Laparoscopic fundoplication for gastroesophageal reflux disease

Gastroesophageal reflux disease(GERD) is a condition that develops when the reflux of gastric contents into the esophagus leads to troublesome symptoms and/or complications. Heartburn is the cardinal symptom, often associated with regurgitation. In patients with endoscopy-negative heartburn refractory to proton pump inhibitor(PPI) therapy and when the diagnosis of GERD is in question, direct reflux testing by impedance-pH monitoring is warranted. Laparoscopic fundoplication is the standard surgical treatment for GERD. It is highly effective in curing GERD with a 80% success rate at 20-year follow-up. The Nissen fundoplication, consisting of a total(360°) wrap, is the most commonly performed antireflux operation. To reduce postoperative dysphagia and gas bloating, partial fundoplications are also used, including the posterior(Toupet) fundoplication, and the anterior(Dor) fundoplication. Currently, there is consensus to advise laparoscopic fundoplication in PPI-responsive GERD only for those patients who develop untoward side-effects or complications from PPI therapy. PPI resistance is the real challenge in GERD. There is consensus that carefully selected GERD patients refractory to PPI therapy are eligible for laparoscopic fundoplication, provided that objective evidence of reflux as the cause of ongoing symptoms has been obtained. For this purpose, impedance-pH monitoring is regarded as the diagnostic gold standard.     

呼出气一氧化氮及食管pH监测对支气管哮喘和胃食管反流病的诊断与鉴别价值

目的探讨呼出气一氧化氮（FeNO）对诊断和鉴别支气管哮喘及合并胃食管反流病的价值及其与24h食管pH测定的关系。方法选取2010年3月至2011年2月在我科住院的支气管哮喘患者16例、胃食管反流病患者20例及支气管哮喘合并胃食管反流病患者16例,分别测定FeNO、白细胞分类计数及百分比、24h食管pH测定中pH〈4的时间百分比,pH〈4的总次数,pH〈4大于5min以上的次数及DeMeester评分,分别比较三组FeNO水平的差异及与上述测定指标的关系。结果FeNO、嗜酸性粒细胞（EOS）、嗜酸性粒细胞百分比（EOS％）在三组组间存在总体差异,组间两两比较发现,哮喘组和哮喘合并胃食管反流病组比胃食管反流病组FeNO、EOS、EOS％均显著增高（P〈0．05—0．01）;哮喘组比哮喘合并胃食管反流病组FeNO显著增高（P〈0．05）,而EOS、EOS％无明显差异;哮喘组FeNO水平与EOS和EOS％有显著相关性（P〈0．05）;但胃食管反流病（GERD）组及哮喘合并胃食管反流病组FeNO水平与EOS没有明显的相关性;胃食管反流病组和哮喘合并胃食管反流病组FeNO水平与pH〈4的时间百分比、pH〈4的总次数、pH〈4发作大于5min的次数及DeMeester评分值均有非常显著的相关性（P均〈0．01）;哮喘组FeNO水平与24h食管pH监测结果没有相关性。结论FeNO是一项检测气道炎症的敏感指标,尤其能反映嗜酸性粒细胞气道炎症;在哮喘合并胃食管反流病患者中,吸入酸性胃内容物可能以双重作用影响FeNO的变化,提示在哮喘合并胃食管反流病患者中,FeNO的增加可能部分反映了胃酸反流的严重程度;FeNO对于哮喘和哮喘合并胃食管反流病患者具有较好的诊断价值,同时为鉴别哮喘和哮喘合并胃食管反流病患者与胃食管反流病提供了可靠的依据。     

Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) has been extensively studied in patients with laryngeal signs and symptoms, gastroesophageal reflux being identified in approximately 50%. Few studies have investigated the incidence and significance of LPR in GERD patients. Two-hundred and seventy-six consecutive patients referred with symptoms of gastroesophageal reflux had dual probe 24 h pH, esophageal manometry, GERD and ENT questionnaires. LPR was defined as at least three pharyngeal reflux events less than pH 5.0 with corresponding esophageal reflux, but excluding meal periods. Fourty-two percent of patients were positive for LPR on 24 h pH monitoring and 91.3% corresponded with an abnormal esophageal acid score. Distal esophageal acid exposure was significantly greater (P < 0.001) in patients with LPR but symptoms of GERD and regurgitation scores showed no significant differences between patients with positive and negative LPR on 24 h pH. There was no significant difference between the incidence of LPR in patients with or without laryngeal symptoms. There is a high incidence of LPR in patients with GERD but its significance for laryngeal symptoms is tenuous. Fixed distance dual probe pH monitoring allows documentation of conventional esophageal reflux and LPR.     

