상부 위장관 스텐트 삽입술의 이해 -적응증 및 추적 관리-

주문경,박종재,Joo, Moon-Kyung,Park, Jong-Jae 한국호스피스완화의료학회 2009 한국호스피스.완화의료학회지 Vol.12 No.2

상부 위장관 스텐트 삽입술은 근치적 수술이 불가능한 상부 악성 종양에 의한 상부 위장관 협착 환자의 폐쇄 증상 완화를 위한 보존적 치료로서 확립되었으며 내시경 개발 기술이 발달하고 임상 경험이 축적됨에 따라서 여러 상부 위장관 질환에서 스텐트 삽입술을 보다 편리하고 안전하게 시행할 수 있게 되었다. 그러나 스텐트 삽입술 이후에는 동통, 출혈, 천공과 같은 조기 합병증이나 스텐트 일탈, 스텐트 폐쇄 등의 후기 합병증이 발생할 수 있으므로 사후 관리 또한 중요하다. Self expandable metal stent (stent) implantation of upper gastrointestinal (UGI) tract is now widely accepted for the palliation of obstructive symptoms caused by inoperable malignant UGI obstruction. With the technical progress and accumulation of clinical experiences, it became possible to perform the procedure easily, safely and effectively. However, clinicians should pay attention to the post-procedural care, because early or late complications such as ulceration, pain, bleeding, food impaction, perforation, migration or in-stent tumor growth could occur. In this review, several topics about stent placement in the UGI tract are discussed, such as major indications for stenting, kinds of stents, and post-procedural management.

약제 유발 소화성궤양과 헬리코박터 제균 치료

주문경 ( Moon Kyung Joo ) 대한소화기학회 2020 대한소화기학회지 Vol.76 No.5

Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin are the most frequently prescribed drugs worldwide, and their long-term use often leads to peptic ulcers (PUs) along with serious complications, such as bleeding and perforation. Helicobacter pylori (H. pylori) infection is a significant risk factor for developing NSAID-related PU and ulcer bleeding during long-term aspirin use. In a revised version of the Clinical Guidelines for Drug-induced Peptic Ulcer, two statements regarding H. pylori eradication are recommended. 1) Patients scheduled for long-term NSAID therapy should be tested and treated for H. pylori infection to prevent PU and its complications. 2) Patients with a history of PU receiving long-term low-dose aspirin (LDA) therapy should undergo treatment for H. pylori infection to prevent PU and its complications. On the other hand, unlike NSAID-naïve patients, the preventive effects of H. pylori eradication in chronic NSAID users are unclear. In addition, anti-ulcer drugs, such as proton pump inhibitors, may be necessary for maintenance therapy after H. pylori eradication in a subset of long-term LDA users, particularly if the patients are taking concomitant antiplatelet agents or anticoagulants. (Korean J Gastroenterol 2020;76:227-231)

복막투석 환자에서 Listeria Monocytogenes에 의한 복막염

주문경 ( Moon Kyung Joo ),고강지 ( Gang Jee Ko ),조원용 ( Won Yong Cho ),김형규 ( Hyoung Kyu Kim ),권보성 ( Bo Sung Kwon ),장진수 ( Jin Su Jang ),박재연 ( Jae Youn Park ),김승영 ( Seung Young Kim ),김진남 ( Jin Nam Kim ),노경호 ( 대한신장학회 2006 Kidney Research and Clinical Practice Vol.25 No.5

Peritonitis in continuous ambulatory peritoneal dialysis is a major cause of technical failure in peritoneal dialysis. The major pathogen is gram positive bacteria, and other main pathogens include gram negative bacteria, mixed infection and fungal infection actively involved in the order named. Coagulate-negative Staphylococcus, Streptococcus, Staphylococcus aureus and Enterococcus cause most of the gram positive bacterial infections, and cases with other pathogens are very rare. We hereby report a case of peritonitis by Listeria Monocytogenes that was not responsive to the usual antibiotics for CAPD-associated peritonitis. A 58-year-old male who has been treated with CAPD for 17 years visited our hospital for abdominal pain, fever and turbid peritoneal fluid. He was diagnosed as diabetes mellitus 20 years ago. White blood cell and neutrophil count increased at the initial peritoneal fluid analysis, so we diagnosed him as CAPD-associated peritonitis. Antibiotic therapy was initiated with intraperitoneal injections of cefazolin/tobramycin, which were soon changed to vancomycin/ceftazidime. However, vancomycin/ceftazidime regimen was also proven ineffective. On the sixth hospital day, L. Monocytogenes was cultured in the peritoneal fluid sampled on the first visiting day. So we accordingly changed the antibiotics for ampicillin/sulbactam, which led to clinical and laboratory improvement. In the cases of CAPD associated peritonitis in immunosuppressive patients such as the elderly, caused either by diabetes or by taking immunosuppressive agent, if they do not respond to the usual antibiotics, we should consider the possible infection by unusual pathogens. Gram positive rod in peritoneal fluid is a supporting evidence of peritonitis by L. monocytogenes. (Korean J Nephrol 2006;25(5):857-861)

