목차 - 삼성서울병원 · 내시경 관찰법 및 내시경 소견의 기술법...

목차

내시경 관찰법 및 내시경 소견의 기술법 …………………………… 7

고위험군에서의 내시경 시행 및 내시경과 관련된 합병증의 관리 … 33

소화관 기능검사의 이해 …………………………………………… 55

2016 gastroenterology Winter School

Session 2. 위식도

내시경 관찰법 및

내시경 소견의 기술법

이 혁


내시경 관찰법 및 내시경 소견의 기술법

삼성서울병원 소화기내과

이 혁

삼성서울병원 2016 GI WINTER SCHOOL

2016 gastroenterology Winter School 7

Pictures to present

– Indicator of quality – At least 8 sections – Any abnormality detected.

Rey JF, et al. Endoscopy 2001

내시경 질 향상에서의 관찰과 기록

Armstrong, et al. CJG 2012

8 2016 gastroenterology Winter School

Cardia

Courtesy of Prof. Jun Haeng Lee (EndoTODAY)

More than 40% of missed cancer

Blind areas


Covered with endoscope

GC side of fundus

이준행. 제48회 대한소화기내시경학회 세미나


Air insufflation is not everything

Courtesy of Prof. Jun Haeng Lee (EndoTODAY)

Covered with gastric rugae

Air insufflation


Avoiding blind spots

Yao K. Ann Gastroenterol 2013

No safe location


훈련을 통해서 마음속으로 코드화 하기

Emura, et al. Rev Gatroenterol Peru. 2013

E2, E3, A6, A7,

U19…….?!

Meticulous examination

Yao K. Ann Gastroenterol 2013


Landmarks in upper endoscopy

Stomach – Cardia – Fundus in retroversion – Lesser curve and antrum overview – Distal extension of examination

3 important anatomical

narrowing

1. Upper esophageal sphincter

- 15-20cm from upper incisor

2. Anterior compression


3 Gastroesophageal junction



Esophagus


Basic principles for endoscopic diagnosis of upper GI lesions

ESGE 2013

Gastro-esophageal junction

이준행. 대한소화기내시경학회지 2009



“Red flag” techniques

Chromoendoscopy & Narrow-band imaging

Show sincerity in examination


How to distinguish? Type I and IIa

Endoscopy 2005

How to measure the lesion?

Endoscopy 2005


Report using Paris Classification

How to distinguish? Type IIc and III

Endoscopy 2005


Validated or consensus classifications

Amstrong D, et al. Gastroenterology 1996

Los Angeles classification for reflux esophagitis

Benign vs. malignant ulcer



Zargar SA, et al. Gastroenterology. 1989

Zargar scale for corrosive injury


Sharma P, et al. Gastroenterology 2006

Prague C & M classification for Barrett esophagus



Forrest classification for peptic ulcer bleeding

Forrest JA, et al. Lancet. 1974

Validated or consensus classifications Esophageal varices: Northern Italian Endoscopy Club and Conn scales

NIEC. N Engl J Med 1988


Validated or consensus classifications Portal hypertensive gastropathy (Baveno classification)

de Franchis R. J Hepatol. 1996


Sarin SK, Kumar A. Am J Gastroenterol. 1989

Gastric varices (Sarin and Kumar scale)


Esophageal screening is much more important for patients with HNSCC

Prevalence of Second Primary ESCC Among Patients With HNSCC

JAMA OTOLARYNGOL HEAD NECK SURG 2013

Field cancerization

Pharynx or larynx is not other doctor’s business

40-60 cases in 1000 examinations


How to report localized lesion

Cohen J, et al. Am J Gastroenterol 2006

Upper endoscopic reporting

• Normal findings

– Landmarks/extent of examination

– Quality of cleansing

– Quality of imaging/inspection

• Localized findings

– Features and location (and therapy)

• Diffuse findings

– Features and extent

ESGE 2013


Photo-documentation Close-range and distant view

Retroflexion and forward-view

Photo-documentation

X

X

X

O

O X


Photo-documentation • Focal lesion

– Overview of lesion and (if possible) nearby landmark – Overview with open biopsy forceps – Close-up showing surface/border/other defining

details – Color filter images as relevant – Post therapy result

• Diffuse lesion – Overview image with landmarks if possible/relevant – Detail of most affected area – Detail of typical lesions – Detail of demarcation line (if relevant)