支气管哮喘患者与胃食管返流的症状相关性

目的　探讨胃食管返流 (GER)与成人中、重度支气管哮喘的症状相关性 ,了解 2 4h食管pH监测对哮喘合并GER的诊断价值及抗返流治疗对合并GER的哮喘患者症状的影响。方法　对 2 6例常规治疗后仍有顽固性咳嗽等症状的成人哮喘患者进行 2 4h食管pH监测 ,严格记录监测期间患者出现的各种症状 ,每小时记录 1次呼气峰流速 (PEF)。筛选出适当病例分组抗返流治疗并观察疗效。结果　 2 6例中有 15例DeMeester总积分≥ 14 72 ,2例虽DeMeester总积分 <14 72 ,但咳嗽与返流的症状相关概率 (SAP)≥ 95 % ,共筛选出 17例。将 17例患者随机分为治疗组 (9例 )和对照组 (8例 )。经抗返流治疗后 ,治疗组咳嗽、胸闷和胸骨后烧灼感等症状均较对照组有明显改善 ,2 4hPEF波动率治疗前 [(3 8± 8) % ]、后 [(16± 3 ) % ]比较差异有显著性 (P <0 0 5 )。结论　 (1)中、重度支气管哮喘患者具有较高的GER发生率 (5 8% )。 (2 ) 2 4h食管pH监测有助于了解哮喘患者的症状与GER的相关性。 (3 )对于有GER并与哮喘症状密切相关的患者 ,抗返流治疗可显著地改善其症状及PEF波动率     

十二指肠胃食管反流在胃食管反流病中的作用

目的　研究十二指肠胃食管反流 (DGER)在胃食管反流病发病机制中的作用及其对非糜烂性反流病 (NERD)的诊断价值。方法　 95例患者根据内镜检查的结果分为反流性食管炎和NERD组 ,对其均进行 2 4h食管 pH和胆汁联合监测。 结果　反流性食管炎患者DGER的各项指标 :吸光度值 >0 14时间百分比 (% )、总反流次数和反流 >5min的次数分别为 19 0 5± 2 3 4 4、30 5 6±34 0 4和 5 90± 6 37,均显著高于NERD组相应的 7 2 6± 11 0 8、15 6 8± 2 0 92和 2 5 9± 3 5 7(P <0 0 5 ) ,而酸反流差异无显著性 ,随着反流性食管炎的程度加重DGER发生率增高 ;18 2 %的NERD患者存在单纯DGER ,联合胆汁监测可使NERD诊断阳性率由 6 5 9%升高到 84 1%。结论　DGER可以单独发生 ,在引起反流性食管黏膜损伤或症状方面都有作用 ,2 4h食管 pH和胆汁联合监测有助于NERD的诊断。     

支气管哮喘合并胃食管反流病相关危险因素分析

目的探讨支气管哮喘合并胃食管反流病（GERD）的相关危险因素,为预防及治疗提供理论依据。 方法回顾性收集自2013年1月至2018年8月在新疆维吾尔自治区人民医院呼吸科就诊的支气管哮喘合并GERD患者187例及单纯支气管哮喘者192例临床资料,统计方法比较两组临床特点,分析哮喘合并GERD相关危险因素。 结果两组患者年龄、性别、过敏史、高血压病史、冠心病病史、糖尿病病史、饮酒史等差异无统计学意义（P＞0.05）;两组患者吸烟史、体重指数（BMI）、哮喘家族史、第一秒末用力呼气量（FEV1）、FEV1/用力肺活量（FVC）、最大呼气流量（PEF）内急性发作次数等有差异性,并差异有统计学意义（P＜0.05）。多因素Logistic回归分析结果显示,高BMI、吸烟、PEF、既往12月内急性发作次数是哮喘合并GERD的独立危险因素（P＜0.05）。 结论高BMI、吸烟、PEF、既往12月内急性发作次数是哮喘合并GERD的危险因素,改善肺功能、积极减重、戒烟,有望预防和减少GERD的发生。     

