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[Á¦4ȸ Web-seminar: À§±Ë¾çÀÇ Áø´Ü°ú Ä¡·á 2¿¡¼­ ³ª¿Ô´ø Áú¹®¿¡ ´ëÇÑ ´äº¯]

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2015³â 8¿ù 4ÀÏ ¿ÀÈÄ 7½Ã web-seminar°¡ ¿­·È½À´Ï´Ù. MERS »çÅ ÀÌÈÄ Ã¹ web-seminar¿´½À´Ï´Ù. Âü¼®ÇØÁֽŠ¸ðµç ºÐµé²² °¨»çµå¸³´Ï´Ù. 8¿ù 4ÀÏ ³ª¿Ô´ø Áú¹® ÀϺο¡ ´ëÇÑ ´äº¯À» Á¤¸®ÇØ º¸¾Ò½À´Ï´Ù.

´ÙÀ½ »ï¼º¼­¿ïº´¿ø ¼ÒÈ­±â³»°ú Web-seminar´Â 9¿ù 8ÀÏ Àú³á 7½ÃÀÔ´Ï´Ù. Helicobacter¿¡ ´ëÇÑ ¿©·¯ À̾߱⸦ ÇØ º¸·Á°í ÇÕ´Ï´Ù.


Q. ÀӽŽà ±Ë¾çÀº ¾î¶»°Ô Ä¡·áÇմϱî?

A. Á¦°¡ »êºÎÀΰú Àǻ簡 ¾Æ´Ï¹Ç·Î °æÇèÀº ¾øÁö¸¸ ¹®Çå¿¡ ÀÇÇϸé H2RA³ª PPI´Â ºñ±³Àû ¾ÈÀüÇÑ °Í °°½À´Ï´Ù. ±×·¯³ª °¡±ÞÀû ¾àÀ» ¾²Áö ¾Ê°Å³ª ´ÊÃß´Â °ÍÀÌ ¾î¶³±î¿ä? »ç½Ç ÀӽŠ½Ã À§½Äµµ¿ª·ùÁúȯ¿¡¼­µµ step up Ä¡·á¸¦ ±ÇÇÏ°í ÀÖ½À´Ï´Ù. H2RA³ª PPI¸¦ °¡±ÞÀû ¾²Áö ¾ÊÀ¸·Á´Â ½ÃµµÀÔ´Ï´Ù. Ç︮ÄÚ¹ÚÅÍ Á¦±ÕÄ¡·á´Â ÀӽŠÀÌÈÄ·Î ´ÊÃß¾î¾ß ÇÕ´Ï´Ù. MisoprostolÀº Àý´ë ±Ý±âÀÔ´Ï´Ù.

¸î °³ÀÇ Âü°íÀڷḦ ±ÇÇÕ´Ï´Ù. ù¹ø°´Â ¼ÒÈ­±â³»°úÀÇ ÀÔÀåÀÌ°í µÎ¹ø°´Â »êºÎÀΰúÀÇ ÀÔÀåÀÔ´Ï´Ù. ¹Ì¹¦ÇÑ Â÷ÀÌ°¡ ÀÖ½À´Ï´Ù¸¸... »êºÎÀΰúÂÊ ÀÇ°ßÀ» Âü°íÇÏ´Â ÆíÀÌ ¾ÈÀüÇÒ °Í °°½À´Ï´Ù. ¹°·Ð °¢ ȯÀÚ »óÅ¿¡ µû¶ó¼­ ÀûÀýÇÑ ¹æ¹ýÀ» ÅÃÇÏ´Â °ÍÀÌ ÃÖ¼±ÀÏ °Í °°½À´Ï´Ù¸¸...

Âü°íÀÚ·á 1: The safety of drugs used in acid-related disorders and functional gastrointestinal disorders. Gastroenterol Clin North Am. 2010

Omeprazole is listed by the FDA as a pregnancy class C medication, whereas all other currently available PPIs are class B, which still denotes a possible serious risk to the fetus. Gill and colleagues recently published a systematic review evaluating the risk of PPI use in pregnancy. Among 1530 PPI-exposed subjects compared with 133,410 controls, they found no association between major fetal malformations, spontaneous abortions, or pre-term delivery. This lack of association was also apparent when omeprazole alone was investigated.

