위장관 질환(소화성 궤양)

위장관 질환(소화성 궤양)

원본: 평범한 칼잡이의 평범한 블로그

일선에서 환자를 진료하면서 참 놀라운 것 중의 하나가 의료인들에게는 아무런 거리낌 없이 사용되고 있는 우리말 의학용어들이 일반인들에게는 무척이나 낯설고 어려운 말들이라는 점입니다. 의학 자체가 어렵기 때문만은 아니고, 우리나라에 들어온 소위 서양의학의 용어들이 과거 일제 강점기를 거치며 일본의 번역체계를 그대로 따랐기 때문입니다. 그래서 그러한 의학용어들이
수 년씩 공부하고 자주 사용하는 사람들에게는 익숙하겠지만 우리가 일상에서 사용하는 말들과는 너무 동떨어져서, 의사-환자간의 소통에 어려움을 주고 있는것입니다.

의사들은 이를 쉬운말로 풀어서 설명을 하려하니 제대로 된 설명을 하기가 힘들어지고, 또 환자들은 의사로부터 무슨 이야기를 듣긴 들은것 같은데 설명이 만족스럽지 못하게 됩니다. 그래서 요 근래에는 어려운 의학용어를 우리말로 쉽게 풀어서 사용하고자 하는 다양한 시도가 이루어지고 있기는 합니다만,  워낙 뿌리 깊게 습관들여진 의학용어들인지라 그리 쉽지만은 않은 현실입니다.

우리말 의학용어의 문제점에 대한 장황한 서론을 늘어놓은 데에는 지금부터 말하고자 하는
'소화성 궤양(peptic ulcer)
'에 대한 일반인들의 오해와 치료의 어려움 때문입니다.

상부 위장관 질환으로 우리가 흔히 듣는 질환으로는 '
위염(gastritis)' 외에 '위궤양(gastric ulcer)'이나 '십이지장궤양(duodenal ulcer)'이 있습니다. 이 글을 준비하며 주변의 비의료인과 환자들을 대상으로 조사해보니, 너무나도 다른 질환들임에도 서로를 혼동하고 있는 경우가 의외로 많았습니다. 더군다나 여기에 '소화성 궤양
'이라는 용어를 추가하니 그 혼동은 더욱 가중되었습니다. 결국 본인의 질병에 대한 정확한 지식이 없이 치료에 임하다 보니 제대로 된 치료가 되기 힘듭니다. 그래서 가급적 모든 질환을 우리말 의학용어들을 중심으로 설명을 해볼까 합니다.

위염에 대한 설명은 이미 이전 글에서 설명이 되어있으므로 소화성 궤양에 대한 설명을 해보도록 하겠습니다.

우선 '
궤양
'이 뭔지 알아보겠습니다. 백과사전에 나온 뜻입니다.

관상장기(管狀臟器)의 점막, 각막, 피부의 일부에 물질적 조직의 결손이 생긴 상태.
즉 구강, 식도, 위, 장, 방광, 담낭 등의 벽내층을 이루는 점막층의 괴사로 점막의 하층에서 벽의 외층인 근층(筋層)에까지 결손이 미친 상태를 말한다.
괴사의 원인으로는 염증, 순환장애, 한랭, 열, 방사선, 화학물질, 신경성 인자 등을 들 수 있다.
궤양의 시초는 점막층만의 천공(穿孔)에 지나지 않으나, 내강(內腔)에 있는 여러 가지 물질조직 및 세균의 영향을 받아 결손은 점점 커지고 깊어간다. 점막층에 한정된 작은 결손은 미란(?爛)이라고 한다.

도대체 무슨 말을 하는건지... ㅠㅠ 뭔가 좀 알아보려고 했다가 오히려 더 머리만 아플 지경입니다. 의학을 전공한 제 자신도 신경을 집중해서 읽어야만 이해할 수 있는 말입니다. 좀 쉬운말로 써놓으면 격이 떨어진다고 생각하기 때문일까요...? 우리나라 백과사전의 문제점이 아닌가 싶습니다. 그래서 아주 쉬운 말로 설명해 보겠습니다.

'궤양'이란 우리 몸의 일부가 움푹 파인 상태를 말한다. 원인은 여러가지가 있으나, 외상에 의한 일차적 상처는 제외된다.

쉽지 않습니까...? '외상에 의한 일차적 상처는 제외된다.'는 말이 혹시 어려운가요? 그럼 다시 더 쉽게 바꾸겠습니다.

