探讨胃食管反流病的临床分型

目的:应用24h食管内胆红素与pH监测(食管内双监测)以及食管内镜检查对胃食管反流病(GERD)进行临床分型研究。方法:根据食管胆红素、pH双监测、食管内镜检查的结果同时结合病人症状将GERD分成3型,观察病人在各型中的分布。结果:食管内24h胆红素与pH监测结果显示:Ⅰ、Ⅱ型病人胆红素吸收值≥0.14及pH<4总时间百分比、酸反流次数和胆汁反流次数较对照组和Ⅲ型明显增加(P<0.05),而Ⅰ型和Ⅱ型之间无显著性差异(P>0.05),Ⅲ型和对照组之间无显著性差异(P>0.05)。GERD病人在3个临床分型中呈正态分布。Ⅰ、Ⅱ、Ⅲ型病人分别为23.3％、65.9％、10.8％。结论:临床上对GERD分型有助于进一步探讨和研究临床治疗。     

正常人和胃食管反流病人的昼夜食管pH和动力变化

目的:为探讨正常人和胃食管反流病(gastroesophageal reflux disease,GERD)病人昼夜食管运动规律以及食管运动与酸反流的关系。方法:45例GERD病人和10名正常人均接受食管测压和动态食管pH及压力同步监测。结果:(1)下食管括约肌压、远端食管蠕动压及有效食管蠕动百分比在酸反流DeMeester高计分组明显低于低计分组(P<0.05),在反流性食管炎组也明显低于非反流性食管炎组(P<0.05)。(2)有GERD症状或食管炎的卧位有效蠕动百分比明显低于立位(P<0.05)。反流性食管炎组80％有夜间或伴有夜间反流,而不伴反流性食管炎的GERD无1例出现夜间反流。结论:昼夜食管pH和压力动态监测有利于进一步探讨GERD的运动病理,除LES功能外,食管清除功能在GERD发病中起重要作用。     

24小时食管pH监测和食管测压在胃食管反流病中的应用

目的：对８０例患者同时进行食管测压和２４小时ｐＨ值监测,探讨压力和２４小时ｐＨ值与胃食管反流及反流性食管 炎间的关系。方法：８０例病人分为Ａ组无反流症状;Ｂ组有反流症状,但内镜或Ｘ线检查无食管炎;Ｃ组有反流症状,内 镜或Ｘ线检查有食管炎。使用多导胃肠功能测定仪测定食管上、下括约肌及食管体静息和吞咽时压力及运动功能; 同时使用便携式２４小时ｐＨ监测仪监测食管２４小时ｐＨ值。结果：Ｂ、Ｃ两组的下食管括约肌压力（ＬＥＳＰ）低于Ａ组（Ｐ＜ ０．０５）,且食管下段蠕动幅度低于Ａ组（Ｐ＜０．０１）;Ｃ组食管下段蠕动低于Ｂ组（Ｐ＜０．０５）;２４小时ｐＨ监测Ｂ、Ｃ两组各项 指标均明显高于Ａ组（Ｐ＜０．００１）。结论：胃食管反流与ＬＥＳＰ降低、食管下段蠕动减弱有关,ＬＥＳＰ低于１１ｍｍＨｇ食管 炎的危险性增加。其诊断以２４小时ｐＨ监测结果为准。     

The Influence of Gastroesophageal Reflux Disease and its Treatment on Asthmatic Cough

Gastroesophageal reflux is known to cause chronic cough and is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease (GERD) in asthmatic patients with chronic cough to analyze the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. Asthmatic patients (126) with chronic dry cough were studied. Diagnosis of GERD was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring. Patients without GERD (negative pH results) consisted of the control group. The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for 3 months) not only diminished GERD symptoms but also improved asthma outcome Baseline FEV₁ and PEF values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another 3 months, the dose of inhaled steroids could be reduced with sustained GERD therapy. Our data showing that reflux events preceded coughing in most cases and that treatment of GERD resulted in an improvement in different outcome measures of asthma suggest that GERD worsens asthma, and its treatment is of clinical importance to effectively manage these patients.     

