Symptom-based diagnosis of reflux disease-how accurate and how necessary ???????????????????

1
??????????????????
??? ??????????????? ??????????
2
????

• ??????????????????
• ??????????????????
• ??????????????????
• ?????????????????

3
GERD????????????
4
GERD???????????

• ?????
• ????
• ????????
• ????
• ?????

• ?????????
• ????
• ???????

5
?????????????GERD??
?? ?? 24h-pH?? ???? ????
NERD - -? ?????????
RE /- /- -? ????????
Barrett /- /- /- ????????????
NSRD - /- /- ????
FH - - - ??????
nonerosive reflux disease (NERD)
???????GERD??
6
?pH????????????
Acid-sensitive vagal sensory pathways and cough.
Pulm Pharmacol Ther. 200720(4)402-11.
7
Epithelial Na channel delta subunit is an acid
sensor in the human oesophagus. Eur J Pharmacol.
2008 Dec 14600(1-3)32-6.
8
?????????GERD?????

• ???????PPIs?????GERD,??????????,??????
• ??PPIs??????????????????

Clin Gastrol Hepital. 2006450-55
9
?????????GERD????????
pHlt56
pHlt4
?????????????????????(??????????????????????)(???
?????,?????)
10
????????GERD???????

• ??????????
• ?????
• ????????????

• ??????
• ????,???
• ?????

Symptomatic gastroesophageal reflux diagnosis
with ultrasound. J Pediatr Gastroenterol Nutr.
1994 Jul19(1)58-64.
Impaired gastric motility and its relationship to
reflux symptoms in patients with nonerosive
gastroesophageal reflux disease. J Gastroenterol.
200944(3)183-9.
11
????????GERD??

• ???????????GS?????,??????????????
• ??GER?,????PSY???PSY,????GS???
• ?????????

Globus sensation pharyngoesophageal function,
psychometric and psychiatric findings, and
follow-up in 88 patients. Arch Intern Med. 1998
Jun 22158(12)1365-73.
12
?????????GERD????????

• ?GERD????
• ?????????????????,?????????,?????????????
• ?????,?????????

• ????????GERD?????
• ????????
• ????????????
• ????????????????

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?
?
13
????GERD??????

• ???? 876 ????
• ??? 74.8,625 (71) ????????
• ?? 158 (91) 173
• ????? 82 (75) 109
• ??126 (68) 185
• ??151 (82) 184
• ??? 68 (44) 153
• ?? 40 (56) 72

14
PPIs??GERD??

• Double PPI
• ????
• (????)
• ???????(NERD)

15
?????????GERD????????

• ???
• ???????????
• ???????????
• ??
• ????????
• ????

• ??????????
• TCA X
• ???v(50-100mg)
• ???v (1-2?)
• SSRI v (??????)
• ??
• ????
• ???????(4-8?8-20? ??)

16
???????????????????
17
FD???????????

• ?????,??????(???)
• ?????
• ???????CDPPU
• ?????????????
• ???????????CDPPU
• ???????(????????????????)

• ?????
• ??????
• ??????
• ?????????
• ?-???????
• ???????

18

• ??vs??
• ????,???????
• ?????????????
• ????????CDPPU(?-??????)
• ????????????????

19
FD????????????????

• PPIs,H2R-i
• ???????
• ????
• ???????(???????????????????????????)
• ???????????????

20
FD??????????RCTs??
?? ???? ???? ?????RR?
???? 19 0.67(0.55-0.82)
PPI 10 0.87(0.80-0.96)
H2RA 12 0.77(0.65-0.92)
?? 6 0.60(0.35-1.03)
??? 2 0.71(0.36-1.40)
TCA 4 0.55(0.36-0.85)
21
???????????????
FD????????????,????????????
???????
22
?????FD???????????

• ??22??????
• ??6,906????????
• ????????31
• ?????????42 (??Hp38PPI34)

???????10
??????
23
??????FD?????vs.??
???? ????? ????? ??????? ??????? ??????? NNT 95????
?? 4 815 3 225
?? 19 6674 9 9 619
Additional data from Hiyama T et al. J Gastro
Hepatol 2007 22304-10
24
???????????-?????????
In the fasting supine
Monitoring the content of hydrogen in the breath
per 15mins
30mins
30mins
Gastrointestinal motility medicine (20ml water at
room temperature)
Oral lactulose15ml NS 50ml
washout period Interval (1 week) Oroal mosapride
5mg, domperidone 10mg, Itopride 50mg, pinaverium
bromide 50mg, trimebudine 100mg ... Respectively.
25
Water
Water
26
Results
Blank
Water
Mosapride 5mg
Domperidone 10mg
Pinaverium 50mg
Itopride 50mg
Trimebudine 100mg
27
PPI?FD????????vs.??
???? ????? ????? ??????? ??????? NNT 95????
?? 1 453 N/A N/A
?? 14 3231 12.5 825
28
????????FD?????(???????)

• ??17??????
• ??3,566????????
• ????????31
• ??????????????38

???????10
??????
29
????????????vs.??
???? ????? ????? ??????? ??????? NNT NNT 95????
?? 9 1007 5 28
?? 14 3231 12.5 825
Additional data from Jin X et al. Helicobacter
2007 12541-6
30
???????FD???????vs.??
???? ????? ????? ??????? ??????? NNT NNT 95????
?? 1 42 5 122
?? 3 547 3 119
31
IBS(??)???????????
32
IBS???????????

