内科：胃食管反流病的药物治疗

胃食管反流病（GERD）包括反流性食管炎（RE）和内镜阴性的胃食管反流病（或称非糜烂性反流病，NERD）。GERD的药物治疗原则主要是控制症状、减少复发、防止并发症。药物治疗GERD多采用递减法，即一开始先用质子泵抑制剂加促胃肠动力药，以求迅速控制疾病，快速治愈食管炎，待症状控制后再减量维持。     

关于食管阻抗术及试验性治疗诊断胃食管反流病的临床分析

胃食管反流病是胃内容物反流入食管导致的疾病.通过测定中国健康志愿者的正常值,探讨烧心患者的胃食管反流模式,子泵抑制剂试验性治疗胃食管反流病,今后国内该方面研究提供参考.     

消化系统疾病查房会诊(一)——胃食管反流病

胃食管反流病是指胃和十二指肠内容物汇流进入食管而引起的临床症状。胃食管反流病在西方国家十分常见，人群中约有7％～15％的人有胃食管反流症状，40-60岁为高峰发病年龄，男女发病无差异。与西方国家比较，我国发病率较低，病情较轻。部分胃食管反流病患者内镜下无反流性食管炎表现，这类胃食管反流病称为内镜阴性的胃食管反流病。     

奥美拉唑联合多潘立酮治疗以哮喘为首发症状的小儿胃食管反流病的临床观察

目的 评价质子泵抑制剂奥美拉唑和胃肠动力药多潘立酮联合治疗以哮喘为首发症状的的小儿胃食管反流病的效果.方法 对62例患儿在联合用奥美拉唑及多潘立酮治疗前后的临床表现、24 h食管pH监测值、电子胃镜检查及内镜下粘膜活检的变化情况及不良反应进行比较.结果 62例患儿用药前及用药后每2周进行临床症状观察,发现治疗后临床症状逐渐改善及消失,24 h食道pH监测各项指标在治疗后均小于治疗前.差异有显著意义(P<0.01),治疗前后的电子胃镜检查及活检对反流性食管炎的评价,发现治疗后反流性食管炎表现逐渐好转或消失,差异有显著意义(P<0.01),治疗后未见明显不良反应.结论 奥美拉唑联合多潘立酮治疗小儿胃食管反流疗效确切,无不良反应.     

胃食管反流病69例临床观察

目的总结胃食管反流病诊治经验,提高对胃食管反流病多种症状的认识。方法收集该院2010年6月—2012年6月间诊治的胃食管反流病69例临床资料,进行回顾性分析。结果 69例胃食管反流病确诊后经过一般综合治疗,药物及进一步诊治,症状得到缓解。食管炎治愈。结论早期准确诊断并给予准确及时治疗是提高胃食管反流病诊治水平的关键。     

儿童胃食管反流病的诊断与治疗

胃食管反流病(GERD)是指胃内容物包括从十二指肠流入胃的胆盐和胰酶等反流至食道引起的不适症状.胃食管反流病(GERD)既可有食管内症状,也可有食管外症状.     

胃食管反流病与慢性咳嗽

胃食管反流病是发病率很高的胃肠道疾病。烧心是胃食管反流病的最主要症状，其他表现包括反酸和吞咽困难。一些胃食管反流病患者可无症状，而另一些可有非典型的症状、包括心绞痛样疼痛或呼吸道症状。     

胃食管反流性咳嗽35例临床分析

目的探讨胃食管反流性咳嗽的临床表现和治疗。方法对2005年7月～2007年12月解放军533医院收治的35例胃食管反流性咳嗽进行回顾性分析。结果 35例患者中,均以日间咳嗽为重,68.6%表现为进食时、进食后咳嗽;5.7%伴随反流相关症状;11例误诊为慢性咽炎,9例误诊为慢性支气管炎,1例误诊为特发性肺纤维化,误诊率达60.0%。35例通过质子泵抑制剂或H2受体拮抗剂和促胃动力药治疗,治疗总有效率100%。结论胃食管反流性咳嗽是慢性咳嗽的常见原因,抗酸治疗有明显效果。     

第一节胃食管反流病

1 概述 胃食管反流病是指由于胃十二指肠内容物反流入食管而产生的症状或并发症,包括了食管黏膜破损或无破损等情况.酸(碱)反流导致的食管黏膜破损称为反流性食管炎,是胃食管反流病中最常见的一种类型,内镜检查是反流性食管炎的主要诊断方法.胃食管反流病的临床特点为胸骨后不适、疼痛、烧心、反酸、咽下疼痛或咽下困难,部分病人反复发作的哮喘、咳嗽、夜间呼吸暂停和咽喉炎等症状可能与胃食管反流病有关.西方国家中,胃食管反流病约占人口的7%～15%、反流性食管炎占人口的3%～4%,男性多于女性.     