However, there is some suggestion that acid suppression alone may have an adverse affect on an exposed fetus. In a recent, large, case-control study investigating children with asthma, Dehlink and colleagues found a relationship between maternal gastric acid suppression with a PPI or H 2 RA and the development of childhood asthma (OR 1.43; 95% CI 1.29-1.59). The postulated mechanism, based on animal model data, is that acid suppression increases type 2 helper cell bias in their offspring, thus predisposing to increased atopy. Based on these data, the immediate fetal developmental risk of PPIs may be negligible. However, possible risks to the fetus that may only become manifest in childhood require further study.

H2RAs are commonly used in pregnancy to control reflux symptoms and seem to have no adverse effects on the fetus. Magee and colleagues investigated H2RA use among 178 women and matched controls in the first trimester of pregnancy and found no difference in adverse fetal outcomes. Ruigomez and colleagues analyzed a large population-based cohort of pregnant women who were exposed to cimetidine or ranitidine (or omeprazole) during the first trimester and found no increase in nongenetic congenital malformations with exposure to any of these medicines.


Âü°íÀÚ·á 2: Creasy and Resnik's Maternal-Fetal Medicine: Principles and PracticeÀÇ ÀӽŠÁß ¼ÒÈ­¼º±Ë¾ç Ä¡·á¿¡ ´ëÇÑ ºÎºÐÀ» ¿Å±é´Ï´Ù.

Management begins with empiric treatment. Because PUD and GERD therapies are similar, a stepwise scheme should be followed before considering EGD. Dietary and lifestyle alterations include avoidance of fat-laden foods, acidic drinks, caffeine, chocolate, NSAIDs, and alcohol. Smoking, stress, anxiety, and nighttime snacks should also be avoided.

Antacids should be used as first-line medical therapy because they have been effective in approximately 75% of duodenal ulcers. Dosages range from 15 to 30?mL, taken 1 hour after meals and at bedtime. Extra doses may be taken 3 hours after meals. Aluminum- and magnesium-containing antacids have little systemic absorption and appear to be safe in pregnancy. Sucralfate, an aluminum-based polysaccharide complex, attaches to the surface of an ulcer, protecting the mucosa from further injury, and it may suppress H. pylori infection. Seventy-five percent of duodenal ulcers heal with 4 weeks of sucralfate therapy. Because of its minimal systemic absorption, it is a preferred drug for treating PUD in pregnancy.

H2-receptor antagonists are an effective treatment for PUD; about 80% of duodenal ulcers heal with this therapy in the general population. Before the discovery of H. pylori and the introduction of proton pump inhibitors, H 2 blockers were the mainstay of treatment. Their safety profile in pregnancy has not been adequately demonstrated. H 2 -receptor antagonists cross the placenta, but their use is justifiable if significant clinical conditions warrant. Cimetidine and ranitidine have had considerable use over the past 20 years. In animal studies, cimetidine has caused a reduction in the size of fetal testes, prostate, and seminal vesicles, presumably by means of a weak antiandrogenic effect. Ranitidine has no such effects in animals, and neither drug has had reports of genital malformations in humans. More than 2000 pregnancies in database studies with exposure to cimetidine or ranitidine have been assessed, and there has not been an associated risk for congenital malformations. There is less information reported for famotidine and nizatidine. Because of conflicting animal data for nizatidine, it is preferable to use the more extensively studied H 2 -receptor antagonists as first-line agents.

Proton pump inhibitors suppress gastric acid secretion at the level of the H + ,K + -ATPase on the parietal cell surface. These agents are highly effective in the treatment of esophagitis and gastroduodenal ulcers, and they are often used in combination therapy for eradication of H. pylori infection. In the nonpregnant population, proton pump inhibitors are usually the initial treatment for suspected or documented reflux esophagitis and PUD. H 2 -receptor antagonists, sucralfate, and antacids are used as secondary medications and for symptomatic relief. During pregnancy, therapy should be modified to avoid fetal harm and also because PUD usually improves during gestation. EGD is usually avoided unless the patient is failing empiric therapy with H 2 -receptor antagonists. There appears to be little benefit in diagnosing H. pylori infection during pregnancy, because treatment involves triple-drug therapy, including antibiotics, and it is usually deferred until after delivery.


Âü°íÀÚ·á 3: Medscape¿¡´Â ¾Æ·¡¿Í °°ÀÌ ¾²¿© ÀÖ½À´Ï´Ù.