'궤양'이란 우리 몸의 일부가 움푹 파인 상태를 말한다. 원인은 여러가지가 있으나, 다쳐서 생긴 상처는 제외된다.

정말 쉽지 않습니까...? 물론 움푹 파인것이 정상적으로 파인것이라면 병이 아니니까 당연히 제외되겠지요. 그렇다면 위궤양이란 '위의 일부가 움푹 파인 상태'를 말한다는 이야기입니다.
위의 점막층(mucosa)만 파일 수도 있고, 점막하층(submucosa)을 넘어서 근육층 (muscularis)까지 파일 수도 있습니다.
(위벽의 구조에 대해서는 이미 (1)위염편에서 다루었습니다.) 그렇다면 십이지장궤양이란...?
그렇습니다. '십이지장의 일부가 움푹 파인 상태'를 말합니다. 앞서 위염은 '위의 점막이 벌겋게 부어오르면서 아픈 상태'를 말한다고 했습니다. 이제는 확실히 위염위궤양의 차이가 무엇인지 구분할 수 있으리라 생각됩니다.


 
위염의 내시경 소견

 
십이지장궤양(좌)과 위궤양(우)의 내시경 소견


그렇다면 소화성 궤양이란 무엇일까요?
'소화'란 뜻이 불끄는 '소화(消火)'가 아니라는것 쯤은 다 알고 있을 것입니다. ^^;  소화성 궤양이란 '소화가 되어서 발생한 궤양'이라는 뜻입니다. 다시 말해서 위에서 분비된 소화액이 음식물을 소화하는 대신, 위를 소화시켜서 궤양이 발생하면 위궤양이 되는것이고, 십이지장을 소화시켜서 궤양이 발생시키면 십이지장궤양이 되는것입니다.

정상적인 위나 십이지장은 소화액으로 부터 안전하게 보호를 받고 있습니다. 그런데 뭔가 문제가 생겨서 위나 십이지장 자체가 소화가 되는것이고 소화가 진행된 부분이 움푹 파이면서 궤양이 생기는 것입니다.

여기서 잠깐 음식물이 소화되는 과정을 간략하게 알아보겠습니다.


 


음식물이 입안에 들어오면(섭취, indigestion) 우선 우리는 그것을 씹어서(저작, mastication) 잘게 부숩니다. 잘게 부수어진 음식물은 타액선(침샘, salivary gland)에서 분비되는 타액(침, saliva)과 섞이고, 타액안에 포함되어있는 아밀라아제(amylase)라는 소화효소(digestive enzyme)에 의해 음식물 중의 탄수화물(특히 녹말)이 일차적으로 분해가 됩니다.

이어 음식물을 삼키게되면(연하, swalloeing) 식도를 타고 위로 들어가서 본격적인 소화작용이 이루어집니다. 위 점막층에 있는 주세포(chief cell)에서 펩시노겐(pepsinogen)이라는 물질이 분비되고, 펩시노겐은 위 내부의 강한 산성환경에서 펩신(pepsin)이라는 소화효소로 활성화됩니다. 펩신은 위산에 녹아있는 음식물 중에서 단백질을 분해하기 시작합니다.

위는 연동운동(연동, peristalsis)을 하여 음식물과 소화효소가 잘 섞일 수 있도록 합니다. 위에서 거의 죽처럼 분해된 음식물들은 십이지장을 거쳐 소장(작은창자, small intestine)으로 내려가게 됩니다. 한편 담낭(쓸개, gall bladder)에서는 담즙(쓸개즙, bile)이 분비되고 췌장(이자, pancrease)에서는 아밀라아제와 리파아제(lipase)가 분비되어 십이지장으로 들어갑니다. 담즙은 지방을 부드럽게 만들어 리파아제가 지방을 분해할 수 있도록 촉진시킵니다. 소장에서는 수 많은 소화효소가 분비되어 이차적으로 분해된 음식물을 흡수하기 좋도록 더 잘게 분해하여
영양소의 상태로 물과 함께 흡수하게 됩니다.

(소화, digestion) (흡수, absorption) 흡수되지 않은 찌꺼기들은 대장(큰창자, colon)에서 약간의 물이 더 흡수된 후 항문(anus)을 통해 배출(배변, defication)됩니다.