Photo-documentation

6-month follow-up endoscopy

여러 가지 수단을 이용하여 병소를 강조


ESD Surgery

Chromoendoscopy

Endoscopic biopsy

Ulcer base, margin, edge를 포함하여 4-6회 생검


Take Home Message

• The endoscopic diagnosis of early gastric cancer is divided into three main steps: detection, characterization and reporting

• Use standardized language in endoscopic reports

- Standards for reporting endoscopy is a prerequisite for effective communication

• If a lesion is detected

- Describe all you would like others to tell you

• If applicable, use validated/consensus classifications

Training in upper endoscopy


감사합니다

Training, training, training! ……to the grave….. Keep your original intention!


고위험군에서의 내시경 시행 및

내시경과 관련된 합병증의 관리

박 정 호


• 고위험군에서의 내시경 검사

– 출혈의 위험성이 높은 환자

– 심폐질환 합병증의 위험성이 높은 환자

• 내시경과 관련된 합병증의 관리

– 출혈

– 천공

– 기타

목차

고위험군에서의 내시경 시행 및 내시경과 관련

된 합병증의 관리

성균관대학교 강북삼성병원 소화기내과 박정호


Antithrombotic Drugs

고위험군에서의 내시경 검사– 출혈 위험성이 높은 환자


Management of Antithrombotic Agents

Procedure Risk for Bleeding


Best Practice Recommendation for the

Management of Dual Antiplatelet Therapy

Bridge Therapy for Wafarin


고위험군에서의 내시경 검사– 심폐질환 합병증의 위험성이 높은 환자

• Systemic conditions

- Sepsis

- Shock

- Dehydration

• Cardiovascular conditions

- Arrhythmias

- Cardiac pacemaker

- Coronary artery disease

- History of myocardial ischemia

- Congestive heart failure

• Psychiatric conditions

- Uncooperative attitude

- Mental disorders

• Pulmonary dysfunction

- Chronic obstructive airways disease

- Interstitial lung disease

• Neurological conditions

- Seizure disorders

- History of stroke

• Gastrointestinal/hepatic conditions

- Active gastrointestinal bleeding

- Liver dysfunction

- Cirrhosis

• Genitourinary conditions

- Renal dysfunction

- Urinary retention

• Social conditions

- Elderly or young age

- Chronic use of prescribed sedatives

- Substance abuse

• History of drug allergy

• Pregnancy obesity

• History of radiation therapy

• Warfarin be restarted within 24 hours of the procedure in

patients with valvular heart disease and a low-risk for

thromboembolism.

• In patients at high risk for thromboembolism, UFH or

LMWH should be restarted as soon as “bleeding stability

allows”

Reinitiation of Antithrombotic Agents


Effect of Endoscopy on CVS (I)

Automomic nervous system in CVS

Endoscopic procedure

parasympathetic↓ sympathetic↑

tachycardia, ischemia, arrythmia

Parasympathetic

bradicardiaslowing AV conduction

decrease atrial contractility

Sympathetic

HR ↑excitability ↑

CBF ↑

Safety of Current GI Endoscopy

• A retrospective cohort , 2000-2003, UK, 11051 patients

One patient death was caused directly by the EGD (1/9000)

McLernon DJ, et al. Endoscopy. 2007;39:692-700.

Maclernon et al. Endoscopy. 2007 Aug;39(8):692-700


Safety and Efficacy of EGD after MI

Cappell MS, et al. Am J Med. 1999;106:29-35.Cena M et al. Cardiol J. 2012;19(5):447-52.

The complication rate was 1.5% (3 patients) in the control group and 7.5%

(15 patients) in the MI group :11 transient hypotension and 2 transient

hypoxia, 1 fatal ventricular tachycardia & 1 near respiratory arrest

A higher complication rate of 9% (9 patients) in the MI group vs. 1% (1

patient) in the control group: 7 transient hypotension, 1 transient bradycardia

& One major complication, death not believed to be related to the procedure

Effect of Endoscopy on CVS (II)

• Procedure related mechanical stress

- Esophageal irritation

- Gastric distension Sympathetic tone ↑

• Anxiety and neuroendocrine stress response

• Sedation and anagesia

- Opioid, midazolam, propofol

Hypoventilation, Parasympathetic tone ↑


Respiratory Complications in Endoscopy

Cappell MS, et al. Am J Med. 1999;106:29-35.J Gastrointestin Liver Dis, September 2014;23(3): 255-259