약제 연관 소화성궤양의 임상 진료지침 개정안 2020

주문경 ( Moon Kyung Joo ),박찬혁 ( Chan Hyuk Park ),김준성 ( Joon Sung Kim ),박재명 ( Jae Myung Park ),안지용 ( Ji Yong Ahn ),이봉은 ( Bong Eun Lee ),이정훈 ( Jeong Hoon Lee ),양효준 ( Hyo-joon Yang ),조유경 ( Yu Kyung Cho ),방창 대한소화기학회 2020 대한소화기학회지 Vol.76 No.3

The Korean guidelines for nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcers were previously developed under co-work with the Korean College of Helicobacter and Upper Gastrointestinal Research and Korean Society of Gastroenterology at 2009. On the other hand, the previous guidelines were based mainly on a literature review and expert opinions. Therefore, the guidelines need to be revised. In this study, a guideline development committee for drug-induced peptic ulcers was organized under the Korean College of Helicobacter and Upper Gastrointestinal Research in 2017. Nine statements were developed, including four for NSAID, three for aspirin and other antiplatelet agents, and two for anticoagulants through de novo processes based on evidence-based medicine, such as a literature search, meta-analysis, and the consensus was established using the modified Delphi method. The primary target of this guideline was adult patients taking long-term NSAIDs, aspirin, or other antiplatelet agent and anticoagulants. The revised guidelines reflect the consensus of expert opinions and are intended to assist relevant clinicians in the management and prevention of drug-induced peptic ulcers and associated conditions. (Korean J Gastroenterol 2020;76:108-133)

최근 12년간 발생한 자발성 세균성 복막염의 균주와 항생제 내성의 변화

주문경 ( Moon Kyung Joo ),연종은 ( Jong Eun Yeon ),이순재 ( Sun Jae Lee ),서상준 ( Sang Jun Suh ),정영걸 ( Young Kul Jung ),김정한 ( Jeong Han Kim ),김지훈 ( Ji Hoon Kim ),임형준 ( Hyung Joon Yim ),변관수 ( Kwan Soo Byun ) 대한내과학회 2008 대한내과학회지 Vol.75 No.1

