非糜烂性胃食管反流病患者大脑皮质诱发电位的研究

目的通过比较食管扩张刺激-脑诱发电位(OD-CEP)的改变,探讨非糜烂性胃食管反流病(NERD)患者食管内脏高敏感性的发生机制,旨在进一步获得NERD患者食管-中枢内脏感觉传导通路失调的客观依据。方法10例正常健康自愿者和21例NERD患者参与试验;采用Synectics内脏刺激器/电子气压泵和带有低顺应性气囊的导管给食管以时相性扩张刺激;利用食管气囊扩张术检测受试者食管最大耐受痛阈,用75%最大疼痛耐受容积作为诱发刺激的强度(刺激频率为12次/分,连续64次);采用OD-CEP系列技术记录并分析NERD患者和正常人CEP的变化。结果食管气囊扩张刺激能诱发出可识别、可重复的、多峰的CEP波形,以NP型为主。与正常对照者比较,NERD患者CEP波形变异性大,其N1、P1、N2波潜伏期明显缩短(P值分别为0·016,0·003,0·031),且NERD患者CEP的P1-N2峰间波幅明显增加(P=0·03)。结论NERD患者经食管时相性扩张后产生的特征性CEP改变证实其食管内脏高敏感性及食管-中枢内脏感觉传导通路的失调。     

非糜烂性反流病患者食管黏膜SP和CGRP的表达

目的 观察非糜烂性反流病(NERD)和反流性食管炎(RE)患者食管黏膜内P物质(SP)和降钙素基因相关肽(CGRP)免疫反应阳性产物的表达,探讨其在NERD发病中的作用.方法 选择有典型胃食管反流症状并经反流性疾病诊断问卷(RDQ)调查、PPI试验、胃镜检查及食管24h pH检测诊断为GERD患者51例,其中RE组21例,NERD酸反流阳性组(NERD+组)12例,NERD酸反流阴性组(NERD-组)18例,采用免疫组化方法 在显微镜下观察NERD、RE患者食管黏膜内SP、CGRP的表达,应用彩色病理图像分析软件,分析计算SP、CGRP免疫反应的阳性指数(PI),并与正常对照组10例比较.结果 NERD-组食管黏膜内SP、CGRP的Pl值为96.77±31.74和24.76±29.15,明显高于NERD+组(73.64±31.38、9.78±10.30)、RE组(67.56±34.62、9.61±6.20)及正常对照组(59.82±46.15、8.64±12.12)(P均<0.05).结论 SP、CGRP在NERD-的患者食管黏膜内有明显表达,可能在食管内脏感觉中发挥着重要的作用.     

非糜烂性反流病患者食管内脏高敏感性与食管下括约肌局部降钙素基因相关肽阳性神经纤维的关系

背景：食管内脏高敏感性是非糜烂性反流病（NERD）最重要的病理生理特征之一，但引起食管内脏感觉过敏的确切机制仍不甚清楚。目的：通过测定NERD患者食管对机械扩张刺激和对酸刺激的敏感性变化和降钙素基因相关肽（CGRP）在食管下括约肌（LES）局部组织中的表达，探讨食管感知阈值与LES局部黏膜CGRP表达之间的关系。方法：采用Synectics内脏刺激器／电子气压泵行食管气囊扩张术以检测食管对机械扩张刺激的敏感性；采用食管酸灌注试验（betastein test）检测食管对酸的敏感性；采用免疫组化法和罔像分析技术观察LES局部组织中CGRP的表达。结果：根据对酸刺激和（或）机械扩张刺激的感知过敏，NERD患者可分为感知过敏组（21例）和感知正常组（10例）。感知过敏组患者食管对气囊扩张刺激的初始感知闽值和最大耐受疼痛阈值较感知正常组和正常对照组显著降低（P〈0．05）。感觉过敏组LES黏膜中CGRP阳性纤维数和平均吸光度（A）值较感知正常组和正常对照组显著增高（P〈0．05）。LES局部组织中CGRP阳性产物A值与食管初始感知阈值和最大耐受疼痛阈值呈直线负相关（r分别为-0．68和-0．79．P〈0．03）。结论：多数NERD患者存在对食管机械扩张刺激和（或）对食管酸刺激感知过敏；感知过敏的NERD患者其LES局部黏膜中CGRP表达增加，提示LES肽能神经的改变可能与食管内脏高敏感性有关。     