胃食管反流病诊断方法及抑酸治疗试验评价

目的　评价胃食管反流病 (GERD)诊断方法及质子泵抑制剂 (PPI)治疗试验的价值。方法　对 10 4例有烧心、反酸或反食 ,伴有或不伴有非心源性胸痛、咽下疼痛及平卧时呛咳等症状的患者进行症状评分、内镜检查、食管测压、2h食管腔内pH监测和 7d的安慰剂或兰索拉唑 (30mg ,每天 2次 )随机分组交叉对照治疗试验 ;以2 4h食管下段pH <4的总时间 >4 %或和 /反流总评分 >14分作为诊断病理性胃食管酸反流的标准 ;用PPI抑制治疗第 5、6、7共 3d的症状总评分与用药前 3d的症状总评分相比较 ,以症状总分下降 >75 %者为治疗试验阳性。结果　 10 4例中内镜检出食管炎 18例 (17% ) ;烧心为主要症状者 83例 (80 % ) ;pH监测结果符合病理性胃食管酸反流 (GERD)者 87例 (84 % ) ;兰索拉唑治疗试验阳性者 85例 (82 % ) ,两种诊断方法的结果显著相关 (P <0 0 1)。胃镜及食管测压对GERD的检出率低 ,由 2 4h食管pH监测诊为GERD者 87例中 ,治疗试验阳性者 82例 (敏感性94 % ) ,pH监测结果阴性者的另 17例中 ,治疗试验阴性 14例 (特异性 82 % ) ,兰索拉唑治疗试验对诊断GERD的准确性为 92 %。结论　对有典型胃食管反流症状的患者 ,质子泵抑制剂抑酸治疗试验用于辅助诊断GERD可先于食管测压及 2 4h食管腔内pH监测进行 ,它具有较高     

Gastroesophageal reflux disease in mentally retarded persons: prevalence, diagnosis and treatment

The prevalence of gastroesophageal reflux disease among institutionalised intellectually disabled individuals with an IQ < 50 is high: about 50% have an deviant 24-hour pH measurement and 70% of them have refluxoesophagitis. Intellectually disabled individuals have an increased risk of gastroesophageal reflux disease in case of cerebral palsy, IQ < 35, scoliosis, use of anticonvulsant drugs or benzodiazepines, not being ambulant, and in case of symptoms such as haematemesis, rumination or dental erosions. To establish the diagnosis is difficult because of the aspecific symptoms. Reflux disease is only diagnosed at a late stage. 24-hour pH measurement should be used in all those intellectually disabled individuals in whom gastroesophageal reflux disease is clinically suspected. For the treatment of gastro-oesophageal reflux disease in adults as well as children, proton pump inhibitors are highly effective, independent of the severity of oesophagitis. Marked improvement of symptoms and quality of life can be noticed after treatment.     

25 years of gastric acid blockers

Since the mid-seventies, it is possible to treat peptic ulcers and reflux oesophagitis with acid secretion inhibitors. The most important medicaments are H2-receptor antagonists (cimetidine was registered in 1977) and proton pump inhibitors (1988: omeprazole). Surgical treatment of these conditions is almost a thing of the past. Many Dutch researchers played an important part in clinical research of acid secretion inhibitors; the first studies of effect and safety were done in patients with severe overproduction of gastric acid (Zollinger-Ellison syndrome) and in those with severe reflux oesophagitis. At present the most important syndromes in which acid secretion inhibitors are used are gastroesophageal reflux disease, gastric or duodenal ulcers and acid-related dyspepsia.     

兰索拉唑联合莫沙比利治疗68例胃食管反流病的疗效观察

[目的]结合临床实践经验,探讨兰索拉唑联合莫沙比利治疗胃食管反流病的临床疗效。[方法]采用对照研究,经患者知情同意,将其分为对照组(34例)与观察组(34例),治疗前2周,所有病例内均未服用H2受体拮抗剂和质子泵抑制剂。对照组给予兰索拉唑(30mg),早晨空腹服用,每日1次。观察组采用联合用药,在对照组的基础上给予莫沙比利(5mg)餐前半小时服用,每日3次。所有患者治疗6周后复查胃镜,比较治疗效果,探讨兰索拉唑联合莫沙比利治疗胃食管反流病的临床疗效。[结果]治疗前后,各组患者差异有统计学意义(P﹤0.05),治疗6周后,观察者患者炎症程度明显低于对照组,差异有统计学意义(P﹤0.05)。观察组总有效率明显高于对照组,差异有统计学意义(χ2=13.29,P﹤0.05),观察组有3例患者出现不良反应(8.82),其中稀便1例,头晕1例,倦怠1例。对照组有4例患者出现不良反应(11.76),其中,稀便1例,头晕1例,口干1例,恶心1例。两组不良反应发生率差异无统计学意义(P﹥0.05)。[结论]采用兰索拉唑联合莫沙比利治疗反流性食管病疗效显著,值得临床推广应用。     