이러한 모든 소화과정에서 가장 문제가 되는 부분이 바로 본격적인 소화가 시작되는 위 속입니다. 위 내부는 pH 1~3의 강한 산성환경을 유지하고 있는데 이는 위 점막층의 벽세포(parietal)에서 분비되는 위산(gastric acid) 때문입니다. 위산의 주 성분은 그 무시무시한 염산(HCl)입니다.
위 내부는 위산으로으로부터 보호하기 위해 점액성 겔 층(mucous gel layer)이라는 특수한 층으로 덮혀있습니다.


 


점액성 겔 층의 형성과정 모식도
또한 점막층이 손상될 경우에는 재빨리 새로운 세포로 대치되기 때문에 정상적인 점막층의 상태를 유지할 수 있는것입니다. 그런데 어떤 이유 때문에 이러한 방어기전이 제대로 작동하지 않으면 위산에 의해 점막층이 파괴되고 소화효소인 펩신에 의해 세포내의 단백질이 분해되어 버립니다.
한번 파괴된 부분이 회복되지 못하면 점점 그 범위가 넓어지고 깊이가 깊어지면서 본격적인 위궤양 상태로 빠져들게 됩니다. 처음에 점막층만 살짝 손상된 상태를 미란(erosion)이라고 하며,
점점 깊어짐에 따라 근육층이 노출되고 마침내는 천공이 발생하게 되기도 합니다.


 
위궤양의 진행 과정


소화성 궤양을 발생시키는데 있어서 위산의 분비와 관련된 여러가지 요인들을 공격인자로, 점액성 겔 층과 같이 위 점막을 보호하는데 관여하는 요인들은 방어인자로 구분하기도 합니다. 공격인자가 너무 강해지거나 방어인자가 너무 약해지면 궤양이 발생하게 되는것입니다.

이러한 인자들의 변화를 가져오는 여러가지 원인중에서 가장 깊이 관여하는 요인은 역시 공격인자인 위산 자체입니다. 그러나 사실 위산과다(hypersecretion of gastric acid)는 위궤양보다는 십이지장궤양을 일으키는 요인으로 주로 작용합니다.
정상적으로 위액(gastric juice)이 십이지장으로 넘어갔을 때 위산은 알칼리성인 담즙(쓸개즙, bile)의 영향으로 중화됩니다. 그러나, 위산의 양이 너무 많은 경우에는 충분히 중화되지 못하여
점액성 겔 층이 없는 십이지장의 점막은 위산의 공격을 받아 궤양이 발생하게 되는것입니다.
그렇다고 위궤양이 전혀 위산과다와 연관이 없는것은 아닙니다. 몇몇 형(type)의 위궤양 환자에게서 십이지장궤양에서와 같은 위산과다가 관찰되기도 하는데, 음식을 섭취한 후의 최대 분비량(maximal secretion)이 증가한 경우 보다는 평상시에 조금씩 분비되는 기초 분비량(basal secretion)이 증가되어 있는 경우가 더 많습니다.
즉, 식사와 상관없이 평소에 위산의 분비가 많은 사람에게서 위산과다로 인한 소화성 궤양이 더 잘 발생한다는 의미가 됩니다.

위궤양의 경우에는 방어인자가 약해져서 발생하는 경우가 더 많습니다.
십이지장궤양이 젊은 층에 많은데 비해 위궤양은 주로 중년층 이후에 많은 이유도 나이가 들게되면 위의 방어인자가 약해지기 때문입니다. 또한 스트레스나 술, 담배 및 자극성 있는 음식 등도 위의 방어인자를 약하게 만드는 요인이 되며, 비스테로이드 소염진통제(NSAIDs)도 한 요인이 됩니다. (NSAIDs, Non-Steroidal Anti-Inflammatory Drugs)

근래에 가장 주목받는 요인으로 헬리코박터 파이로리(Helicobacter Pylori)가 있는데, 위궤양 환자 약 80%와 십이지장궤양 환자 약 90%에서 이 균에 감염되어 있는것으로 알려져 있습니다.
헬리코박터 파이로리의 감염은 위산의 분비를 증가시키고 위와 십이지장벽의 방어기전을 약하게 합니다. 공격인자와 방어인자 둘 다에 문제를 일으키는 셈입니다.