Effect of Endoscopy on Lung Function

• Arterial O2 saturation ↓- Pretreatment

- Presence of the scope in the oropharynx

- Aspiration of gastric content

• Actually safe if pulmonary diseases are

controlled- O2 supply and saturation monitoring

- Less sedation


Monitoring

• Preprocedural evaluation

- History, P/E, medication, drug allergies

- Cardiopulmonary status

- HR, BP, RR, SpO2

• Pulse oxymeter

• Continuous electrocardiogram

• Transcutaneous CO2 and end tidal CO2 monitoring

• Bispectral monitering

Major Complications related to Endoscopy

• Cardiopulmonary complication

• Complications related to sedation

• Bleeding

• Perforation

• Infectious complication

• Oral cavity injury


수면마취??

Routine Use of Supplemental Oxygen

• Elderly Patients

- Relatively decreased baseline arterial oxygen saturation

- Blunted cardiovascular response to hypercarbia and hypoxia

- Exaggerated response to opioid-induced respiratory

depression

• Abnormal baseline oxygen saturation

• Severe cardiovascular disease

• Desaturation during the examination


Bleeding

• 약 0.03%

• Mallory-Weiss 증후군 또는 조직검사에 의한 출혈

• 위험 인자

– 항응고제인 wafarin 등을 복용하고 있는 경우

– 간경화 환자, 혈액 투석 중인 환자

– 혈관 이상, 출혈의 기왕력이나 가족력이 있는 경우

진정(sedation)과 마취(anesthesia)의 레벨

경미한 진정Minimalsedation

(Anxiolysis)

중등도 진정Moderate sedation

(Conscious sedation)

깊은 진정Deep sedation

전신마취General

anesthesia

반응Responsiveness

말소리에 정상반응Normal response

to verbal stimulation

말소리나 가벼운자극에 반응

Purposeful response to verbal or tactile stimulation

반복적 혹은아픈 자극에 반응

Purposeful response after repeated or painful

stimulation

아픈 자극에도깨어나지 않음

Unarousable even with painful stimulus

기도Airway

영향을 받지 않음Unaffected

기도 확보 필요치 않음No intervention required

기도 확보 필요할 수 있음Intervention may be

required

기도 확보 필요함Intervention often

required

자발성 호흡Spontaneousventilation


적절히 유지됨adequate

부적절할 수 있음May be inadequate

부적절함Frequently inadequate

심혈관 기능Cardiovascular

function


대개 유지됨Usually maintained

대개 유지됨Usually maintained

영향을 받음May be required

.

ㅍ

ㅍ

ㅍ

ㅍ


Bleeding by Biopsy

Mallory-Weiss syndrome


Bleeding after CPP during Aspirin Therapy

Hematemesis 4 Hours after EMR


Esophageal Perforation - Therapeutic

• Most frequently after esophageal dilatation

• Incidence: low (0.09 ~ 2.2%) for simple ring, stricture

• Mortality rate: 0 ~ 20%

Paspatis GA et al. Endoscopy. 2014; 46(8):693-711

Perforation – Diagnostic Endoscopy

• Incidence: 0.05 ~ 0.1%

• Mortality rate: 0.008%

• Diagnostic blind insertion

• Pharynx or upper esophagus

British Journal of Surgery 1995: 82(4) 530-533


Retroperitoneal perforation during Diagnostic Colonoscopy

Colonic Perforation

• Incidence: 0.03 – 0.8% for diagnostic & up to 5% for

therapeutic endoscopy

• A risk of 1.1 % for colorectal perforation when polyps

were larger than 10mm in the right colon or 20mm in

left colon or when there were multiple polyps

• Post ESD: 20.4% → 1.9 ~ 4.7% (Japan)



Risk Factors for Perforation

• 과도한 공기주입, 무리한 조직검사, 환자의 비협조

• 비만한 환자, 고령 환자, 기관내 삽관 상태의 환자

• 식도게실 (Zenker’s diverticula), 위저부 추벽형성술 (fundoplication)

• 척추후굴증 (kyphosis), 경추의 골관절염돌기 (osteoarthritic spurs)

