복통의 진단적 접근

최석채 ( Suck Chei Choi ),류한승 ( Han Seung Ryu ) 대한내과학회 2012 대한내과학회지 Vol.83 No.5

Abdominal pain is a common chief complaint that brings patients to emergency departments and outpatient offices. The causes of abdominal pain are numerous, ranging from life-threatening to self-limiting disorders. Diagnostic approaches are often difficult because of the nonspecific and overlapping nature of pain, regardless of the underlying cause. A careful medical history taking is the initial diagnostic step. All patients should undergo systematic examinations, regardless of the differential diagnosis suggested by the history. On the basis of the clinical suspicion and laboratory investigations, the physician will consider imaging examinations to help establish the correct diagnosis. Various endoscopic and imaging modalities have important roles in diagnosing many causes of abdominal pain. Diagnostic approaches rely on the likelihood of disease obtaining from histories of patients, physical examinations, laboratory tests, and imaging studies. Furthermore, the evaluation of abdominal pain must be efficient and lead to an accurate diagnosis early in the presentation. It is also important to consider special populations such as women especially during pregnancy and the elderly, because of presentations may differ and are often complicated by coexistent disease. (Korean J Med 2012;83:553-561)

건강한 한국인에서 보행성 24시간 식도내압 검사

최석채(Suck Chei Choi),나용호(Young Ho Nah),임종채(Jong Chae Lim) 대한소화기학회 1995 대한소화기학회지 Vol.27 No.1

N/A Background/Aims: The aim of thi study was to documcnt the circadian rhythmic variation of esophageal motor functions, and the effects of food on esophageul peristalsis. Methods: Standard esophageal manometry and 24-hour ambulatory esophageal pressure monitoring were done in 20 healthy volunteers(male: 14, female: 6, mean age: 26.5 years), using a newly developed miniaturized electronic pressure transducers and portable digital data recorders. Results: Compared to the wet swallow, the food elicited a significant increae in the amplitude of contractions. With 24-hour monitoring, approximately 1,000 contractions were recorded over a 24-hour period. Meals were ass<x.iated with increase in contraction frequency and amplitude. During night, when the subjects were in supine position, esophageal motor activity was markedly decreased and disorganized, with a large percentage of the contractions being simultaneous and of high amplitude. However, even during the upright and meal periods there was a high incidence of simultaneous contractions, l7% and S% respectively. Conclusions: There are circadian rhythmic variotions in esophageal motor pattern and the normal values in a healthy Korean are: contraction amplitude; greater than 25mmHg and less than 100mmHg, simultaneous contractions; less than 40fo in upright position and less than 55% in supine position, multipeaked contraction; less than 10%. (Korean J Gastroenterol 1995;27: 1-8)

식도의 원주상피 피복 점막에서 점액유전자 발현 및 세포증식능에 대한 연구

최석채 ( Suck Chei Choi ),김용성 ( Yong Sung Kim ),김기훈 ( Ki Hoon Kim ),김헌수 ( Hun Soo Kim ),조향정 ( Hyang Jeong Jo ),윤기중 ( Ki Jung Yun ) 대한소화기기능성질환·운동학회 2007 Journal of Neurogastroenterology and Motility (JNM Vol.13 No.1