Gastroesophageal reflux in adolescents

Gastroesophageal reflux disease (GERD) occurs in adolescents but its frequency and severity is less than in adults. Typical symptoms of heartburn and regurgitation generally do not require a diagnostic evaluation unless they are associated with alarm signs including odynophagia, dysphagia, upper gastrointestinal bleeding, weight loss, atypical chest pain, or respiratory disease. Empiric treatment with proton pump inhibitors (PPIs) provides relief in most patients. Patients with persistent symptoms requiring PPI therapy should undergo endoscopy. Those with chronic GERD require medical or surgical therapy, whereas those with nonerosive reflux disease often benefit from changes in lifestyle or intermittent, on-demand medical therapy with a therapeutic aim of symptom relief. Surgical therapy is rarely required but may have a role in adolescents with respiratory complications of gastroesophageal reflux or neurologic handicap.     

Hypercalcemia and peptic ulcer disease-related Milk-alkali syndrome.

Milk-alkali syndrome was considered "extinct" by 1985 because of the advent of non-alkaline ulcer medications (ie, histamine-2 receptor blockers and proton pump inhibitors). At that time, it was thought to cause <1% of hypercalcemia, which occurred when one ingested a sufficient quantity of calcium and alkali together. This case emphasizes the importance of considering this syndrome in patients who self-medicate for control of symptoms related to gastroesophageal reflux and peptic ulcer disease and for those using calcium supplementation for prevention or treatment of osteoporosis.     

Refractory chronic cough due to gastroesophageal reflux: Definition,mechanism and management

Refractory chronic cough due to gastroesophageal reflux is a troublesome condition unresponsive to the standard medical anti-reflux therapy. Its underlying mechanisms may include incomplete acid suppression, non-acid reflux, transient lower esophageal sphincter relaxations and esophageal hypersensitivity. The diagnosis of this disorder depends on both the findings of multi-channel intraluminal impedance-pH monitoring and the subsequent intensified anti-reflux therapy. The strategies of pharmacological treatment for refractory chronic cough due to reflux include the optimization of proton pump inhibitors and add-on therapies with histamine H₂ receptor antagonists, baclofen and gabapentin. However, the further study is needed to satisfy its management.     

Lansoprazole ineffective for functional dyspepsia

Patients with functional dyspepsia, which involves no organic disease and no reflux, do not benefit from lansoprazole, a proton pump inhibitor. Any improvement seen is probably related to a placebo effect. Prescribing proton pump inhibitors for these patients just for their placebo effect is going to further raise health care costs. Antacids and H2 blockers are less expensive alternatives.     

Reasons for proton-pump-inhibitor failure in the treatment of gastroesophageal reflux disease

The introduction of proton pump inhibitors (PPI) has facilitated the successful management of patients with gastroesophageal reflux disease (GERD). In a minor, but still relevant proportion of patients with GERD-like symptoms, PPI therapy has also proved to be ineffective. In such cases, the first question to be answered is if the symptoms and complaints are related to GERD indeed, or another disorder should be searched for. If GERD is still the most likely diagnosis, patients' compliance should be thoroughly investigated before any further diagnostic and therapeutic measure is taken. If PPI failure is not a result of inadequate management of GERD, there are several other disorders to be ruled out. In our review, we summarize the most important differential diagnostic issues of PPI failure.     

As-needed treatment with gastric acid inhibitors in gastroesophageal reflux disease

Although proton pump inhibitors and H2-receptor antagonists are usually prescribed for continuous use by patients with gastro-oesophageal reflux disease, at least 50% of such patients do not take their medication daily and some take it only sporadically. On-demand treatment with proton pump inhibitors or H2-receptor antagonists is safe and cost-effective. Indications are: (a) incidental reflux episodes of short duration, (b) periodic reflux lasting several weeks or months, (c) chronic reflux not requiring continuous treatment. On-demand treatment is unsuitable for patients with reflux disease who either require daily medication or in whom the maximal dosage is insufficient. There are three types of on-demand treatment. Type 1: use of medication only in case of incidental symptoms. Type 2: continuous medication for 2-4 weeks when symptoms appear. Type 3: continuous use because of chronic symptoms, but the interval between doses is determined by the patient on the basis of his symptoms. All antacids can in principle be used for on-demand treatment; for type 3 treatment, antacids with a rapid onset of action are preferred. A favourable response to the two weeks of initial therapy is a good predictor for successful on-demand treatment.     

Clinical pharmacological aspects of the proton pump inhibitor therapy: importance of pharmacogenetic differences in the clinical practice

Proton pump inhibitors (PPIs) are widely used for the treatment of gastroesophageal reflux disease, as well as other acid-related disorders. Omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole effectively suppress gastric acid secretion by blocking the gastric acid pump, H+/K+ -adenosine triphosphatase (ATPase).Understanding the pharmacokinetic properties of PPIs and examining the pharmacogenetic differences may help clinicians to optimize PPI therapy and to perform individual treatment, especially in non-responder patients with GERD or ulcer or after failed eradication therapy.