• 문합부위, 협착부위 그리고 염증, 허혈, 종양 또는 부식제 등에 의하

여 점막벽이 약해져 있는 부위

Management of Colonic Perforation



상부 내시경 관련 외인성 감염

Clin Microbiol Rev 26(2): 231-254

내시경적 감염 – 내인성 감염

• 낭성종양에서 EUS-FNA 후의 감염

률은 14% - fluoroquinolone 시술전,

후 3일간 예방적 투여

• 경피적 위루 삽입(PEG)전에 항생제

를 투여하면 피부 누공 주위의 감염

을 줄인다 – PEG 시술 30-60분 전

에 cefazolin

• 간경변증에서 위장관출혈이 있을때

예방적 항생제를 사용하면 감염률

과 사망률을 줄인다 – ceftriaxone

정맥 투여 또는 경구용 norfloxacin


Superbug Transmission via Endoscopy

• NDM producing E. coli

• 2013년 3월 부터 7월까지 미국에서 9명

의 환자가 보고되었는데, 이들 중 8명이

northeastern Illinois에 위치해 있는 병원

에서 발생하였다.

• 높은 수준의 소독 후에도, NDM-

producing E. coli 와 K. pneumoniae 가

ERCP 내시경의 terminal section (the

elevator channel) 에서 발견되었다.

Morbidity and Mortality Weekly Report of CDC, 2014.1.3

하부 내시경 관련 외인성 감염

Clin Microbiol Rev 26(2): 231-254


흡인 (Aspiration)

• Common status

- Advanced age, massive upper GI bleeding (1-4%)

- Altered mental status, absent gag reflex

- Unstable cardiopulmonary status

• Prevention

- Avoidance of topical anesthetics

- Prevention of oversedation

- Maintaining the head of the bed at a 30-40O angle

- Minimizing air insufflation

Other Complications

• 복부 팽만

• 이하선 또는 악하선의 종대

• 측두하악관절(temporomandibular joint)의 탈골

• 하부식도나 식도 열공 헤르니아에 내시경이 감돈

(impaction)되는 경우

• 급성 위점막 병변

• 결막하 출혈

• 폐암환자에서의 상대정맥 폐쇄


소화관 기능검사의 이해

민 양 원


Testing of esophageal function

Upper endoscopy Barium radiography Esophageal manometry (+impedance) Ambulatory pH monitoring Advanced techniques

• Three-Dimensional high-resolution manometry• Impedance planimetry

Neurogastroenterol Motil 2013;25:99-133

식도 기능 검사의 이해

Yang Won Min, MD, PhD

Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

2016 삼성서울병원소화기내과윈터스쿨


Esophagography

Upper endoscopy


Esophageal manometry

1. Define esophageal motor function2. Delineate a treatment plan based on motor abnormalites

Gastroenterology 2005;128:207-224

Timed barium esophagogram (TBE)

J Neurogastroenterol Motil 2013;19:251-256


Catheters

Conventional manometry

Neurogastroenterol Motil 2003;15:591


A normal swallow in a Clouse plot

High resolution esophageal pressure topography

Neurogastroenterol Motil 2012;24 Suppl 1:2-4

High resolution manometry (HRM) Pressure topography plotting (Clouse plots)

Clouse plot

Peristalsis

Am

plit

ude


Esophageal pressure topography (Clouse plot) - key landmarks used in the Chicago Classification

Clinical HRM Study

Series of ten test swallows of 5 ml water each in a supine posture


Optimally distinguish normal from impaired EGJ relaxation Measurement

• Accurately localizing the margins of the EGJ• Demarcating the time window following deglutitive upper

sphincter relaxation within which to anticipate EGJ relaxation to occur

• Applying an e-sleeve measurement within that 10 s time box and then finding the 4 s during which the e-sleeve value was least (These 4 s are not necessarily continuous but can be scattered over the 10 s time window.)

The upper limit of normal for the IRP using the Given Imaging (Sierra) HRM assembly is 15 mmHg.