非糜烂性胃食管反流病患者酸灌注及食管扩张脑诱发电位的研究

目的研究非糜烂性胃食管反流病(NERD)患者和正常人食管扩张刺激(OD)-脑诱发电位(CEP)的特征及食管酸灌注后 CEP 的改变,探讨 NERD 患者食管内脏高敏感性的发生机制。方法10例健康志愿者和21例 NERD 患者参与试验;采用 Synectics 内脏刺激器/电子气压泵和带有低顺应性气囊及多个灌注式压力通道的导管给食管以时相性扩张刺激和酸灌注;利用食管气囊扩张术检测受试者食管最大耐受痛阈,用75%最大疼痛耐受容积作为诱发刺激的强度(刺激频率为12次/min,连续64次);采用 OD-CEP 系列技术记录并分析食管酸灌注前后 NERD 患者和正常人 CEP 的变化。组间比较采用 t 检验,多组间比较采用单因素方差分析。结果食管时相性机械扩张刺激诱发出可识别、可重复、多峰的 CEP 波形,以 NP 型为主。正常对照者 N1、P1、N2波潜伏期分别为(246±77)、(388±84)和(502±78)ms,NERD 患者 CEP 波形变异性大,其 N1、P1、N2波潜伏期分别为(192±46)、(293±76)和(440±79)ms,较对照组明显缩短(P 值均<0.05);P1-N2峰间波幅明显增加[(6.2±1.9)μV 比(7.8±3.2)μV,P<0.05]。食管酸灌注能明显缩短 NERD 患者 N1、P1、N2波潜伏期,与酸灌注前相比差异有统计学意义(P 值均<0.05),且酸灌注后 NERD 患者 P1-N2皮层波幅值较酸灌注前显著增加(p<0.05),健康对照组除 CEP 的 N1波潜伏期较对应基线值显著降低(P=0.05)外,其余 CEP 参数均无明显改变。结论 NERD 患者存在食管对机械和酸刺激的高敏感性及食管-中枢内脏感觉传导通路失凋。     

食管扩张刺激后兔食管内脏感觉改变及其中枢机制的实验研究

目的 探讨食管扩张刺激后兔食管内脏感觉改变及P物质(SP)、降钙素基因相关肽(CGRP)、5-羟色胺(5-HT)、Fos蛋白在中枢神经系统的作用.方法 新西兰白兔20只分为三组:食管扩张组(A组,n=8)和对照组(B组,n=6),分别给予0.9cm食管球囊扩张及假手术刺激,每次持续30 s,每日2次,共14 d,以及空白对照组(C组,n=6).采用动物行为学评分评价食管内脏感觉改变,免疫组化法观察幼兔食管下段黏膜、脊髓和脑组织中神经递质CGRP、SP、5-HT及Fos蛋白的表达.结果 动物食管机械扩张后,在行为学评分为1、2、3分时,A组球囊直径较B、C组明显减小(P＜0.05);A组食管、脊髓和延髓孤束核(NTS)的SP表达明显高于B、C组(P＜0.05),而B、C组间差异无统计学意义(P＞0.05);A组食管黏膜、脊髓、NTS、中脑导水管周围灰质(PAG)、丘脑的CGRP、Fos阳性细胞数较B、C组明显增多(P＜0.05);在食管和脊髓,A组5-HT的表达较B、C组显著升高(食管:27.67±3.27比11.00±1.79和11.17±1.33;脊髓24.00±5.22比11.33±2.94和11.83±2.48,P＜0.01),而在PAG,B组(17.67±2.07)和C组(16.83±2.32)5-HT的表达较A组(13.17±2.04)增多(P＜0.05).在脊髓,CGRP与Fos、SP与Fos、CGRP与SP有明显的相关性(相关系数分别为0.813、0.779、0.772,P值分别为0.025、0.034、0.036).结论 持续的食管扩张可引起食管内脏敏感性增高,食管的机械扩张刺激通过脊髓、NTS、PAG、丘脑传导,且SP、CGRP、5-HT等在食管内脏感觉发生中发挥着重要作用.     