食管阻抗-pH监测在胃食管反流病诊断中的作用

阻抗-pH监测是目前监测胃食管反流病(GERD)的新技术,可通过对胃反流物的pH值和阻抗值进行检测,从而了解反流物为酸反流、弱酸反流或非腹反流,并可区分反流物的性状。阻抗-pH监测可应用于GERID的诊断,尤其适用于对弱酸反流或非酸反流的诊断、对难治性GERD的诊断以及非典型症状GERD的诊断。本文主要就阻抗-pH监测的机制和临床应用作一论述。     

非特异性食管动力障碍与胃食管反流病的关系研究

目的探讨非特异性食管动力障碍(NEMD)常见的临床类型,各类型与胃食管反流病(GERD)的关系。方法对食管测压检出的52例NEMD患者分别进行胃镜、食管内24h动态pH和胆汁监测,埃索美拉唑(耐信)治疗试验。结果NEMD主要类型有非传导性收缩43例、低幅性收缩39例、LES不松弛或松弛不全致LES残余压增高31例,多峰收缩9例。食管内24h动态pH和胆汁监测证实17例(32.7%)伴有病理性胃食管反流,伴有反流者多为不伴LES松弛功能障碍者,而LES松弛障碍者反流不明显,耐信治疗试验进一步证实了pH和胆汁监测的结果。结论NEMD部分与GERD相关,但更多可能为原发性食管动力障碍。     

多通道腔内阻抗技术在胃食管反流病诊断中的应用

24h食管pH监测有助于诊断胃食管反流病（GERD）,但其只能发现pH〈4的酸反流。多通道腔内阻抗（MII）技术通过记录食管腔内食团通过所引起的阻抗值变化,可在多种食管水平上发现胃食管反流事件而不依赖于反流物的pH值,同步联合pH监测可明确反流物的酸度、反流持续和清除时间、反流到达近端食管的高度等。本文就MII技术及其在GERD诊断中的临床应用作一综述。     

胃食管反流病食管测压与24小时pH监测的相关性研究

目的：对５２例有胃食管反流症状的患者进行食管测压及２４小时ｐＨ监测，运用统计学方法分析测压和ｐＨ结果，研究其相关性。方法：应用多导胃肠功能测定仪及便携式ｐＨ监测记录仪，对５２例有胃食管反流症状的患者进行食管测压及２４小时ｐＨ监测。结果：应用多元回归分析发现，ｐＨ的百分比和腹段下食管括约肌（ＬＥＳ）的长度、ＬＥＳ静息压及远端食管的蠕动压明显相关。依据测压及ｐＨ结果，使用ｔ检验方法，结果提示食管蠕动压不仅与ｐＨ＜４的百分化相关，也与酸反流大于５分钟的时间、最长反流时间有关（Ｐ＜００１）。结论：腹段ＬＥＳ的长度及食管下段的蠕动收缩是重要的抗反流屏障。食管酸暴露时间延长减弱食管体部酸清除能力     

Proton Pump Inhibitors Improve Acid-Related Dyspepsia in Gastroesophageal Reflux Disease Patients

It has been reported that proton pump inhibitors are more effective than H2 receptor antagonists in patients with functional dyspepsia. Dyspeptic symptoms that respond to proton pump inhibitors are classified as acid-related dyspepsia. A new questionnaire for assessing gastroesophageal reflux disease (GERD), the Frequency Scale for Symptoms of GERD, covers the 12 most common symptoms of GERD patients. A quantitative assessment of the changes of reflux symptoms and acid-related dyspepsia was made in GERD patients receiving proton pump inhibitor therapy. Sixty-eight GERD patients receiving proton pump inhibitor therapy completed the questionnaire before and after treatment for 8 weeks. There is a significant positive correlation between reflux symptoms and acid-related dyspepsia before and after therapy (r = 0.569 and r = 0.569; both P's < 0.001) and acid-related dyspepsia in patients with both nonerosive and erosive GERD. We conclude that GERD patients suffer not only from reflux symptoms, but also from acid-related dyspepsia, and proton pump inhibitors improve both types of symptoms.     

The Effect of Gastroesophageal Flap Valve Appearance on the Management of Patients with Symptoms of Gastroesophageal Reflux Disease

Purpose To assess the effectiveness of anti-reflux treatment in gastroesophageal reflux disease patients classified according to esophagogastric junction morphology (Hill classification). Results A symptom score and endoscopic grading of gastrooesophageal flap valve appearance were determined in 49 symptomatic patients (female 26, male 23; mean age 49 years, range 21–76 years). Patients received 8 weeks of continuous rabeprazole at a daily dose of 20 mg and, upon symptom control, continued with on-demand treatment for 3 months. The mean symptom score at 8 weeks was significantly reduced in all groups. However, at the end of the on-demand therapy, patients with Hill grade IV had used more rabeprazole tablets than those in the two other groups (II: 10.86 ± 14.52, III: 14.73 ± 14.58, IV: 25.78 ± 15.85; P = 0.002). Conclusions Continuous treatment is effective in all groups of patients with reflux disease. Grading patients according to the gastroesophageal flap valve appearance is useful as a prognostic factor, especially when on-demand therapy is considered to be an option. The authors who have taken part in this study declare that they have no relationship with the manufacturers of the drugs involved and did not receive funding from the manufacturers to carry out their research. The authors did not receive money from any source to carry out this study.     