목적 : 바렛식도는 지속적인 위식도역류 등으로 원위부 식도에 정상적으로 존재하는 편평상피세포 대신에 배상세포를 포함하는 장형 원주세포로 식도 점막이 피복되는 것을 말한다. 그리고 이형성을 거쳐 선암종으로 진행할 수 있기 때문에 이형성 이전 단계인 바렛식도의 발암과정에 대한 연구가 필요하다. 이에 바렛식도와 배상세포를 포함하지 않은 원주세포만 있는 식도를 대조군으로 하여 점액유전자 및 세포증식능에 대해 비교 연구하였다. 대상 및 방법 : 임상 및 내시경적으로 바렛식도가 의심되어 원위부 식도에서 생검한 환자들 중에서 배상세포가 있어 조직학적으로 바렛식도로 증명된 25명의 환자와 배상세포가 없었던 환자들 중에서 무작위로 선택한 30예를 대조군으로 하였다. 생검 당시의 나이와 성별 그리고 MUC1, MUC2, Ki-67에 대한 면역조직화학적 염색을 시행하였다. 결과 : 바렛식도의 평균 나이 및 남자 비율은 각각 65.3±10.1세, 76.0%이였고, 대조군의 평균 나이 및 남자 비율은 각각 53.0±14.8세, 60.0%로 바렛식도의 나이가 대조군식도보다 의의있게 높았다. MUC1은 바렛식도 및 대조군 모두에서 100% 발현되었고, MUC2 발현율은 바렛식도 및 대조군에서 각각 92%, 20%이었다. Ki-67 발현율은 바렛식도 및 대조군에서 각각 80.0%, 70.0%이였고, Ki-67 발현 강도의 평균은 바렛식도 1.20±0.76, 대조군 0.77±0.57로 발현 강도에서 바렛식도가 의의있게 높았다. 결론 : 바렛식도는 원주세포만 있는 식도에서 보다 좀더 지속적인 위식도역류 등의 자극으로 생긴다. 그리고 MUC2는 주로 바렛식도에서 발현되고 세포증식능은 바렛식도에서 좀더 높으며 이는 MUC2 발현과 관련될 수 있다고 생각된다. Background/Aims: Barrett`s esophagus is characterized by the presence of metaplastic columnar epithelium with goblet cells in the distal esophagus. Barrett`s esophagus progresses through low grade dysplasia and high grade dysplasia to adenocarcinoma. We studied the patient age, the mucin gene and the proliferation activity of biopsy-proven Barrett`s esophagus and simple columnar epithelium-lined esophagus. Methods: To evaluate the mucin gene expression and proliferation activity, twenty five cases of Barrett`s esophagus and thirty cases of control esophagus were examined immunohistochemically with using the monoclonal antibodies to MUC1, MUC2 and Ki-67. Results: The Barrett`s esophagus patients were older (mean: 65.3±10.1 years) than the control patients (mean: 53.0±14.8 years). The MUC1 expression was 100% in both Barrett`s esophagus and the control esophagus. An MUC2 expression was observed in 92.0% of the Barrett`s esophagus and 20.0% of the control esophagus. The rate and intensity of the Ki-67 expression was higher in the Barrett`s esophagus (80.0%, 1.20±0.76) than that in the control esophagus (70.0%, 0.77±0.57). Conclusions: Barrett`s esophagus is a metaplastic lesion due to the more long-standing gastroesophageal reflux than that in a simple columnar epithelium-lined esophagus. The cause of increased proliferation activity in Barrett`s esophagus may be related to the MUC2 expression. (Kor J Neurogastroenterol Motil 2007;13:21-25)

한국인 궤양성 대장염 환자의 말초혈액에서 CCL20 유전자의 발현 및 sulphasalazine과 glucocorticoid에 의한 조절작용

최석채(Suck Chei Choi),나용호(Yong Ho Nah),정연태(Yeun Tai Chung),한원철(Won Cheol Han),이명수(Myeung Su Lee),전창덕(Chang-Duk Jun) 대한해부학회 2004 Anatomy & Cell Biology Vol.37 No.6