Advances in diagnostic testing for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) contributes substantially to morbidity and to costs in the United States health care system. The burden of this disease has resulted in attempts at improving diagnosis and characterizing patients. Numerous research and technical advances have enhanced our understanding of both the utility and limitations of a variety of diagnostic modalities. The purpose of this review is to highlight recent advances in GERD diagnostic testing and to discuss their implications for use in clinical practice. Topics addressed include esophageal pH monitoring, impedance testing, symptom association analyses, narrow-band imaging, and histopathology.     

咳嗽变异型哮喘与胃食管反流的关系

目的许多研究发现支气管哮喘与胃食管反流有关，通过本文研究明确咳嗽变异型哮喘与胃食管反流的关系，并指导其治疗。方法将咳嗽变异型哮喘患者200例进行筛选，伴有胃食管反流108例，根据治疗方法分为对照组52例，实验组56例。结果两组比较，实验组缓解率大于对照组，差异具有显著性（P〈0．05）。结论大约54％的咳嗽变异型哮喘伴有胃食管反流。抑酸及增加胃动力可以明显缩短缓解时间。     

Correlation of 24-hr esophageal pH patterns with clinical features and endoscopy in gastroesophageal reflux disease

We performed 24-hr ambulatory esophageal pH monitoring in north Indian patients with gastroesophageal reflux disease (GERD) and correlated it with symptom severity and endoscopic abnormalities. Thirty-six consecutive patients with symptomatic GERD and 16 healthy volunteers underwent objective grading of clinical symptoms and endoscopic findings. Total, supine, and upright reflux periods as well as frequency and duration of reflux episodes were determined from the 24-hr pH-metry record using standard software. This was abnormal in 32 patients, who could be categorized into upright refluxers (31.2%), supine refluxers (34.4%), and combined refluxers (34.4%). Supine reflux and upright reflux were distinct entities that did not correlate with each other (r=0.22,P=NS). In upright refluxers, symptoms (P<0.02) and=" endoscopic=" abnormalities=">P<0.005) were=" milder=" than=" in=" combined=" refluxers.=" total=" duration=" of=" acid=" exposure=" correlated=" significantly=" with=" severity=" of=" symptoms=">P<0.001) and=" endoscopic=" esophagitis=">P<0.005). patients=" with=" gerd=" had=" three=" distinct=" patterns=" of=" abnormal=" gastroesophageal=" reflux,=" with=" upright=" refluxers=" having=" milder=" disease=" and=" supine=" and=" combined=" refluxers=" having=" more=" severe=" disease.=" this=" may=" reflect=" differences=" in=" underlying=" mechanisms=" of=">     

Gastro-oesophageal reflux disease and asthma

Abstract Gastro-oesophageal reflux disease (GOR) and asthma are both common medical conditions that often co-exist. Studies using oesophageal manometry and 24 h ambulatory pH monitoring have shown that up to 80% of asthmatics have abnormal GOR. A number of mechanisms whereby GOR may trigger asthma have been proposed, and it is believed that acid reflux may stimulate vagal receptors in the lower oesophagus causing reflex bronchoconstriction. However, GOR may be worsened by asthma causing abnormal diaphragm mechanics and by its treatment. Formal evaluation of GOR should be considered a part of asthma assessment, particularly if asthmatic symptoms are precipitated by factors known to trigger GOR such as reclining, alcohol ingestion, and the use of theophylline. Twenty-four hour ambulatory intra-oesophageal pH monitoring remains the gold standard for the diagnosis of GOR. Medical therapy with anti-refux medications, such as acid suppressive agents and prokinetic agents may improve both GOR and asthma control. In those who fail medical therapy, anti–reflux surgery may be warranted in some.     