Review: Treatment of Gastroesophageal Reflux Disease in the Elderly

The prevalence of gastroesophageal reflux disease (GERD) increases with age; older patients are more likely to develop severe disease. Common symptoms of GERD in the elderly include dysphagia, vomiting, and respiratory problems. Older patients are more likely to require aggressive therapy, and usually their management is compounded by the presence of comorbidities and consumption of various medications. Proton pump inhibitors are the mainstay of GERD treatment in the elderly because of their profound and consistent acid suppressive effect. Overall, proton pump inhibitors seem to be safe for both short- and long-term therapy in elderly patients with GERD. Antireflux surgery may be safe and effective in a subset of elderly patients with GERD.     

The Usefulness of the Measurement of Esophagogastric Junction Distensibility by EndoFLIP in the Diagnosis of Gastroesophageal Reflux Disease

Background/AimsIncreased esophagogastric junction (EGJ) relaxation is the most important mechanism involved in gastroesophageal reflux disease (GERD). An endoscopic functional luminal imaging probe (EndoFLIP^Ⓡ) is a device used to quantify EGJ distensibility in routine endoscopy. The aim of the current study was to assess the usefulness of EndoFLIP^Ⓡ for the diagnosis of GERD compared to normal controls.MethodsWe analyzed EndoFLIP^Ⓡ data from 204 patients with erosive reflux disease (ERD), 310 patients with nonerosive reflux disease (NERD), and 277 normal subjects. EndoFLIP^Ⓡ uses impedance planimetry to measure 16 cross-sectional areas (CSAs) in conjunction with the corresponding intrabag pressure within a 4.6 cm cylindrical segment of a fluid-filled bag. The EGJ distensibility was assessed using 40 mL volume-controlled distensions.ResultsThe mean distensibility index values were 13.98 mm²/mm Hg in ERD patients, 11.42 mm²/mm Hg in NERD patients, and 9.1 mm²/mm Hg in normal subjects. There were significant differences in EGJ distensibility among the three groups (p<0.001). In addition, the CSAs were significantly higher in the ERD (291.03±160.77 mm²) and NERD groups (285.87±155.47 mm²) than in the control group (249.78±144.76 mm², p=0.004). We determined the distensibility index cutoff value of EGJ as 10.95 for the diagnosis of GERD by receiver operating characteristic curve analysis.ConclusionsThe EGJ distensibilities of GERD patients were higher than those of normal subjects, regardless of the presence of reflux esophagitis. Thus, the measurement of EGJ distensibility using the EndoFLIP^Ⓡ system could be useful in the diagnosis of GERD.     

19例胃食管反流病患者根除幽门螺杆菌后食管酸反流的变化

目的：在胃食管反流病(GRED)患者根除幽门螺杆菌(Hp)是否会加重胃食管反流目前存在很大争议。本研究将采用食管内24h pH监测及食管测压检查的方法,定量观察GERD患者根除Hp治疗前后食管酸暴露及食管动力的变化。方法：连续选取我院门诊就诊的Hp阳性GERD患者。Hp感染诊断依据RUT和UBT或UBT和血清学检查。所有入选对象均在内镜检查后1～3d内行食管内24h pH监测和食管测压检查,同时评估反流症状。给予1周三联根除Hp治疗(奥美拉唑20mg,克拉霉素0．25g,阿莫仙1．0g,均bid)。疗程结束3个月后^14C—UBT检查,证实Hp根除者复查食管内24h pH监测和食管测压,同时重新评估反流症状。随访期间不用抑酸剂及促动力剂。结果：共23例Hp阳性GERD患者入选了本研究,其中19例患者完成了根除Hp前后的对比研究。在入选时有6例患者内镜下表现符合反流性食管炎,24h食管内pH监测提示病理性反流者10例。在确定根除Hp3个月后反酸、腹痛症状明显改善,食管24h pH监测各项参数与根除前相比均无显著性差异。LESP根除前10mm Hg(7．7—15．9),根除后15mm Hg(10—20．6),前后相比有显著性差异。食管体蠕动无明显改变。结论：本研究在GERD患者根除Hp3个月后反流症状有改善,食管酸暴露情况无明显变化,LESP较根除前增高,提示在GERD患者根除Hp有可能改善胃食管反流症状。     