목적: 자발성 세균성 복막염(Spontaneous Bacterial Peritonitis, 이하 SBP)은 간경변증의 주요 합병증으로 최근 치료방법의 개발 등으로 예후가 향상되었으나 예방적 항생제의 사용이나 침습적 시술 등으로 인하여 원인 균주 및 항균제 내성균 비율의 변화가 보고되고 있다. 이번 연구에서는 최근 12년간 SBP로 진단된 예의 원인균 및 항균제 내성 균주비율의 변화에 대하여 고찰하고자 하였다. 방법: 1996년 1월부터 2007년 8월까지 본원에서 SBP로 진단된 예 중 복수 배양검사에서 양성인 113예의 의무 기록을 후향적으로 분석하였다. 1996년 1월부터 2001년 12월까지는 기간 A, 2002년 1월부터 2007년 8월까지는 기간 B로 분류하였다. 결과: 전체 12년간 SBP로 진단된 410예 중 113예에서 복수 배양 양성이었고(배양 양성율: 27%), 이 중 37예는 기간 period A, 76예는 기간 B에 속하였다. 병원 획득 SBP는 기간 B에서 유의하게 증가하였으나 기타 다른 대상 환자의 특성은 두 기간 사이에 유의한 차이는 없었다. 그람 음성균은 78%, 그람 양성균은 19%였으며 역시 두 기간 사이에 유의한 차이는 없었다. 가장 흔한 동정 균주는 E.coli (60%)였으며, 그 외에는 Klebsiella pneumoniae (12%), Viridans streptococcus (4%) 순이었다. Ampicillin과 ciprofloxacin 내성균의 비율은 두 기간 사이에 유의한 차이는 없었으나 cefotaxime 내성균 비율은 기간 B에서 유의하게 증가하였고 (3% 대 26%, p=0.002), E.coli 중 ESBL 생성 균주는 기간 A에서 동정되지 않았으나 기간 B에서 14예가 동정되었다(0% 대 32%, p=0.002). 일차 치료 항균제로 대다수의 환자에서 cefotaxime을 사용하였고, 이차 치료 항균제 중 carbapenem은 기간 B에서만 12예에서 사용되었다(0% 대 55%, p=0.007). 원내 사망률은 양 시기간에 유의한 차이는 없었고, 다변량 분석 결과 ESBL 생성 균주는 원내 사망을 예측하는 유의한 인자였다(OR: 4.14, 95% CI: 1.09-15.07, p=0.037). 결론: 최근 12년간 본원에서 발생한 SBP 환자를 시기별로 비교하였을 때 복수에서 배양된 균주는 이전과 큰 차이가 없었으나 이전 6년과 비교하여 최근 6년간 병원 획득 SBP의 비율, cefotaxime 내성 비율, E.coli에 대한 ESBL 생성 균주의 비율은 유의하게 높았으며 ESBL 생성 균주는 원내 사망에 대한 유의한 위험인자였다. Background/Aims: Recently, the prognosis for spontaneous bacterial peritonitis (SBP) has improved; however, the causative microorganisms and antibiotic resistance rates are changing. We evaluated the changing pattern of causative agents and antibiotic resistance rates of SBP over a 12-year period. Methods: We retrospectively analyzed 113 patients who were diagnosed with SBP and in whom ascites cultures were positive between 1996 and 2007. The 12-year period was subdivided into 6-year terms (period A, 1996~2001; and period B, 2002~2007). Results: One hundred thirteen of 410 cases of SPB had positive ascites cultures. Thirty-seven cases were from period A and 76 cases were from period B. Hospital-acquired SBP was more common during period B. Gram negative microorganisms were isolated from 78% of SBP cases, and the most common microorganism was E.coli (60%). The resistance rates for ampicillin and ciprofloxacin were similar between the two periods, but resistance to cefotaxime was more frequent in period B (3% vs. 26%, p=0.002), and ESBL-producing E.coli was only cultured in period B (0% vs. 32%, p=0.002). Most of the initial antibiotics used were cefotaxime; carbapenem was used as a secondary antibiotic only in period B (0% vs. 55%, p=0.007). ESBL-producing microorganisms were the only predictor of in-hospital mortality based multivariate analysis (OR: 4.14, 95% CI: 1.09-15.07, p=0.037). Conclusions: No change in pattern of microorganisms in the ascites of patients with SBP was noted during the 12-year period under study, but there was a significant increase in the incidence of hospital-acquired SBP, resistance to cefotaxime, and ESBL-producing E.coli when comparing the outcomes of periods A and B. ESBL-producing microorganisms were the only predictor of in-hospital mortality. (Korean J Med 75:68-76, 2008)

무증상 담석에서 이형성 및 악성 종양 발생의 예방을 위한 담낭 절제술의 유용성 검토

정성주 ( Sung Joo Jung ),김재선 ( Jae Seon Kim ),홍승권 ( Seung Goun Hong ),주문경 ( Moon Kyung Joo ),이범재 ( Beom Jae Lee ),김지훈 ( Ji Hoon Kim ),연종은 ( Jong Eun Yeon ),박종재 ( Jong Jae Park ),변관수 ( Kwan Soo Byun ),박영태 대한소화기학회 2010 대한소화기학회지 Vol.55 No.1