神经肽参与NERD内脏高敏感外周机制的研究进展

内脏高敏感是胃食管反流病(gastroesophageal reflux disease,GERD)重要发病机制,尤其在非糜烂性反流病(non-erosive reflux disase,NERD)患者中。某些神经肽类物质如P物质(substance P,SP)和降钙素基因相关肽(calcitonin gene-related peptide,CGRP)在介导伤害性或非伤害性刺激致痛觉过敏的发生和调控中发挥关键作用,是参与痛觉信息传递过程中的重要神经递质。新近研究显示,SP和CGRP在NERD患者食管黏膜中的表达明显增加,且与疼痛感觉阈值呈明显负相关,推测某些神经肽类物质可能共同参与NERD内脏高敏感的外周机制。     

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。     

反流性食管炎与非糜烂性反流病食管酸暴露的特点比较

目的　比较反流性食管炎 (RE)与非糜烂性反流病 (NERD)各亚组食管酸暴露特点。方法　具有典型反酸 烧心等症状的 12 8例患者 ,经胃镜等系统检查诊断为胃食管反流病 (GERD)。便携式 pH监测仪行胃食管 2 4hpH监测 ,DeMeester积分≥ 15分为存在病理性酸反流。 结果　 12 8例患者中 ,37例 (2 8 9% )存在RE ,91例 (71 1% )为NERD。pH监测阳性在RE组和NERD组中分别为 2 5例 (6 7 6 % )和 4 6例 (5 0 5 % ) ,差异无统计学意义 ;两组DeMeester积分均值差异亦无统计学意义 (5 3 4 5± 6 2 0 4比 4 0 0 4± 6 1 80 ,P >0 0 5 )。RE组长反流次数显著高于NERD组 (8 16±10 2 7比 3 96± 6 87,P =0 0 0 4 )。以症状指数 >5 0 %为阳性 ,NERD阳性组 (pH值监测异常 )症状指数阳性率显著高于NERD阴性组 (pH值监测正常 ) (43 5 %比 15 6 % ,P <0 0 0 1)。NERD阴性组中具有阳性症状指数的患者 7例 (15 6 % ) ,阴性症状指数者 38例。前者总反流次数及立位反流时间百分比显著高于后者。RE患者中 ,12例 pH监测阴性者食管及胃内pH的中位值显著高于 pH监测阳性者。结论　RE患者长反流发生率高于NERD患者 ;症状的发生与酸反流相关 ;NERD患者根据酸反流与症状关系可分为不同的亚组。RE阴性组可能存在混合反流或胆汁反流     

非糜烂性反流病临床和动力特征的初步研究

目的　对非糜烂性反流病 (NERD)临床和食管功能检查的特征进行初步的探讨。方法　 74例根据内镜检查、2 4h食管pH和胆汁联合监测的结果分为NERD组 ( 3 6例 )和反流性食管炎 (RE) ( 3 8例 ) ,对其进行一般状况、内镜表现和动力检查等方面的比较分析。结果　NERD组的女性发病倾向、合并食管裂孔疝少 ,与RE存在显著差异。两组 2 4h食管pH监测无显著差异 ,但NERD组 2 4h食管胆汁监测的各项指标 :光吸收值 >0 .14时间百分比 ( % )、反流 >5min的次数分别为 8.6± 11.8、3 .0± 3 .8,均显著RE低于相应的 17.1± 2 2 .2、5 .4± 6.0 ,体部收缩波幅则高于RE患者 (P <0 .0 5 )。结论　NERD与RE患者的临床、食管动力特征存在差异 ,RE患者中十二指肠胃食管反流 (DGER)发生更频繁 ,相对更为严重 ,提示两者病理生理机制可能有不同之处     

非糜烂性胃食管反流病食管黏膜肥大细胞的改变

目的探讨在非糜烂性胃食管反流病（non erosive reflux disease，NERD）患者中食管黏膜肥大细胞的改变。方法选择14例NERD患者（NERD组）与10例正常健康志愿者（对照组），取食管黏膜组织，行免疫组化法染色观察并计数肥大细胞，电镜下观察肥大细胞超微结构。结果NERD组患者食管黏膜肥大细胞数量显著高于对照组（P〈0．01）；黏膜脱颗粒肥大细胞比率显著高于对照组（P〈0．01）；电镜观察到NERD组患者肥大细胞内高尔基体、线粒体及内质网较多，有特异性分泌颗粒，存在较多脱颗粒后留下的空泡。结论NERD患者食管黏膜肥大细胞数增多，功能活跃，可能在NERD的发病机制中具有一定作用。     

High Expression of Calcitonin Gene-Related Peptide and Substance P in Esophageal Mucosa of Patients with Non-Erosive Reflux Disease

Background

Visceral hypersensitivity is an important etiology of non-erosive reflux disease (NERD). Calcitonin gene-related peptide (CGRP) and substance P (SP) are involved in the sensitization of afferent neuronal pathways.