염증성 장 질환 (inflammatory bowel disease; IBD)은 만성적인 염증으로 궤양성 대장염 (ulcerative colitis)과 크론씨 병(Crohn,s disease)으로 분류되어진다. 최근 혈액의 단핵구 세포와 장 상피세포에서 발현되어지는 Nod2 유전자가 크론씨 병의 원인 유전자로 알려지면서 혈액의 단핵구 세포가 염증성 장 질환에 중요한 역할을 수행할 수 있을 것으로 재조명되었다. 본 연구는 Nod2 유전자처럼 단핵구 세포와 장 상피세포에서 공통으로 발현하며, 인체에서 선천성 면역능과 후천성 면역능을 연결하는 것으로 알려진 CCL20 유전자가 한국인에서 발병율이 높은 궤양성 대장염에서 어떻게 발현이 조절되는지 알아본 것이다. CCL20 유전자는 정상인에 비하여 대부분의 궤양성 대장염 환자의 혈액 단핵구 세포 및 장 상피조직에서 발현이 증가되어져 있었다. 본 연구에 참여한 환자의 disease activity index (DAI)와 CCL20 유전자 발현의 상관관계를 구한 결과 흥미롭게도 CCL20가 높게 발현된 환자들은 대다수 이전에 약물치료를 받지 않은 것으로 나타났다. 이러한 결과는 CCL20 유전자가 초기 궤양성 대장염의 발병에 관여하고 있으며 항-염증제 치료에 반응을 하는 유전자라는 것을 암시하는 결과이다. 이를 증명하기 위하여 이전에 항-염증치료를 받지 않은 궤양성 대장염 환자에 대하여 3개월 간 5-amino salicylic acid (5-ASA)와 glucocorticoid 유도체인 dexamethasone (DEX)으로 약물치료를 수행하였다. 이 결과 CCL20 유전자의 발현이 이들 약물치료를 받은 환자에서 급격히 감소하였음을 알 수 있었다. 이를 세포수준에서 확인하기 위하여 THP-1 단구세포와 HT-29 장 상피세포에 TNF-α 또는 IL-1β로 CCL20를 유도한 다음 5-ASA와 DEX를 처리한 결과 환자에서와 같은 효과를 검정할 수 있었다. 이러한 결과는 CCL20가 궤양성 대장염 환자에서 혈액 및 장 조직의 면역학적 병리작용에 중요하게 관여하고 있으며 궤양성 대장염의 진단 및 예후 판정에 도움을 줄 수 있음을 시사한다. Discovery of Nod2 has brought to light the significance of mononuclear cells as well as epithelial cells in inflammatory bowel disease (IBD) pathogenesis. Similarly, CCL20 is expressed in both mononuclear cells and epithelial cells and is likely to link innate and acquired immunity. We therefore asked whether CCL20 expression is altered in the peripheral blood mononuclear cells (PBMCs) from patients with ulcerative colitis (UC), a major type of IBD in Korea, and is correlated with the disease activity. The expression levels of CCL20 mRNA were significantly high in the PBMCs from the patients with UC. CCL20 protein expression was also up-regulated in the mucosal epithelium in UC but not in normal controls. Interestingly, however, disease activity index (DAI) revealed that untreated UC groups express higher expression levels of CCL20 mRNA than treated UC groups, implying that CCL20 may be a potential target for the anti-inflammatory treatments. In an agreement with this, three months follow up study revealed that the UC patients who were treated with 5-amino salicylic acid (5-ASA) and glucocorticoid showed dramatic decrease in their CCL20 mRNA levels as compared to untreated ones. Moreover, TNF-α- or IL-1β-induced CCL20 secretion in human epithelial HT-29 cells was significantly diminished by the treatment with 5-ASA and/or dexamethasone, suggesting that CCL20 may be one of the central targets of the anti-inflammatory drugs. Collectively, these results suggest that CCL20 expression in UC may be associated with altered immune and inflammatory responses in the blood as well as the intestinal mucosa and further implied a potential for CCL20 as an important diagnostic marker for UC.

정상성인에서 달리기 운동이 식도운동과 위산역류에 미치는 영향

최석채(Suck Chei Choi),나용호(Yong Ho Nah),최석준(Suck Jun Choi) 대한내과학회 1997 대한내과학회지 Vol.53 No.4