목적: 담석에 의한 담낭 점막의 만성적인 자극과 염증에 의해 점막의 이형성 및 악성 종양이 발생할 수 있음은 이미 알려져 있다. 이번 연구는 무증상 담석 환자에서 이형성 및 악성 종양의 조기진단 및 치료로서 담낭 절제술의 유용성을 알아보고자 시행하였다. 대상 및 방법: 2004년 1월부터 2008년 7월까지 고려대학교 구로병원에서 담석으로 담낭절제술을 시행하였던 703예를 대상으로 후향적으로 의무기록을 분석하였고 수술 후 병리조직에서 이형성 및 악성 종양의 빈도를 조사하였다. 결과: 담석으로 담낭 절제술을 시행하였던 703예 중 증상이 있어 담낭 절제술을 시행하였던 경우는 542예(77.1%), 무증상으로 수술을 시행한 경우는 161예(22.9%)였다. 수술 후 병리조직에서 증상군에서 저도이형성 4예, 고도이형성 1예가 관찰되었다. 무증상군에서는 저도이형성 4예, 악성종양 2예가 관찰되었다(p=0.012). 증상군에서 이형성은 용종과 연관이 없었고 무증상군에서 이형성이나 악성종양은 용종과 연관이 있었다. 무증상군 161예 중용종을 동반한 경우에 용종의 크기에 따라 분석하였다. 용종의 크기가 1 cm 이상인 12예 중에서 저도이형성 2예, 악성종양 2예가 관찰되었고, 용종의 크기가 1 cm 미만인 12예 중에서 저도이형성 2예가 관찰되었다. 결론: 무증상 담석환자에서 용종을 동반하지 않은 경우에 담낭의 이형성 및 악성 종양을 예방하기 위해 담낭 절제술을 시행할 필요는 없으나, 용종을 동반한 무증상 담석 환자에서는 용종의 크기에 따라 담낭 절제술을 시행해야 할지에 대해서는 추가연구가 필요할 것으로 여겨진다. Background/Aims: It has been known that chronic trauma and inflammation of gallbladder (GB) mucosa by gallstones (GS) can induce epithelial dysplasia, carcinoma in situ, and invasive cancer. This study was designed to investigate the usefulness of cholecystectomy in patients with asymptomatic GS for the early diagnosis and removal of dysplasia or cancer. Methods: From January 2004 to July 2008, the clinical records of 703 cases with GS who underwent cholecystectomy at Korea University Guro Hospital were reviewed, and the prevalence of dysplasia and cancer was analyzed. Results: In symptomatic GS (542 cases) group, low grade dysplasia was found in 4 cases (0.74%) and high grade dysplasia in 1 case (0.18%). In asymptomatic GS (161 cases) group, low grade dysplasia was found in 4 cases (2.48%) and cancer in 2 cases (1.24%) (p=0.012 vs. symptomatic cases). Dysplasias in symptomatic GS group were not associated with polyps, but dysplasias and cancers in asymptomatic GS group were associated. Patients with asymptomatic GS and polyps were analyzed according to the size of polyps. In those (12 cases) with larger polyps (≥1 cm), low grade dysplasia was found in 2 cases and cancer in 2 cases. And in those (12 cases) with smaller polyps (<1 cm), low grade dysplasia was found in 2 cases. Conclusions: Extending indication of prophylactic cholecystectomy in patients with asymptomatic GS without polyp to prevent GB dysplasia or cancer beyond the existing indication does not seem to be justifiable in Korea. However, further studies are needed in patients with asymptomatic GS and polyp of any size. (Korean J Gastroenterol 2010;55:52-57)

바렛식도와 이형성증, 조기식도선암의 진단과 치료: 미국과 유럽의 임상지침을 중심으로

유아영 ( Ah Young Yoo ),주문경 ( Moon Kyung Joo ) 대한소화기학회 2019 대한소화기학회지 Vol.74 No.1

Barrett’s esophagus (BE) is one of the most prominent diseases in Western countries because of its potential to progress to dysplasia or adenocarcinoma. Recently, the American College of Gastroenterology (ACG), American Gastroenterology Association (AGA), and European Society of Gastrointestinal Endoscopy (ESGE) developed clinical guidelines for the diagnosis and management of BE. All three guidelines commonly stressed the necessity of the endoscopic eradication of confirmed, nonnodular low grade dysplasia or high grade dysplasia, as well as the endoscopic elimination of the remaining BE after an endoscopic resection of visible mucosal abnormalities. An endoscopic resection is also considered for the optimal management of esophageal adenocarcinoma confined to the mucosa (T1a), and even in selective cases of submucosal invasion (T1b). As endoscopic therapy becomes the mainstay for the treatment of BE and its complications, the eligibility of pathologic or endoscopic experts and the BE expert center are being set and strengthened. This paper introduces the statements of the ACG, AGA and ESGE guidelines and compares the similarities and differences between them. (Korean J Gastroenterol 2019;74:11-16)