难治性胃食管反流病的诊疗

难治性胃食管反流病目前已成为临床上的棘手问题。其发生机制尚未完全阐明。上消化道内镜、食管内动态pH监测以及食管多通道腔内阻抗-pH值监测等技术能够对难治性胃食管反流病的诊断提供帮助。通过改善患者的服药依从性以及调整质子泵抑制剂的剂量、种类和服药时间,配合促胃肠动力药、一过性下食管括约肌松弛抑制剂、疼痛调节剂或抗反流手术均有助于改善患者的顽固症状。     

��������θʳ�ܷ������������Ƶ��о�

目的探讨非糜烂性胃食管反流病不同于反流性食管炎的发病机制。方法选择1996～2004年北京大学人民医院因反酸、胃灼热感等反流症状确诊为胃食管反流病患者57例,按照内镜下食管黏膜有无破损分为非糜烂性胃食管反流病组和反流性食管炎组,比较两组的一般情况、反流症状、是否合并H.pylori(Hp)感染,以及食管动力测定和食管胃24hpH监测结果。结果两组患者年龄、性别、烟酒嗜好等一般情况及合并Hp感染情况比较差异无显著性。非糜烂性胃食管反流病组不典型反流症状(胸骨后痛)的发生率明显高于反流性食管炎组。两组患者都存在病理性酸反流,但两组患者之间酸和(或)碱反流比较无差异。非糜烂性胃食管反流病患者的食管体部各段蠕动波峰值明显高于反流性食管炎患者。非糜烂性胃食管反流病患者卧位胃酸分泌高于反流性食管炎患者。结论非糜烂性胃食管反流病的不典型反流症状发生率更高。在两组发病机制异同上,反流的强弱并非主要因素,重要的是食管防御机制的差别。     

Epidemiological study of symptomatic gastroesophageal reflux disease in China: Beijing and Shanghai

OBJECTIVE : To explore the 1‐year point prevalences (July–September 1996) of symptomatic gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD) and reflux esophagitis (RE) in the adult population of two Chinese city‐regions (Beijing and Shanghai) and to identify the conditions that predispose patients to GERD. METHODS : Phase I: 5000 residents of the two regions aged between 18 and 70 years were studied via a questionnaire. The study was carried out by cluster sampling from city, suburban and rural areas by using simple random sampling. Symptom scores (Sc) of the intensity and frequency of heartburn, acid reflux and regurgitation within 1 year of the time of study were taken as indices of acid reflux (highest score, Sc = 18) and Sc ≥ 6 indicated the presence of symptomatic GER. Phase II: a small number of patients who were identified as having symptomatic GER in the survey were enrolled in a case– control study using gastroscopy and 24‐h pH monitoring to obtain correct diagnostic rates of GERD and RE. Estimates of the prevalence of GERD and RE were then adjusted according to the rates of correct diagnosis. RESULTS : A total of 4992 subjects completed the survey, 2.5% had heartburn once daily, 8.97% had symptomatic GER (Sc ≥ 6) and the male to female ratio was 1:1.11. Point prevalences for the year for GERD and RE were 5.77 and 1.92%, respectively. Stratified analysis indicated that the prevalence of symptomatic GER in Beijing (10.19%) was higher than that in Shanghai (7.76%) and there was also a higher prevalence of GER in males, manual laborers, people from rural areas and people older than 40 years of age in Beijing as compared with Shanghai. Stepwise logistic analysis indicated that GER had a close relationship with dental, pharyngolaryngeal disorders and respiratory diseases. The conditions that predispose patients to GERD are (OR, odds ratio): age > 40 (OR = 1.01), eating greasy/oily food (OR = 6.56), overeating (OR = 1.99), tiredness (OR = 2.35), emotional stress (OR = 2.22), pregnancy (OR = 6.80) and constipation (OR = 1.65). CONCLUSIONS : Gastroesophageal reflux disease is a common disease in the adult Chinese population and it is more common in Beijing than in Shanghai.     