EPT-Specific Metrics II- the Integrated Relaxation Pressure (IRP) -

Pressure Topography MetricsMetric Description

Integrated relaxation pressure (mmHg)

Mean EGJ pressure measured with an electronic equivalent of a sleeve sensor for four contiguous or non-contiguous seconds of relaxation in the ten-second window following deglutitive UES relaxation

Distal contractile integral (mmHg-s-cm)

Amplitude x duration x length (mmHg-s-cm) of the distal esophageal contraction >20 mmHg from proximal (P) to distal (D) pressure troughs

Contractile deceleration point [(CDP) (time, position)]

The inflection point along the 30 mmHg isobaric contour where propagation velocity slows demarcating the tubular esophagus from the phrenic ampulla

Distal latency (s) Interval between UES relaxation and the CDP

All pressures referenced to atmospheric pressure except the IRP, which is referenced to gastric pressure


Achalasia subtype

Type I Type II Type III

Calculate IRP


PerOral Endoscopic Myotomy (POEM)

S/P POEM for Achalasia type III

TBE at 5 min TBE at 1 min


Impedance planimetry- concept

Balloon is filled with conductive fluid

Impedance rings are evenly spaced throughout (17 rings in 8 cm)

Constant AC current Cross sectional diameter at

midpoint of each ring pair (total 16) can be measured based on impedance

Impedance planimetry- measures cross sectional area of the esophagus

in response to its distension

EndoFLIPTM

EndolumenalFunctional LumenImaging Probe


Summarize the vigor of the distal esophageal contraction Measurement

• Segment spanning from the proximal to distal pressure trough (or to the EGJ)

• Conceptualized as the volume of the pressure from P to D • The first 20 mmHg is ignored.

The upper limit of normal defined by the 95th percentile in a normal population is 5000 mmHg-s-cm, whereas when defined as the value never encountered in a normal population it is 8000 mmHg-s-cm.

EPT-Specific Metrics III- the Distal Contractile Integral (DCI) -

Impedance planimetry- information obtained

Diameter between each ring pair

Cross-sectional area of balloon

Intraballoon pressure Distensibility can be

measured by measuring these data at different balloon volume


Hypertensive peristalsis

Calculate DCI


Jackhammer esophagus

DCI: 11156 mmHg-s-cm

Dysphagia and chest discomfort- M/58


All pertain to the rate of contractile propagation in the distal esophagus.

• CDP, the transition from peristaltic propagation to the late phase of esophageal emptying

• CFV, measured for the segment preceding the CDP to be reflective of the peristaltic mechanism proper

• DL, measured from the time of upper sphincter relaxation to the CDP, again making it reflective of peristaltic timing and the period of deglutitive inhibition

EPT-Specific Metrics IVContractile Deceleration Point (CDP), Contractile Front Velocity (CFV)

and Distal Latency (DL)

S/P Diverculectomy with myotomy

Max DCI: 11156 7169 mmHg-s-cm


Statement 1: GERD is defined as a disorder in which gastric contents reflux recurrently into the esophagus, causing troublesome symptoms and/or complications.

Statement 2: Typical symptoms of reflux are heartburn (retrosternal burning sensation) and acid regurgitation, which are commonly experienced by Asian patients.

Fock KM et al, J Gastroenterol Hepatol 2008;23:8-22

Vakil N et al, Am J Gastroenterol 2006;101:1900-1920


PPI efficacy for potential manifestations of GERDEstimates based on available RCT data

Kahrilas PJ and Boeckxstaens G. Gut 2012;61:1501-1509

Persistent reflux symptoms on PPI therapy 19 primary care and community studies

El-Serag H et al, Aliment Pharmacol Ther 2010;32:720-737


No 100% specific symptom of GERD

Persistent GERD symptoms may be related to Esophagitis of another etiology Severe dysmotility Rumination Functional heartburn Functional chest pain Insufficient acid suppression Weakly acidic reflux

Etiology of PPI failure

Compliance and adherence Residual acid, weakly acidic, and weakly

alkaline reflux Functional heartburn Psychological comorbidity, delayed gastric

emptying, eosinophilic esophagitis, and concomitant functional bowel disorder

Nocturnal acid breakthrough

Hershcovici T and Fass R. Dis Esophagus 2013;26:27-36


Esophageal pH monitoring

Indications

1. Patients with typical GERD symptoms who fail 4 weeks of PPI therapy

2. Patients with atypical GERD symptoms who fail 6 to 8 weeks of PPI therapy

3. Patients being considered for endoscopic or surgical reflux therapy

4. Patients who have undergone endoscopic or surgical reflux therapy who continue to have GERD symptoms

Distinct phenotypes of incomplete PPI response to consider

GERD assessment tools

Esophageal pH monitoring Combined pH-impedance monitoring Manometry

Key questions:1. Do these patients have GERD?2. If they have GERD, what is the explanation for the lack

of response?


pH parameters

1. Percentage of total time pH < 42. Percentage of supine time pH < 43. Percentage of upright time pH < 44. Total number of reflux episodes5. Number of reflux episodes > 5 minutes6. Duration of the longest reflux episode

pH < 4

• Pepsinogen is converted to its active form pepsin.• Heartburn often occur. • Normal subjects show pH ≥ 4 about 98.5% of the

time.