증 례 : 위에서 발견된 함몰증식성 폴립 1예 보고 및 문헌고찰

이연호 ( Yeon Ho Lee ),주문경 ( Moon Kyung Joo ),이범재 ( Beom Jae Lee ),이지애 ( Ji Ae Lee ),김태현 ( Taehyun Kim ),윤진구 ( Jin Gu Yoon ),이정민 ( Jung Min Lee ),박종재 ( Jong Jae Park ) 대한소화기학회 2016 대한소화기학회지 Vol.67 No.2

An inverted hyperplastic polyp (IHP) found in stomach is rare and characterized by downward growth of hyperplastic mucosal component into the submucosa. Because of such characteristic, IHP can be misdiagnosed as subepithelial tumor or malignant tumor. In fact, adenocarcinoma was reported to have coexisted with gastric IHP in several previous reports. Because only 18 cases on gastric IHP have been reported in English and Korean literature until now, pathogenesis and clinical features of gastric IHP and correlation with adenocarcinoma have not been clearly established. Herein, we report a case of gastric IHP which was initially misdiagnosed as gastrointestinal stromal tumor and resected using endoscopic submucosal dissection. Literature review of previously published case reports on gastric IHP is also presented.

조기위암의 내시경 절제술: 일본과 유럽의 임상지침 비교

고진성 ( Jin Sung Koh ),주문경 ( Moon Kyung Joo ) 대한소화기학회 2018 대한소화기학회지 Vol.72 No.2

An endoscopic resection is performed widely and has been established as a standard therapeutic modality for the treatment of early gastric cancer (EGC) without lymph node metastasis. On the other hand, the selection of suitable patients by a thorough pre-procedural evaluation is mandatory for the successful management of EGC. Moreover, a clear and unified interpretation of a resected specimen and the definition of a curative resection is the mainstay for decision-making of an additional surgical resection and post-procedural surveillance schedule. This paper summarizes the key statements of Eastern (Japan Gastroenterological Endoscopy Society) and Western (European Society of Gastrointestinal Endoscopy) guidelines for an endoscopic resection of EGC, regarding the clinical staging and indication; pre-operative evaluation; definition of a curative resection; and post-procedural surveillance, focusing on the similarities and differences between the two guidelines. (Korean J Gastroenterol 2018;72:79-82)

당뇨에서의 췌장암 유병률 및 췌장암과 연관된 당뇨의 임상 양상 -췌장암을 동반한 당뇨 환자와 일반 당뇨 환자의 비교-

홍승권 ( Seung Goun Hong ),김재선 ( Jae Seon Kim ),정성주 ( Sung Joo Jung ),주문경 ( Moon Kyung Joo ),이범재 ( Beom Jae Lee ),연종은 ( Jong Eun Yeon ),박종재 ( Jong Jae Park ),변관수 ( Kwan Soo Byun ),박영태 ( Young Tae Bak ) 대한소화기학회 2009 대한소화기학회지 Vol.54 No.3

Background/Aims: In Korea, the prevalence of pancreatic cancer (PC) in general population has been reported as 7 in 100,000. However, that in diabetes mellitus (DM) has not been elucidated yet. This study was designed to estimate the prevalence of PC among DM patients, and characterize and compare the patients with DM with and without PC. Methods: 5,082 patients (4,890 DM without PC, 78 PC with DM, and 114 PC without DM) were enrolled from Korea University Guro Hospital during a period of 4 years between January 2004 and January 2008. Results: The prevalence of PC in DM patients was 1.6% and that of DM in PC patients was 40.6%. No significant differences in the clinical characteristics except HbAIc and ALP were observed between PC patients with DM and without DM. Among 78 PC patients with DM, DM was diagnosed in 19 (29.4%) and 29 (37.1%) patients concomitantly or within 2 years prior to the diagnosis of PC, respectively. Among the cases with recent onset DM (less than 2 years` duration), the disease duration of DM before the diagnosis of PC was less than 1 year in 14 patients (17.9%) and 1 to 2 years in 15 patients (19.2%). DM patients with PC were found to have significantly higher ALT, total bilirubin, and ALP levels than in DM patients without PC. Conclusions: The prevalence of PC in DM patients was 1.6% and was higher than in the general population. Recent onset DM was frequent in PC patients (less than 2 years` duration). We recommend close follow-up for at least 2 years in new-onset diabetes. (Korean J Gastroenterol 2009;54:167-173)