Aim

The objectives of this study were to evaluate visceral hypersensitivity in NERD patients, investigate the association between visceral hypersensitivity and mucosal expression of SP and CGRP, and assess their involvement in the pathogenesis of NERD.

Methods

Twenty-six NERD patients and 12 healthy volunteers were recruited. Intraesophageal balloon distention was performed, and initial perception threshold (IPT) and threshold of discomfort (ToD) were determined. Immunohistochemical staining was used to measure the optical density (OD) of CGRP and SP-reactive levels in esophageal mucosa, and the numbers of CGRP and SP-reactive neural fibers.

Results

IPT and ToD were 9.6 ± 4.8 and 12.3 ± 3.2 ml, respectively, in NERD patients, significantly lower than for controls (13.2 ± 7.5 and 21.6 ± 5.7 ml, P < 0.05 and P < 0.01, respectively). Mean OD values for CGRP and SP staining were significantly higher in NERD than for controls (both P < 0.05) and, in NERD, were negatively correlated with IPT and ToD (all P < 0.01). Numbers of CGRP and SP-reactive neural fibers in esophageal submucosa of NERD patients were significantly increased (both P < 0.05).

Conclusions

Expression of esophageal epithelial CGRP and SP is increased, and correlates negatively with perception thresholds in NERD. These findings may aid understanding of peripheral visceral hypersensitivity and the development of new therapeutic approaches for management of NERD.     

P物质和降钙素基因相关肽及炎症因子在非糜烂性食管炎发生中的作用研究

ObjectiveTo explore the mechanism of substance P (SP), calcitonin gene-related peptide (CGRP) and inflammatory cytokines in the development of non erosive reflux disease. MethodsA total of 25 NERD patients and 10 normal controls were enrolled. All the subjects underwent GERDQ score, 24 h pH monitoring, high resolution esophageal manometry monitoring and endoscopic removal of the local mucosa at 3 cm of the esophageal dentate line as specimens. The expression of SP, CGRP and inflammatory cytokines (IL-1β, IL-6, IFN-γ, TNF-α) was detected by HE staining and RT-PCR. Results24 h esophageal pH monitoring showed that the number of weak acid reflux (4＜pH＜7), acid reflux (pH≤4), acid reflux (%) in proximal esophagus and DeMeester score in NERD group were significantly higher than in control group the t values were -2.365, -2.145, -2.782 and -2.776, and the P values were 0.025, 0.021, 0.021 and 0.017, respectively (P＜0.05). H&E staining showed that there were obvious neutrophil infiltration and pre-inflammatory reaction in esophageal mucosa of NERD group, and the score of inflammation injury was significantly higher than that of control group,the P value were 0.003 (P＜0.01). The relative expression of SP and CGRP in NERD group was significantly higher than that in control group, the P values were 0.0046,0.002, respectively (P＜0.01). In NERD group, the relative expressions of IL-1β, IL-6, IFN-γ and TNF-α in esophageal mucosa were significantly increased,P values were 0.0034, 0.0043, 0.004 and 0.0028, respectively (P＜0.01). Pearson correlation analysis showed that the acid reflux score (DeMeester) in NERD group was positively correlated with the expression of SP, CGRP and inflammatory factors (IL-1β, IL-6, IFN-γ, TNF-α) respectively. The P values 0.003, 0.000, 0.002, 0.005, 0.004 and 0.000, respectively (P＜0.01), the correlation coefficients were r=0.678, 0.686, 0.90, 0.482, 0.374 and 0.415, respectively. ConclusionThe expression of SP, CGRP and inflammatory cytokines in NERD patients increased significantly, which may be closely related to the increase of esophageal acid sensitivity caused by acid reflux and the occurrence of inflammation.     