N/A Objectives: Physical exercise has become popular in recent years. It has been known that exercise is related to the development of heartburn, belching, regurgitation and chest pain. However there are few data concerning the effect of exercise on esophageal motor function and gastroesophageal reflux. We evaluated the effect of exercise intensity on esophageal motor activity and gastroesophageal reflux. Methods: We studied healthy volunteers (15 males, age: 28±5 years, BW: 68±10㎏) using a 24 hours ambulatory esophageal pressure, pH catheter and portable digital data recorder (Microdigitrapper 4Mb, Synetics Medical, Sweden). Subjects exercised on a treadmill (Marquette Case 15 Electronic INC) at 50% and 70% maximal heart rate for 30 min. Subjects rested 2 hours before exercise (base line) and for 30 min between exercise sessions. Results: 1) Exercise of 50% maximal heart rate reduced total contraction, contraction duration, percentage of simultaneous contraction and repetitive contraction, (P<0.05) but increased percentage of contractions above 20mmHg amplitude (P<0.05). 2) Exercise of 70% maximal heart rate decreased total contraction, esophageal amplitude, contraction duration and percentage of peristaltic contraction, (P<0.05) but increased percentage of simultaneous contraction (P<0.05). 3) Gastroesophageal reflux was not change on both 50% maximal heart rate and 70% maximal heart rate exercise. Conclusion: More propulsive esophageal motility are induced following exercise of 50% maximal heart rate, but not 70% maximal heart rate.

방사성동위원소를 이용한 대장분절 통과시간의 정량적 연구

최석채(Suck Chei Choi),김제형(Jae Hyung Kim),황호근(Ho Geun Hwang),양세훈(Sei Hoon Yang),김진아(Jin Ah Kim),나용호(Yong Ho Nah),이춘호(Choon Ho Lee),김창근(Chang Guhn Kim) 대한소화기학회 1997 대한소화기학회지 Vol.29 No.1

N/A Background/Aims: Measurements of regional transit are highly relevant to an understanding of normal colonic function and of any derangements associated with disease. Currently available clinical tests of colonic transit, such as the radiopaque marker method, are useful in detecting delayed transit but may be less sensitive for rapid transit. Our aim was to develop a method whereby the transit of solid residue measvred unprepared human colon. Methods: We used a noninvasive method to label the solid phase of contents in the unprepared human colon. 'Indium-labeled Amberlite IR-120 beads(Siga Chemica] Co.) were placed in a gelIatin capsule which was then coated with methacrylate. When ingested by healthy controls, capsules released radiolabeled beads in the dista] ileum or proximal colon in 22 of 22 controls. Transit of 'Indium-pellets through the unprepared colon could be quantitated radioscintigraphically. Results: Emptying of the ascending colon was characterized by an initial lag period(112.50' 80.75 min, mean + S.D). Mean colonic transit times were measured using both the radiopaque markers and radioscintigraphy. The mean colonic transit times were 1212.50<413.98min (rnean < S.D) in radioscintigraphy, and 1014.40+631.67min(mean < S.D) in radiopaque marker. So there was a good correlation(r=0.7) between radioisotope method and radiopaque marker method. Radioactivity counts were distributed equally between ascending colon, transverse colon, descending colon, and rectosigmoid colon at the 12th hour. Geometric center analysis showed an initial progression of activity in the proximal colon and a linear progression distally. Conclusions: Colonic scintigraphy is a safe and quantitative method for evaluating the colonic transit of fecal material and may provide a usefu] tool for evaluating large intestinal physiology. In healtby adults, normal orol-cecal transit time is about 5 hours and normal colonic transit time is about 24 hours when using radioscintigraphic method.(Korean J Gastroenterol 1997; 29:1-8)