36例难治性胃食管反流病患者阻抗-pH监测结果分析

质子泵抑制剂（PPIs）广泛用于治疗胃食管反流病（GERD）,但部分患者对抑酸治疗的疗效不佳,称为难治性GERD。目的：研究难治性GERD患者食管内反流的严重程度和反流物性质,以探讨难治性GERD症状形成的因素。方法：选取2009年1月-2010年12月华东医院确诊的难治性GERD患者36例,以PPls治疗后症状得到缓解的12例GERD患者作为对照。行24h阻抗-pH监测,根据反流物pH值和阻抗值,分析比较两组的反流情况。结果：难治性GERD组24h总反流和弱酸反流次数的中位数（第25百分位数,第75百分位数）分别为98（58,136）和62（40,86）,均显著高于对照组（P〈0．001）;两组酸反流次数均控制在较低水平,且组问差异无统计学意义（P：0．423）。难治性GERD组的气体反流和液气混合反流次数分别为48（31,61）和41（22,58）,均显著高于对照组（P〈0．001,P=0．002）;液体反流次数无明显差异（P=0．757）。结论：弱酸反流在难治性GERD患者症状形成中起一定的作用,气体反流可能加重反流症状的感知。     

Acid Gastroesophageal Reflux Reports in Infants: A Comparison of Esophageal pH Monitoring and Multichannel Intraluminal Impedance Measurements

Twenty-four-hour tracings generated from combined esophageal pH and multichannel intraluminal impedance measurements of 14 infants (nine males, median age 3.5 months) were examined retrospectively. For each tracing, two acid reflux assessment reports were generated using either pH monitoring alone or pH monitoring combined with impedance. Significantly fewer acid reflux episodes were detected using pH monitoring combined with impedance when compared to pH monitoring alone (25.1±4.0 versus 99.9±18.3 episodes/patient, p=.001). Estimates of esophageal acid exposure using pH monitoring alone were two-fold higher (137.4±23.7 versus 66.6±15.9 min/patient, p=.002) than estimates derived using both techniques. Of the total acid reflux episodes detected by pH monitoring alone, 71.8% could not be confirmed by combined pH and impedance. Detection of significant numbers of “pH-only” episodes raises concerns regarding possible over-estimations of acid exposure that may occur when estimates are based solely on esophageal pH monitoring.This study was funded in part by a grant from the National Institutes of Health (NIH 5R03DK62755-02) (HM) issued on July 1, 2002 (NIH, 900 Rockville Pike, Bethesda, MD).     

Role of Esophageal Function Tests in Diagnosis of Gastroesophageal Reflux Disease

Clinicians typically make the diagnosis of gastroesophageal reflux disease (GERD) from the clinical findings and then prescribe acid-suppressing drugs. Endoscopy is usually done for persistent or severe symptoms. Esophageal function tests (EFTs: esophageal manometry and 24-hr pH monitoring) are generally reserved for patients who have the most severe disease, including those being considered for surgery. We hypothesized that EFTs are more accurate than symptoms and endoscopy in the diagnosis of GERD. This was a retrospective study undertaken in a university tertiary care center. Between October 1989 and November 1998, 822 patients with a clinical diagnosis of GERD (based on symptoms and endoscopic findings) were referred for EFTs. The patients were divided into two groups depending on whether the 24-hr pH monitoring score showed GERD (group A, GERD^–; group B, GERD⁺). The groups were compared with respect to the incidence and severity of symptoms, presence of a hiatal hernia on barium x-rays, presence and severity of esophagitis on endoscopy, and esophageal motility. In all, 247 patients (30%) had normal reflux scores (group A, GERD^–), and 575 patients (70%) had abnormal scores (Group B, GERD⁺). Eighty percent of group A and 88% of group B had been treated with acid-suppressing medications. The incidence of heartburn and regurgitation was similar in the two groups. Grade I–II esophagitis was diagnosed by endoscopy in 25% of group A and 35% of group B, and grade III esophagitis in 4% of group A and 11% of group B. Esophageal manometry showed that group B more often had esophageal dysmotility, consisting of a hypotensive lower esophageal sphincter and abnormal esophageal peristalsis. These data show that: (1) symptoms were unreliable for diagnosing GERD; (2) endoscopic evidence of grade I–II esophagitis was diagnostically nonspecific, and grade III was much less certain than claimed in other reports; and (3) pH monitoring identified patients with GERD and stratified them according to the severity of the disease. We conclude that esophageal manometry and pH monitoring are important in diagnosing GERD accurately. More liberal use of these tests early in patient management would avoid much improper and costly medical therapy and would help single out for special attention the patients with GERD who have the most severe disease.