 
헬리코박터 파이로리의 모습


헬리코박터 파이로리는 소화성 궤양 뿐만 아니라 앞글에서 다루었던 위염의 발생에도 깊은 연관이 있으며, 위암(gastric cancer)의 발생에도 관여하고 있습니다. 위암을 '악성 궤양(malignant ulcer)'이라고도 하는데, 이는 어느정도 진행된 위암에서 혈액공급이 잘 되지않은 중앙부분에 괴사가 일어나 궤양이 발생하기 때문입니다.
악성 궤양에 반하는 개념으로 소화성 궤양을 양성 궤양(benign ulcer)
이라고 합니다. 내시경 검사에서 위궤양이 발견되었을 때에는 양성 궤양인지 악성 궤양인지 꼭 감별을 해야합니다. 물론 아래 사진에서와 같이 내시경상 육안으로도 어느정도 구분은 됩니다만, 확진을 위해서는 궤양의 주변 벽을 조직생검(biopsy)을 하여 현미경적으로 관찰을 해야 합니다. (위암에 대한 자세한 이야기는 따로 다루도록 하겠습니다.)



  
위의 소화성 궤양(좌)과 악성 궤양(우)의 내시경 소견
소화성 궤양은 모양이 비교적 동그랗고 주변이 깨끗하게 보이는 반면 악성 궤양은 모양이 불규칙하고 주변도 지저분하게 보인다.

지금까지 알아봤듯이 위궤양십이지장궤양은 둘 다 소화성 궤양이긴 합니다만, 그 발생기전에 약간의 차이가 있습니다. 때문에 그 증상에도 약간의 차이가 있을 수 있는데, 대표적인것인 상복부 통증에 대한 것입니다. 위궤양의 경우에는 대부분 음식물을 먹을 때 통증이 심해지는 반면, 십이지장궤양의 경우에는 공복시에 통증이 심하고 음식물을 먹으면 통증이 다소 가라앉습니다.

위궤양의 경우에는 궤양이 위에 있기 때문에, 섭취된 음식물에 직접적인 자극을 받을 뿐만 아니라, 소화를 위해서 분비되는 위액에 자극을 받아서 통증이 심해지는 것이며, 십이지장궤양의 경우에는 공복시에 열려있는 유문괄약부(pyloric sphicter)를 통해서 평상시에 분비되는 위산이 흘러내려가서 궤양 부위를 자극하기 때문에 통증이 심했다가, 음식물을 먹게되면 위의 소화작용을 위해 유문괄약부가 닫히면서 위에서 내려오는 자극이 없어지기 때문에 통증이 가라앉는 것입니다. (100% 정확한 설명은 아닙니다만 이정도만 이해해도 훌륭한겁니다... ^^)
그래서 새벽녘에 속이 쓰려서(혹은 아파서) 잠을 자주 깬다면 십이지장궤양일 확률이 아주 높은것입니다.

물론 소화성 궤양 환자들의 증상은 아주 다양합니다. 오심(nausea), 구토(vomiting), 소화불량(dyspepsia) 등 상부 위장관에 문제가 있을 때 나타나는 증상은 다 나타날 수 있습니다. 심지어는 궤양이 심한데도 통증이 없을 수도 있습니다. 그러한 무통성 궤양은 비스테로이드 소염진통제를 습관적으로 복용하는 사람들에게서 자주 볼 수 있는데, 그런 경우에는 궤양 자체보다 궤양으로 인한 합병증이 더 무섭습니다.

가장 심각한 합병증 중에 하나로 출혈(bleeding)을 들 수 있습니다. 주로 위궤양의 합병증으로 자주 나타나는데, 궤양이 심해지면서 점막하층을 지나는 비교적 큰 혈관까지 손상이 되어
출혈이 발생하는 것입니다. 자칫 처치가 늦어지면 저혈성 쇼크(hypovolemic shock)로 사망할 수도 있었기 때문에 과거 응급실 당직을 섰을 때 가장 힘들었던 응급질환 중 하나였습니다.


 
위궤양 출혈

위내시경을 시행하여 출혈부위를 확인한 후 전기소작술(electrocautarization)을 시행하거나 경화제(sclerotic agents) 등을 사용하여 지혈을 시켜야 합니다. 지혈이 여의치 않을 때에는 서둘러 응급수술을 시행하여야 합니다.


  
위궤양 출혈의 내시경 소견

사실 위의 내시경 소견 정도의 출혈은 새발의 피입니다. 궤양 부위를 확인할 수 없을 정도로 펑펑 쏟는 경우도 많습니다.

다음으로 나타날 수 있는 소화성 궤양의 합병증으로 천공(perforation)을 들 수 있습니다. 구멍이 난다는 이야기이죠.