• ??
• ????
• ????(??????)
• ??????
• ?????
• ???????

33
(No Transcript)
34
????????

• ??????(?????)(??????????)
• ????(????Bristol??????????????)
• ????????(??????)
• ???????(5-HT4s?TCA?SSRI?SNRI?)

35
Gut 2009 58 367-378
36
??????IBS??Asian Neurogastroenterology and
Motility Association (ANMA)
J Gastroenterol Hepatol. 2010 Jul
25(7)1189-205.
37
??IBS????????????(19-29?)

• Statement 19 IBS??????????????????????????
• Statement 20??????????,????????(??????)
• Statement 21???????????(?????????)
• Statement 22IBS-DGI????IBS-CGI????
• Statement 23??????IBS?????????????,??????????????
  ???????????
• Statement 24??????IBS??(??????????????????????
  ???????????????)
• Statement 25??IBS?????????????(???PPT)

38
??IBS????????????(19-29?)

• Statement 26????????IBS??????(??, ??, ???,
  ??????????)Hong Kong, Japan, and India
  ?????IBS????????????,??55?IBS????????
• Statement 27?????IBS????????????
• Statement 28??????IBS????
• Statement 29????????IBS????,?????-??????( China
  IBS-C?5-HTTLPR allele L/Lgenotype ????Korean
  the serotonin transporter (SERT)???)

39
??IBS?????????(30-37?)

• Statement 30IBS????????????????????(????)
• Satement 31?????????,??????????????
• Statement 32??????????????????????????????????
  ??
• Statement 33??????,????????????????????
• Statement 34??????,????????????????????????????

40
??IBS?????????(30-37?)

• Satement 35????????????5-HT?????????????????IBS??
  ?????,???????????
• Statement 36????????IBS,??????????????IBS???????
  ???????????
• Statement 37???IBS??????????????????

41
(No Transcript)
42
SSRI?????IBS???????,?????????

1. ????????(???IBS??5HT???????????)
2. ???????
3. ????????????

43
5-HT???????????
44
???????IBS?????

• ??IBS??????????????
• ????????????
• ??????????
• ???IBS-C??????????????????

45
FGIDs????????

• ????
• ???????????????,?????????????????
• ???????????????????

• ???????
• ????????GI?????????????
• ???????1)??????????????2)??GI???????????

46
FGIDs?????, ???????????????

• ???????IBS????
• 1 ????????,??????????
• 2 ????????,?????????,??????????????

1
2
47
???????????????

• ????????????(81)
• ???????(????57????34)
• ??????(????43????34)

Zaman A. Irritable bowel syndrome. Clin
Cornerstone. 20024(4)22-33
Roma III
Chen SL M.D. Ph.D.
48
????????????????????????????????
?????????

• IBS?FMRI?????????????
• ??????(ACC)??????????

49
?????????
???
??
??
???
???
???
50
????????

• ??IBS??ACC????
• ??????ACC?, CRD???VMR??
• ??ACC?,??IBS????
• ?????ACC,CRD???VMR??
• ?ACC???CamkII?RB2???,VMR??

CRD?????VMR??????
Chen SL M.D. Ph.D.
51
????????????

• ltIBS??gt??????????????
• TCA
• SSRI

Vagal
5-HT3R???????????,???????????,???????
52
Chen SL M.D. Ph.D.
53
5-HT???????????
Chen SL M.D. Ph.D.
54
FGIDs?,???????????????????????????

• ??????
• ????????,CRD???VMR??
• ????????(??)??(?????????),VMR??
• ?????????,VMR??
• ?????????,?????????????????????

• ????
• IBS???????????????
• ????????????????(?????)
• ??????????????????????????????

Chen SL M.D. Ph.D.
55
???????

• SCI??
• Neurogastroenterol Motil. 2009 21(11)
  1222-e113.
• Am J Physiol Gastrointest Liver Physiol. 2008
  294(6) G1441-9.
• Gastroenterology. 2008 134(2) 535-43.
• Gastroenterology. 2009 136(5) 1732-40.e3.
• Am J Physiol Gastrointest Liver Physiol. 2006
  290(6) G1350-8.
• Neurogastroenterol Motil.201123(1)62-9,e6
• ??????????
• 2011.01-2012.12 ??????5-HT3R /ECB/CB1
• 2012.01-2014.12??????E2/IMMC/5-HT3R..

• ?????
• ?????(??????)

?????? 5-HT3R??
56
??????FGIDs?????

• TCA
• ??IBS-D?????????????,????,??????
• SSRI
• ?????????????,????????????????????????
• ???
• ???,?????,??????????????(??????????????????
  ?????)???FGIDs??????????????????????????????????
  ??
• ???
• ?????????,????????????????????(???SSRI),????
  ?????

57
??????

• ?????
• ?????(????)10mg/T
• ???????(NA?5-HT)???
• ??????
• ???? 0.5mg/T
• ????? D1?D2????D2

58
???????????

• ??? ???? DA ??
• ???? 5HT NE
• ??????,????????????????

59
???????

• ?????????12?,????,?????1??
• ?????2????34??,????1?,?23??????,??12??????
• ?????2?????????(?2???),???????????????

60
??????????

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• ???????
• ??????
• ?????????
• ?????????
• ???????
• ??????????(??????????????????)
• ???????(?)?????????

61
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