H2-receptor antagonists (eg, cimetidine, ranitidine, famotidine) are the first choices of treatment for peptic ulcer disease. Treatment for Helicobacter pylori gastritis should be initiated after the pregnancy and breastfeeding periods are complete, because some of the recommended medications are relatively contraindicated in pregnancy. Lansoprazole has been reported to be safe in pregnancy.


Q. PPI Àå±â »ç¿ë½Ã Æó·Å À§ÇèÀº ¾î¶°Çմϱî?

A. Gastroenterol Clin North Am (2010)ÀÇ Ç¥¸¦ ¿Å±é´Ï´Ù. Pneumonia´Â probableÇÏ°í fracture´Â negiligable ÇÏ´Ù´Â °ÍÀÔ´Ï´Ù. Áõ»ó Á¶ÀýÀ» À§ÇÑ ÃÖ¼Ò¿ë·®ÀÇ PPI¸¦ »ç¿ëÇÑ´Ù¸é ´ëºÎºÐÀÇ °æ¿ì µæÀÌ ½Çº¸´Ù Å©´Ù°í »ý°¢ÇÕ´Ï´Ù.


Q. Asprin, clopidogrel, NSAID·Î ÀÎÇÑ ulcer bleeding Hx°¡ ÀÖ´ø ºÐµé²² NSAID³ª aspirinÀ» Áö¼ÓÀûÀ¸·Î µå½Ã´Â ºÐµéÀº ¾àÀ» µå½Ã´Â µ¿¾È PPI¸¦ half dose·Î °è¼Ó µå¸°´Ù°í Çϴµ¥, ±×·³ »óº´ÄÚµå´Â ¾î¶»°Ô ³Ö°í ÁֽôÂÁö¿ä?

A. Áß¿äÇÑ Áú¹®À̶ó°í »ý°¢ÇÕ´Ï´Ù. ¿ì¸®³ª¶ó Á¦µµ¿¡¼­ ¿¹¹æÀû Ä¡·á¿¡ ´ëÇÑ ºÎºÐÀÌ »ó´ëÀûÀ¸·Î Ãë¾àÇÕ´Ï´Ù. ±Ë¾ç ÃâÇ÷ °ú°Å·ÂÀÌ ÀÖ´Â ºÐÀº NSAID, aspirin (°æ¿ì¿¡ µû¶ó¼­´Â clopidogrelµµ)À» ¾²´Â °æ¿ì PPI¸¦ ÇÔ²² ó¹æÇÏ°í ÀÖ½À´Ï´Ù. º¸Åë half dose¸¦ »ç¿ëÇÏ°í ¸î ³â °£ ¹®Á¦°¡ ¾øÀ¸¸é half dose¸¦ ÀÌƲ¿¡ Çѹø µå½Ãµµ·Ï ±ÇÇÏ°í ÀÖ½À´Ï´Ù. ÀúÀÇ °æ¿ì code´Â ±×³É ±Ë¾ç Äڵ带 ¾²°í Àִµ¥ ¾ÆÁ÷ »è°¨´çÇÏÁö ¾Ê°í ÀÖ½À´Ï´Ù. Àǹ«±â·Ï¿¡ ¿¹¹æÀû PPI¸¦ µå¸®´Â ÀÌÀ¯¸¦ ¸íÈ®È÷ ½á µÎ°í Àִµ¥ ÀÌ°ÍÀÌ µµ¿òµÇ´Â °Í °°½À´Ï´Ù. ¼±»ý´Ô¿¡ µû¶ó¼­´Â K21.9¸¦ Ãß°¡·Î ÄÚµùÇÏ´Â ¼ö°¡ ÀÖ´Ù°í ÇÕ´Ï´Ù. ²À ¿ÇÀº ÀÏÀº ¾Æ´ÏÁö¸¸... »ê¿ª·ù¿¡ ÀÇÇÑ Áõ»ó°ú ±Ë¾ç Áõ»óÀÌ ºñ½ÁÇÒ ¼ö ÀÖÀ¸¹Ç·Î ÀüÇô Ÿ´ç¼ºÀÌ ¾ø´Ù°í ÇÒ ¼ö ¾ø´Â Àü·«ÀÎ °Í °°½À´Ï´Ù.


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© ÀÏ¿ø³»½Ã°æ±³½Ç ¹Ù¸¥³»½Ã°æ¿¬±¸¼Ò ÀÌÁØÇà. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.