Alterations in cerebral potentials evoked by rectal distention and drinking ice water in patients with irritable bowel syndrome

AIM: Visceral hypersensitivity has been found to be present in irritable bowel syndrome (IBS). The current study sought to study visceral afferent hypersensitivity in IBS patients and obtain further objective evidence of alterations in intestinal afferent pathways in IBS patients by cerebral evoked potentials (CEP). METHOD: We studied 30 female IBS patients and 12 female healthy subjects. Rectal perception thresholds to balloon distention were measured and CEP was recorded in response to rhythmic rectal distention (two distention series, each of 100 repetitions at a frequency of 1 Hz) at the volume of perception thresholds. All subjects were then asked to drink 220 mL 4 degrees C ice water and the above steps were repeated 20 min later. RESULTS: Rectal distention led to recognizable and reproducible CEP. Compared to healthy subjects, IBS patients demonstrated significantly shorter N1, P1 and N2 latencies (P < 0.05). After drinking ice water, IBS patients exhibited further shortened N1, P1 and N2 latencies (P < 0.05), but drinking did not alter the latencies of healthy controls and the amplitudes of both IBS patients and healthy controls. CONCLUSION: The shorter latency of cerebral potentials evoked by rectal distention and ice water stimulation in IBS patients provided further objective evidence for defective visceral afferent transmission in IBS patients.     

Relevance of ineffective esophageal motility and hyperactive acid sensitization in patients with gastroesophageal reflux

BACKGROUND AND AIM: Esophageal motor abnormalities including ineffective esophageal motility (IEM) and visceral hypersensitivity have been frequently observed in patients with gastroesophageal reflux. The aim of this study was to observe the incidences of hypersensitivity to acid infusion and motor abnormalities in non-erosive reflux disease (NERD) compared with erosive esophagitis. METHODS: We performed upper GI endoscopy, an acid perfusion test and esophageal manometry on 113 NERD patients and 37 erosive esophagitis patients. RESULTS: The frequency of acid sensitization was 69.9% in NERD and 67.6% in erosive esophagitis. The frequency of esophageal motor abnormality in patients with erosive esophagitis (48.6%) was higher than in patients with NERD (25.7%, P = 0.014). The most frequent esophageal motor abnormality was IEM. The frequency of IEM was 15.9% in NERD patients, 42.9% in Los Angeles grade A, 53.8% in Los Angeles grade B and 66.7% in Los Angeles grade C esophagitis (chi(2) = 16.67, P < 0.0001). CONCLUSION: Our results suggest that no difference exists between visceral hypersensitivity in patients with NERD and those with erosive esophagitis, and that IEM occurs in NERD as well as erosive esophagitis patients. The occurrence of IEM is associated with the endoscopic severity of gastroesophageal reflux disease.     

Role of Nociceptors/Neuropeptides in the Pathogenesis of Visceral Hypersensitivity of Nonerosive Reflux Disease

Background and Aims

Esophageal visceral hypersensitivity has been proposed to be a pathogenesis of heartburn in nonerosive reflux disease (NERD), but its further mechanisms are unclear. Recently, it has been suggested that nociceptors and neuropeptides control sensory and pain mechanisms. Therefore, the objective of the present study was to estimate expression of acid-sensitive nociceptors such as transient receptor potential vanilloid 1 (TRPV1) and acid-sensing ion channel 3, protease-activated receptor 2 (PAR2), neuropeptides such as substance P and calcitonin-gene-related peptide, and their receptors such as neurokinin 1 receptor (NK1R) and receptor activity-modifying protein 1 in the esophageal mucosa of NERD patients.

Methods

Biopsy samples were taken from NERD patients and healthy control subjects without heartburn. The expression level of nociceptors, neuropeptides, and their receptors were assessed by real-time RT-PCR and enzyme immunoassay. Localization of substance P and CGRP in the esophageal mucosa was determined by immunohistochemical staining.

Results

Expression of mRNA for TRPV1 and PAR2 was significantly elevated in the esophageal mucosa of NERD patients. Substance P protein level and its receptor NK1R mRNA also increased in NERD patients. A positive correlation between the substance P protein level and reflux symptoms was observed. Immunohistochemical study revealed the presence of substance P-positive nerves in the lamina propria of the esophagus.

Conclusions

These findings suggest that visceral hypersensitivity in NERD patients is involved in neurogenic inflammation showing the increase in both substance P release and NK1R expression, which may be associated with the activation of TRPV1 and PAR2.