 
위궤양 천공(드물다.)

출혈이 위궤양에서 많이 나타나는 반면 천공은 십이지장궤양에서 많이 나타납니다. 위는 그 벽이 두껍기 때문에 궤양이 심해져도 천공이 잘 발생하지 않지만, (그렇다고 아예 없다는 뜻은 아닙니다.) 십이지장은 벽이 얇기 때문에 출혈보다는 천공이 더 자주 발생합니다. 특히 십이지장궤양은 십이지장 중에서도 위의 유문부(pylous)를 막 지나서 약간 넓어진 부위인 십이지장구(duodenal bulb)에서 잘 발생하는데, 그 부위가 상대적으로 얇기 때문에 특히 천공이 잘 발생하게 됩니다.


 
십이지장궤양에서 천공이 발생하는 과정


천공이 발생하면 위나 십이지장 속에 있던 내용물이 복강안으로 흘러나오게 되고, 복막염(peritonitis)을 일으키게 됩니다. (복막염에 대한 구체적인 이야기는 나중에 다룰 예정입니다.)
그대로 방치하면 끔찍한 통증도 통증이려니와 패혈증(sepsis)을 일으켜 결국 사망까지 이를 수 있으므로, 역시 수술을 서둘러야 합니다.

단, 소화성 궤양의 천공이 의심되는 경우에는 내시경 검사나 상부위장관 조영술을 시행하면 안됩니다. 복막염이 더 심각해질 수 있기 때문입니다.

다음으로 발생할 수 있는 합병증으로 폐쇄(obstruction)가 있습니다. 음식물이 내려가는 길이 막혔다는 의미입니다. 주로 십이지장궤양에서 잘 발생하며 위궤양 중에서도 유문부에 궤양이 있을 때 잘 발생하는데, 동일한 부위에 궤양이 발생했다가 좋아졌다가를 반복하는 경우에 잘 생깁니다. 궤양이 나아가면서 반흔(흉터, scar)이 생기는데, 잦은 악화와 호전을 반복하다 보면 반흔이 두꺼워져서 음식물이 내려가는 통로를 막아버리게 되는것입니다. 역시 수술적 처치를 시행해줘야 합니다.

하지만 이러한 심각한 합병증이 있지 않은 이상 소화성 궤양의 치료는 약물치료가 우선입니다.

약물치료의 기본은 위산으로부터 궤양부위를 보호하는것입니다. 위산의 효과를 약화기키기 위해 제산제(antacid)를 사용하며, 위산 분비를 줄이기 위해 위산분비 억제제(antiulcerants)를 사용합니다. 위산분비 억제제에는 cimetidine, ranitidine, famotidine, nizatidine과 같은 H2 수용체 길항제(H2-receptor antagonist, H2RAs)가 있고, omrpazole과 같은 수소이온펌프 억제제(proton pump inhibitor)가 있습니다. 또한, 위나 십이지장의 점막 방어력을 향상시키기 위해
sucralfate제제(아루사루민®)를 사용하기도 합니다.

헬리코박터 균에 감염되어 있는 경우에는 amoxicillin이나 clarithromycin 제제의 항생제(antibiotics)를 한 가지를 단독으로 사용하든지 혹은 두 가지를 같이 사용합니다.

소화성 궤양에 대한 수술적 처치는 위에서 언급한 세 가지의 합병증 외에 약물치료에 반응하지 않는 심각한 소화성 궤양 등 몇 가지 제한적인 경우에만 시행합니다.

위산분비를 자극하는 미주신경(vagus nerve)을 절단하고 유문부를 절개후 성형하는 간단(?)한 수술에서부터, 위의 절반 혹은 2/3를 잘라내고 십이지장이나 소장에 연결해주는 수술 등  비교적 다양한 방법이 있습니다. 최근에는 개복을 하지 않고 복강경을 이용한 수술(laparoscopic surgery)도 많이 시행하고 있습니다.


 
합병증으로 천공이 발생한 십이지장궤양의 수술법
(Truncal Vagotomy and Pyloroplasty)

 
합병증으로 유문부 폐쇄가 발생한 위궤양의 수술법

(Antrectomy with Gastroduodenostomy(Billoth I) and Truncal Vagotomy)

by 약초마을 | 2009/01/16 18:32 | 질병정보 | 트랙백(42663) | 핑백(9) | 덧글(0)

트랙백 주소 : http://yakcho.egloos.com/tb/3541799
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