positivity of CEA and CA19-9. 7) CEA and CA19-9 positivity in AFP-positive gastric cancer was 66.7%, 46.7%, respectively, and 83.3%, of cases belonged to stage IV, while distant metastasis was present in 73.3% of cases, among which liver was the most common site (43.3%). The AFP was demonstrated in the cancer tissue of 21 cases (91.3%) of 23 cases on which immunohistochemical staining was done. TGF β and EGF were present in 17 cases (81.0%) and 9 cases (42.9%) of AFP-positive 21 cases. Conclusion: Serum CEA and CA19-9 was not useful as a screening test in the diagnosis of gastric cancer, but may be useful in differentiating between early and advanced cases, in determining depth of invasion, and in detecting nodal and distant metastasis. Especially, CA19-9 was superior to CEA in stage grouping and in determining depth of invasion. AFP may be of some help in pred

삼킴곤란의 접근

박무인 ( Moo In Park ) 대한소화기학회 2021 대한소화기학회지 Vol.77 No.2

Dysphagia has been reported to be relatively common and seems to be increased in Korea. Dysphagia can be classified as oropharyngeal dysphagia or esophageal dysphagia. In patients with swallowing difficulties, it is important to determine whether the dysphagia is oropharyngeal or esophageal. Patients with orophayngeal dysphagia are likely to develop aspiration and aspiration pneumonia, so accurate diagnosis should be made in the early stages of complaining of swallowing difficulties. Patients with orophayngeal dysphagia complained difficulty initiating a swallow. Swallowing may be accompanied by coughing, choking, nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Patients with esophageal dysphagia complained difficulty swallowing several seconds after initiating a swallow and a sensation of food getting stuck in the esophagus. Esophageal dysphagia should be characterized by analyzing whether foods that cause swallowing difficulties are solid, liquids or both, whether symptoms are progressive or intermittent, how severe, and associated symptoms, such as weight loss, heartburn, or regurgitation. The approach to diagnostic testing to determine the cause of esophageal dysphagia is based upon the medical history. If esophageal motility disorder is suspected, barium esophagogram is performed first, and upper endoscopy is performed first if structural abnormalities are suspected. If an upper endoscopy shows normal findings, but the esophagus is still suspected of mechanical obstruction, a barium esophagogram is performed. Esophageal manometry should be performed in patients with swallowing difficulties who are suspected of esophageal motility disorder or have normal findings in upper endoscopy. (Korean J Gastroenterol 2021;77:57-63)

되새김

박무인 ( Moo In Park ) 대한소화기학회 2017 대한소화기학회지 Vol.70 No.6

Rumination syndrome is one of the functional gastroduodenal disorders. Effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by rechewing and reswallowing or spitting are the characteristic clinical features. This disorder is believed to be uncommon, but many patients with this disorder are overlooked by their physicians. Rumination might be caused by a reversal of the gastric contents through the esophagogastric junction, which is initiated by an increase in intragastric pressure. The characteristic symptoms are sufficient for the diagnosis of rumination syndrome. Postprandial high resolution esoph-ageal impedance manometry can detect gastric pressurization exceeding 30 mmHg associated with the return of ingested material into the proximal esophagus, which is a pathognomonic finding of rumination syndrome. An extensive explanation of the condition and the underlying mechanism is the first step of the treatment of rumination syndrome. Behavioral therapy through diaphragmatic breathing is the mainstay of treatment. Further studies on the long term effects of biofeedback therapy as well as a proper strategy for refractory rumination syndrome are needed. (Korean J Gastroenterol 2017;70:278-282)

3차 병원에 내원한 한국인 변비 환자의 특성은 서구와 다른가?

박무인 ( Moo In Park ) 대한내과학회 2013 대한내과학회지 Vol.84 No.1

Constipation is a common gastrointestinal disease affecting approximately 14% of the world population. Characteristics of Korean patients with constipation who visited a tertiary referral center may be different from those of western patients. A recent retrospective study by Kim et al. published this month showed less preponderance of female, slightly higher average age of the patients, and more frequent use of folk remedies in Korean constipation patients compared to western patients. The rate of pelvic floor dysfunction among patients with functional constipation was more than 50% in a Korean tertiary referral center, which is comparable to that of western patients. Further large scale prospective studies will be needed to elucidate the characteristics of constipation in a Korean tertiary referral population. (Korean J Med 2013;84:43-45)

로마 기준 IV 이해하기: 식도 질환

박무인 ( Moo-in Park ) 대한내과학회 2017 대한내과학회지 Vol.92 No.4

The Rome IV criteria, published in 2016, encompass upper gastrointestinal lesions of functional esophageal disorders and func-tional gastroduodenal disorders. Functional esophageal disorders include functional chest pain, functional heartburn, reflux hyper-sensitivity, globus, and functional dysphagia. Patients with functional esophageal disorders typically have esophageal symptoms that are not associated with structural, inflammatory, or major esophageal motor disorders. Although the mechanisms of symptom generation in functional esophageal disorders are unclear, visceral hypersensitivity and hypervigilance may play a role. Therefore, treatment options include drugs and modalities that affect peripheral triggering and central perception. Further well-designed stud-ies are needed to identify the mechanisms of symptom generation in, and to develop appropriate therapies for, functional esophageal disorders. (Korean J Med 2017;92:354-361)

기능성 위장관 질환에 있어서 약물유전체학

박무인 ( Moo In Park ) 대한소화기기능성질환·운동학회 2006 Journal of Neurogastroenterology and Motility (JNM Vol.12 No.2

변비 치료에 관한 임상진료지침

박무인 ( Moo In Park ),신정은 ( Jeong Eun Shin ),명승재 ( Seung Jae Myung ),허규찬 ( Kyu Chan Huh ),최창환 ( Chang Hwan Choi ),정성애 ( Sung Ae Jung ),최석채 ( Suck Chei Choi ),손정일 ( Chong Il Sohn ),최명규 ( Myung Gyu Choi ) 대한소화기학회 2011 대한소화기학회지 Vol.57 No.2

While constipation is a common symptom in Korea, there are no existing treatment guidelines. Although constipation may occur as a result of organic cause, there is no obstructive mucosal or structural cause in the vast majority of patients with constipation. The present paper deals with only the management of functional constipation: lifestyle changes; bulking agents and stool softeners; osmotic agents; stimulant laxatives; prokinetics; biofeedback and surgical treatments. Exercise and dietary fiber are helpful in some patients with constipation. Laxatives including bulking agents, stool softeners, osmotic agents, and stimulant laxatives have been found to be more effective than placebo at relieving symptoms of constipation. New enterokinetic agents that affect peristalsis through selective interaction with 5-hydroxytryptamine-4 receptors can be effective in patients with constipation who cannot get adequate relief from current laxatives. Biofeedback can relieve symptoms in selected patients with pelvic floor dyssynergia. Surgical treatments can be helpful in some patients with refractory constipation. (Korean J Gastroenterol 2011;57:100-114)