건강한 성인에서 콩가루 호기수소 검사법을 이용한 구강 맹장 통과시간의 측정

최석채(Suck Chei Choi),나용호(Young Ho Nah) 대한내과학회 1996 대한내과학회지 Vol.51 No.4

N/A Objectives: The hydrogen breath test has been widely used as a noninvasive and simple method of determining orocecal transit time after ingestion of unabsorbable disaccharide lactulose. But there are several disadvantages in using such a low molecular weight, and hence osmotically active substance. Raked bean contains sufficient poorly absorbable carbohydrate to yield a rise in breath hydrogen of 30-40 pm starting after 3-4 hours after ingestion and this meal more closely resembles normal food and also gives reproducible responses. But the time of arrival of baked bean in the cecum is variable by different researchers. The most common criteria of transit is a sustained rise of > 10 ppm above baseline, though other authers used a rise of sustained 3 ppm or double baseline. The aim of this study was to determine whether changes of test meal aftect the oracecal transit time. The orocecal transit time using baked bean was measured in 20 healthy volunteers and was compared with the orocecal transit time using lactulose. Medthods: Subjects were instructed to not eat any foods containing unabsorbable carbohydrates the day before the test and not smoke for at least 1 hour prior to the test. After an overninght fast subjects brush their teeth and rinse their mouth, the basal end-expiratory breath sample is obtained and assayed for hydrogen using a gas chromatograph (12i MicroLyzer, Quintron, Milwaukee). The test meal containing 120g of baked bean and water (513 kCal) were taken, and then every 10 minitues the sample were collected and measured until they dropped to a level of 10 ppm. The all subjects returned one months later, at which time 15 gm of the lactulose was administered following the same protocol. Transit time were defined as the time at which there were 3 ppm sustained increase, 10 ppm and twofold rise in breath hydrogen over baseline. Results: Orocecal transit time using baked bean rising above 10, 3 ppm sustained increase above baseline and double baseline were 324.5(±87.15), 254.5(±96.38), and 244.5(±111.83) minutes, respectively. Bat orocecal transit time using lactulose were 125.38(±28.47), 97.69(±40.86), and 110.77(±35.7) minutes, respectively. Orocecal transit time was significantly delayed in the method using baked bean than in the method using lactulose. Conclusion: Based on these study, baked bean hydrogen breath test is more accurate modality then lactulose hydrogen breath test in evaluating orocecal transit time. Transit time should be defined as the time of 10 ppm rise over baseline. In healthy adult Korean, upper limit of OCTT is about 5 hours.

내시경적 식도정맥류 결찰요법의 식도하부 운동과 식도내 pH에 대한 영향

최석채(Suck Chei Choi),김형언(Hyeong Eon Kim),유광현(Kwnag Hwon You),류준형(Jung Hyung Ryu),김태현(Tae Hyeon Kim),김학철(Haak Cheoul Kim) 대한소화기학회 1995 대한소화기학회지 Vol.27 No.2

N/A Background/Aims: A recently developed method that uses sma11 rubber bands for treating bleeding varices, endoscopic variceal ligation(EVL), may affect the lower esophageal motility. The aim of this study was to assess the effects of EVL on esophageal motility and gastroesophageal reflux. Methods: We prospectively performed lower esophageal manometry and 24-hour ambulatory esophageal pH monitoring before and after EVL therapy in 34 patients with esophageal varices. Results: The EVL caused considerable decrease in the size of esophageal varix by mean 7.8(range 3 21) ligations in mean 1.5(range l -3) sessions. There were no significant changes in the length, pressure, relaxation percent and duration of the lower esophageal sphincter(LES), in the speed of peristaltic wave in the lower esophagus and all pH parameters after EVL. Conclusions: Endoscopic variceal ligation therapy may cause little motility dysfunction in thc lower esophagus, even though there were significant differences in the contraction amplitude and duration in the lower esophagus after EVL. (Korean J Gastroenterol 1995;27: 151 - 158)

십이지장 팽대부의 융모성선종

최석채(Suck Chei Choi),송승렬(Seung Ryel Song),임동석(Dong Suk Lim),조규혜(Kyoo Hye Cho),유재규(Jae Kyu Ryu),김학철(Hak Chel Kim) 대한소화기학회 1993 대한소화기학회지 Vol.25 No.4

Villous adenoma of the ampulla of Vater Which is sometimes the cause of extrahepatic obstructive jaudice is uncommon disease. But they are important in spite of their rarity, because of frequent malignant change in the tumor as a focal or all occult tumor. Recently, the early diagnosis of ampullary tumors has become possible due to the ide application of fiberoptic endoscopy and increasing knowledge about the ampullary tumors. Although the biopsies were taken during the endoscopy, sometimes one might miss the area of malignant degeneration. But, it could increase the diagnostic accuracy by performing a hiopsy at the highly suspected site ofl malignancy, like our case in which fixed and discolorecl areas in the lesion were biopsied. So we recommed an affn.ssive endoscopic study and hypotonic duodenogram. Even thought it is diagnosed as benign, and can be treated with endoscopic pelypectorny, but we recommend the complete resection of the tumor because of high incidence of recurrence and malign ant transformati on.

