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KERD
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한국의 비심인성 흉통의 진단 및 치료의 고유한 특징

Distinct Characteristics of Noncardiac Chest Pain in Korea

김정환
대한내과학회 (The Korean Association Of Internal Medicine)|2011.06|대한내과학회지 (The Korean Journal of Medicine)|제80권 제6호|pp. 649-655

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키워드

비심인성 흉통; 위식도역류질환; 상부위장관 내시경; 프로톤펌프억제제
주제분류내과학

초록

NCCP는 서양뿐만 아니라 동양에서도 비교적 흔한 질환으로서, 삶의 질이 의미있게 저하된다. 그러므로 이에 대해서 올바르게 이해하는 것은 매우 중요하다. NCCP는 우리나라에서도 흔한 질환임에도 불구하고 아직까지 우리의 현실에 맞는 진단 및 치료에 대한 지침이 없이, 단지 서양의 진단 및 치료의 기준이 도입되어 있는 현실로써, 이를 그대로 적용하기 어려운 경우가 있다. 따라서 보고된 문헌들에 따른 객관적 사실에 근거하여 우리나라의 현실에 맞는 NCCP의 진단 및 치료에 대해 다음과 같은 기준을 제시해 본다(Fig. 4). 첫째, NCCP의 원인 중 GERD가 가장 흔하며 따라서 GERD의 전형적인 증상인 heartburn과 acid regurgitation 및 비전형적인 증상에 대해서도 신뢰성이 높은 설문지 및 적극적인 인터뷰를 통해 증상에 대한 분석이 필요하다. 둘째, 위암이나 소화성 궤양 등의 Figure 4. Proposed diagnostic evaluation of patients with NCCP in Korea. 빈도가 높은 우리나라에서는 경고 증상이 없는 경우라 하더라도, 소수의 예외를 제외한 대부분의 환자에서 먼저 EGD를 시행한다. 셋째, EGD에서 이상이 없는 경우 PPI 검사를 시행하되, 치료 용량의 두 배 용량을 투여하며, 그 적정기간은 서양과는 달리 2주로 한다. 넷째, 24시간 식도 pH 검사 및 manometry는 일차적인 진단검사로써보다는 적응증이 되는 경우에 제한적으로 이용한다. 다섯째, NCCP의 치료로써 GERD-related NCCP에는 PPI를 non GERD- related NCCP에서는 식도운동질환이 배제된다면 새로운 정신작용약제인 SNRI를 고려해 볼 수 있다.

Abstract

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and was reported to cause 41% of cases of NCCP in a recent study of Korea. Typical reflux symptoms were reported to be frequent in Korean patients suffering from NCCP. Therefore, a careful history of the symptoms is relatively indicative of GERD diagnosis in Korea. In Korea, contrasting Western countries, patients with NCCP but present no alarm features should undergo endoscopy to exclude gastric cancer or peptic ulcer. In a primary care setting, PPI test is sufficient for the presumptive diagnosis of GERD. Specifically in Korea, the optimal duration of PPI test may be at least 2 weeks because of less frequent or atypical GERD symptoms. In patients diagnosed with GERD-related NCCP, the initial long term therapy (more than 2 months) followed to the maintenance therapy is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement in chest pain control in non GERD-related NCCP. Unfortunately, the majority of traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects may be needed, such as the serotonin-norepinephrine reuptake inhibitors. (Korean J Med 2011;80:649-655)

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