胃食管反流病伴或不伴食管损伤与食管动力及酸反流之间的关系

目的 研究胃食管反流病(GERD)患者伴或不伴食管损伤与食管动力和酸反流之间的相关性.方法 对符合GERD诊断标准的25例受试者行胃镜检查,随后进行高分辨率食管测压检查,并检测进食标准试验餐后的动态食管pH值变化.比较伴或不伴食管损伤组患者之间的食管动力和餐后食管酸反流时间的差异.同时按DeMeester评分将受试者分为非酸反流组和酸反流组,比较两组食管动力学指标的变化.统计学处理采用t检验和秩和检验.结果 伴或不伴食管损伤组之间下食管括约肌(LES)压力基础值、LES压力残余平均值、食管蠕动传播速度、食管pH＜4的时间和DeMeester评分均差异无统计学意义(P均＞0.05),但是伴食管损伤组的食管收缩幅度明显弱于不伴食管损伤组(31.9 mm Hg比64.2 mm Hg,1 mm Hg=0.133 kPa;Z=-2.37,P=0.02).酸反流组和非酸反流组之间LES压力基础值、LES压力残余平均值、食管蠕动传播速度差异均无统计学意义(P均＞0.05),但酸反流组的食管收缩幅度明显弱于非酸反流组(36.4 mm Hg比71.8mm Hg;Z=2.25,P=0.02).结论 GERD患者LES压力及食管酸反流与食管损伤之间无显著关系,食管蠕动性收缩功能可能与食管损伤及酸反流有关.     

Tolerance to H2 receptor antagonist correlates well with the decline in efficacy against gastroesophageal reflux in patients with gastroesophageal reflux disease

BACKGROUND AND AIM: The attenuated antisecretory activity of H2 receptor antagonists (H2RA) during continuous administration is known as the tolerance phenomenon. The authors recently clarified that presence or absence of Helicobacter pylori infection influences the occurrence of the tolerance phenomenon. The aim of this study was to clarify whether tolerance to H2RA is correlated with attenuation of the inhibitory effect against gastroesophageal acid reflux in patients with gastroesophageal reflux disease (GERD). METHODS: Ten male patients with GERD symptoms and abnormal gastroesophageal reflux were investigated by pH monitoring on days 1 and 15 of continuous oral famotidine administration at 20 mg twice daily, and H. pylori infection was examined using the urea breath test. RESULTS: Intragastric and intraesophageal acidity were significantly decreased on the first day of famotidine administration, but then increased during the 15-day administration period in seven patients who were negative for H. pylori. In contrast, the efficacy of famotidine against gastric acid secretion and gastroesophageal acid reflux was not attenuated in three H. pylori-positive patients. The changes in GERD symptoms were correlated with the change in the degree of gastroesophageal reflux. CONCLUSION: The presence or absence of tolerance to H2RA during 15-day administration is correlated with the efficacy for inhibition of gastroesophageal acid reflux.     

Prevalence of gastroesophageal reflux disease in patients with asthma and chronic obstructive pulmonary disease

Background and Aim: It is speculated that the prevalence of gastroesophageal reflux disease (GERD) might increase with asthma or chronic obstructive pulmonary disease (COPD). The aim of the present study was to evaluate the prevalence of GERD in patients with asthma and COPD in an area representative of developing countries. Methods: A validated GERD questionnaire was conducted face‐to‐face with 308 consecutive asthma (240 women) and 133 COPD (35 women) patients in the tertiary referral pulmonary outpatient clinic, and 694 controls from the research area. Detailed histories of patients and pulmonary function tests were also recorded. Results: The prevalence of GERD (heartburn/regurgitation once a week or more) was 25.4%, 17.0%, 19.4% and occasional symptoms (less than weekly) were 21.2%, 16.3% and 27.0% of patients with asthma, COPD and controls, respectively. The prevalence was higher in the asthma group compared with the controls and the COPD group. No significant difference was found between the COPD group and the controls. Heartburn started following pulmonary disease in 24.1% of the asthma group, and 26.4% of the COPD group. The majority of additional symptoms were significantly higher in asthmatics compared with the controls. No difference was found in the consumption of pulmonary medications in asthmatic patients in groups with different symptom frequency. Heartburn was increased 13.8% by the consumption of inhaler medications. Conclusions: These results implicate that the prevalence of GERD in asthma and COPD are lower than in published reports in a tertiary referral center. These differences might be related to the characteristics of developing countries, increased consumption of powerful medications in GERD and pulmonary diseases, or methodological flaws in earlier studies.     