위 아전절제술 후 십이지장 위 역류성 위염에서 p53 및 Ki-67 단백 발현 양상

최석채 ( Suck Chei Choi ),김용성 ( Yong Sung Kim ),김기훈 ( Ki Hoon Kim ),김헌수 ( Hun Soo Kim ),윤기중 ( Ki Jung Yun ) 대한소화기기능성질환·운동학회 2007 Journal of Neurogastroenterology and Motility (JNM Vol.13 No.2

목적 : 십이지장 위 역류성 위염은 위절제 등에 의해서 발생하는 것으로 후에 암종이 발생할 가능성이 높은 것으로 알려져 왔다. 그러나 사람에서 십이지장 내용물의 역류와 암종 발생 사이의 병인론적 연구가 흔하지 않다. 이에 십이지장 위 역류성 위염을 보이는 환자의 조직과 대조군 환자의 조직을 대상으로 Ki-67 및 p53 단백 발현 정도를 측정하여 상피 세포증식 유도 및 암억제 유전자의 발현 정도를 비교 연구하였다. 대상 및 방법 : 위암종으로 위아전절제술을 받은 총 57예 중 내시경 및 조직학적으로 십이지장 위 역류성 위염으로 진단된 16예의 내시경 조직과 대조군 16예의 내시경 조직을 대상으로 하여 Ki-67 및 p53 단백 발현을 면역조직화학적 염색을 하였고 그 강도를 점수화하였다. 결과 : 십이지장 위 역류성 위염 소견을 보인 환자의 내시경적 추적 기간은 평균 607일, 대조군 556일 그리고 57예의 평균은 471일로 유의한 차이는 없었다. 십이지장 위 역류성 위염 환자의 Ki-67 발현 강도의 중간값은 3.0로 대조군 중간값 2.0보다 의미있게 높았으며, p53 단백의 발현 강도 중간값도 2.0으로 대조군 중간값 1.0 보다 의미있게 높았다. 결론 : 십이지장 위 역류성 위염은 담즙 등이 점막의 상피세포 증식을 유도하고 유전자 이상을 초래할 가능성이 높아 시간 경과 후 암종이 발생할 가능성이 대조군에 비해서 높을 수 있음을 알 수 있었다. Background/Aims: Duodenogastric reflux of bile and other contents of duodenum is one of the main etiologic fators in chronic gastritis, and chronic inflammation has been recognized as a risk factor of human cancer. The aim of this study was therefore to evaluate the expression of p53 and Ki-67 protein in duodenogastric reflux gastritis. Methods: To evaluate the proliferation activity and tumor suppressor gene expression, 16 cases of duodenogastric reflux gastritis and 16 cases of control gastric tissue after subtotal gastrectomy were examined immunohistochemically using the monoclonal antibodies to Ki-67 and p53 protein. Results: The mean duration of follow-up endoscopic biopsy after subtotal gastrectomy was 607 days in duodenogastric reflux gastritis and 556 days in control groups. The mean intensity of Ki-67 in duodenogastric reflux gastritis was significantly higher than that of control tissues (3.0 vs 2.0). The mean intensity of p53 protein in duodenogastric reflux gastritis was significantly higher than that of control tissues (2.0 vs 1.0). Conclusions: The high expressions of Ki-67 and p53 protein in duodenogastric reflux gastritis may be one of the main mechanisms in the development of gastric stump carcinoma. (Kor J Neurogastroenterol Motil 2007;13:118-122)