Esophageal pH monitoring

pH 전극(하부식도 괄약근상단의 5 cm 상방)

5 cm

15 cm

상부식도 괄약근

하부식도 괄약근


Symptom indices

If a patient’s symptom is actually related to acid reflux episodes during pH monitoring.

1. Symptom index (SI)2. Symptom sensitivity index (SSI)3. Symptom association probability (SAP)

Sensitivity Specificity

SI 34.8% 80%

SSI 73.9% 73.3%

SAP 65.2% 73.3%

Normal values for 24h pH monitoring

Johnson/DeMeester1 Richter et al2

Percentage of total time pH < 4 < 4.2 < 5.78

Percentage of supine time pH < 4 < 1.2 < 3.45

Percentage of upright time pH < 4 < 6.3 < 8.15

Total number of reflux episodes < 50 < 46

Number of reflux episodes > 5 minutes ≤ 3 < 4

Duration of the longest reflux episode (min) < 9.2 < 18.45

1Johnson and Demeester. Am J Gastroenterol 1974;62:325-332 2Richter et al. Dig Dis Sci 1992;37:849-856


Symptom association probability

• Probability (association between reflux and symptoms) calculated using the Fisher’s exact test

• SAP = (1-probability) x 100• Positive ≥ 95%

Positive SymptomPositive Reflux

Positive SymptomNegative Reflux

Negative SymptomPositive Reflux

Negative SymptomNegative Reflux

Symptom-reflux association analysis


Principles of intraluminal impedancometry

Nguyen et al. Am J Gastroenterol. 1999;94:306-317

Combined impedance and pH

Acid vs nonacid reflux Persistent Sx on PPI

ComforTEC® Impedance-pH


Bolus movement detected by MII

Antegrade bolus movement Retrograde bolus movement

Conchillo and Smout. Aliment Pharmacol Ther. 2008;29:3-14

Bolus movement waveform

baseline

air

contraction

50% baseline

Tutuian et al. Clin Gastroenterol Hepatol. 2003;1:174-182


Recommended definitions for reflux

1. ‘‘Acid reflux’’ - refluxed gastric juice with a pH less than 4 which can either reduce the pH of the oesophagus to below 4 or occur when oesophagealpH is already below 4

2. ‘‘Superimposed acid reflux’’ - an acidic reflux episode that occurs before oesophageal pH has recovered to above 4

3. ‘‘Weakly acidic reflux’’ - reflux events that result in an oesophageal pH between 4 and 7

4. ‘‘Weakly alkaline reflux’’ - reflux episodes during which nadir oesophageal pH does not drop below 7

Sifrim et al. Gut 2004;53:1024-1031

Recording of Imp-pH monitoring


Refractory GERD management

Kahrilas PJ, et al. Best Pract Res Clin Gastroenterol 2013;27:401-414

Subcategories of reflux

Sifrim et al. Gut 2004;53:1024-1031


경과

2013.11 Pneumatic balloon dilatation 2013.12 잘 먹는다 (Eckardt score 9 3)

Manometry Esophagography

Final Diagnosis : Achalasia type II

Refractory GERD for 1 year, M/29


F/59

• 목이 따갑다. 신물이 올라오고 가슴이 쓰리기도...

• 역류성식도염이라 듣고 두 달 약 복용했는데 효과 없다.

• 1년 전 외부 내시경에서 이상 없었다.

Refractory GERD

Kahrilas PJ, et al. Best Pract Res Clin Gastroenterol 2013;27:401-414


24Hr Imp-pH monitoring, off PPI

Pathologic acid reflux and increased esophageal bolus exposure

EGD


Insufficient acid suppression

• Esomeprazole 40mg 1T 1 회AM 60일

약 먹고 좋아짐. 역류가 덜하다.

pH 4

pain

Acidic reflux


목차 - 삼성서울병원 · 내시경 관찰법 및 내시경 소견의 기술법...

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