Inclusion of supine period in short-duration pH monitoring is essential in diagnosis of gastroesophageal reflux disease

Prolonged esophageal pH monitoring is the most accurate method for detecting abnormal gastroesophageal reflux (GER) in patients with gastroesophageal reflux disease (GERD). However, some investigators have found that short-duration postprandial pH monitoring in the upright position is also useful, while others have failed to find such results. Therefore, we have compared a 6-hr period of pH monitoring (3-hr postprandial period after daytime meal and 3-hr supine period) with a total 24-hr period in detecting abnormal gastroesophageal reflux. Sixty-five patients (44 men, mean age 41.3 years) with GERD and 16 healthy volunteers (11 men, mean age 34.3 years) underwent 24-hr pH monitoring according to a standard protocol. Various reflux parameters during 24-hr pH monitoring were compared with reflux parameters during the 6-hr period. Abnormal GER was detected in 56 patients presenting with typical symptoms of GERD (sensitivity 86.2%). These patients could be further divided into upright (N=18), supine (N=15), and combined (N=23) refluxers, depending on the posture in which abnormal reflux occurred. Esophageal pH monitoring during the 3-hr postprandial upright period showed abnormal reflux in only 35 patients (sensitivity 53.8%;P<0.00005, compared with the 24-hr pH monitoring period). Abnormal GER was identified in 13 of 18 upright, 19 of 23 combined, and only one of 15 supine refluxers, as well as in two of nine patients with normal 24-hr pH-metry. However, inclusion of the 3-hr supine monitoring period in the 3-hr postprandial upright period improved detection of abnormal GER to 78.5% (51 patients;P=NS compared with 24-hr pH monitoring period). This was related mainly to improved detection of abnormal GER in supine refluxers (11 of 15; 73.3%). Esophageal acid exposure time correlated significantly with severity of esophagitis only during the total and supine periods of both the 24- and 6-hr periods and not during the upright period. Esophageal acid clearance correlated significantly with increasing grades of esophagitis for the supine and total periods only. We conclude that 3-hr postprandial pH monitoring, as has been conventionally practiced, is not appropriate in the detection of abnormal GER; inclusion of a supine period in the short-duration pH monitoring schedule increases the detection of pathological reflux. We therefore recommend that a supine period should be included in short-duration pH monitoring schedules. We also found that supine reflux was the most important factor in the development of esophagitis.     

Electron microscopic study of intercellular space: correlation analysis of bronchial asthma and gastroesophageal reflux disease

Background and Aims: Bronchial asthma (BA) is considered an extra‐esophageal syndrome of gastroesophageal reflux disease (GERD) with poor pathophysiological background. We analyzed the correlation between GERD and BA, examining esophageal epithelium with transmission electron microscopy (TEM), along with clinical findings. Methods: BA patients of controlled and partly‐controlled levels were enrolled in the study. A pulmonary and gastrointestinal (GI) questionnaire was given. Patients with no symptoms joined the control group. Esophageal mucosal tissue was taken by esophagogastroduodenoscopy from both groups and processed for TEM. Intercellular space (IS) was measured with an image analyzing program, 100 times for each patient. Results: The control (n = 20) and BA (n = 20) groups revealed no significant differences in baseline characteristics. All BA patients were using corticosteroid inhalers, with seven patients having a recent history of acute exacerbation. Patients with at least one GI symptom made up 70% (14/20) of the BA group, and heartburn and/or regurgitation were detected in 40% of patients. Endoscopic findings of GERD were mucosal breaks (n = 3). The IS of the control group was 0.389 ± 0.297 um, while the BA group was 0.806 ± 0.556 um (P = 0.001). The presence of GERD symptoms (P = 0.306) and a history of recent asthma attacks (P = 0.710) did not show significant differences. Conclusions: The BA group showed a significant difference in the dilatation of IS compared to the control group, suggesting a higher prevalence of GERD in BA patients and a close pathophysiological correlation.