妊娠晚期胃食管反流病的特点分析

目的探讨妊娠晚期胃食管反流病的特点。 方法收集2014年1月至2015年12月,在乌鲁木齐市友谊医院妇产科收治的82例妊娠晚期妇女临床资料,记录孕产史,胃灼热和反酸症状的频率及程度,分析妊娠晚期妇女胃食管反流症状的特点。 结果其中62例(76%)孕妇有胃灼热症状,58例(71%)孕妇有反酸症状,20例无症状,平均孕周为(33.8±3.7)周,35例(43%)孕妇有胃灼热和反酸家族史,54例经产妇(65%)在既往的妊娠期出现过胃灼热症状,57例(70%)怀孕前无症状。 结论妊娠期胃食管反流症状发病率明显升高,胃食管反流具有家族性特点,既往妊娠期与本次妊娠晚期出现的胃灼热症状具有相关性。     

Gastroesophageal reflux disease during pregnancy

Approximately two thirds of pregnant patients develop heartburn. The origin is multifactorial, but the predominant factor is a decrease in LES pressure caused by female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare; therefore EGD and other diagnostic tests are infrequently needed. Symptomatic GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line medical therapy. If symptoms persist, H2RAs should be used. Ranitidine is probably preferred because of its documented efficacy and safety profile in pregnancy, even in the first trimester. Proton-pump inhibitors are reserved for the woman with intractable symptoms or complicated reflux disease. Lansoprazole may be the preferred PPI because of its safety profile in animals and case reports of safety in human pregnancies.     

妊娠期胃食管反流病的症状特征研究

目的探讨妊娠期胃食管反流病（GERD）症状的发生率及严重程度。 方法选取2018年1月至2019年1月,新疆维吾尔自治区人民医院住院就诊的120例孕妇设定为研究组,进行了一项前瞻性纵向队列研究,通过GerdQ问卷调查妊娠期GERD的患病率。同期选取健康体检者40例非怀孕妇女作为对照组。2组每3个月均记录反流症状的频率和严重程度。 结果妊娠（早、中、晚期）和非孕妇GERD问卷调查结果表示,妊娠晚期的评分范围（3~7分、8~10分、11~14分及15~18分）均明显高于对照组,差异均有统计学意义（P＜0.05）。在孕妇中,5.0%的患者在怀孕前3个月（早期）至少每周有1次反流。在妊娠晚期,15.0%的孕妇每周至少有1次反流,2.50%的非孕妇每周发生1次以上的反流,各组间比较具有统计学意义（P＜0.05）。在孕妇中,5.0%的妊娠早期至少每周有1次烧心。妊娠中期为10.0%,晚期为17.5%,2.5%的非孕妇每周至少有1次烧心,在妊娠晚期,发生烧心的妇女占17.5%,各组间比较具有统计学意义（P＜0.05）。从妊娠早期到妊娠中、晚期,个别症状（反流,烧灼感）的频率与非孕妇组比较均明显增加,在妊娠晚期症状出现的频率达到高峰,与非孕妇组以及妊娠早期比较,具有明显的统计学意义（P＜0.05）。根据症状诊断及发生情况,GERD在妊娠早期发病率为24.5%,在中期为37.5%,在妊娠晚期为52.5%,非孕妇（对照组）GERD患病率为7.5%。 结论妊娠晚期GERD症状发生率明显高于非孕妇,且在妊娠过程中发生率逐渐增高。     

Evidence-based treatment recommendations for gastroesophageal reflux disease during pregnancy: A review

Gastroesophageal reflux disease (GERD) occurs in approximately two-thirds of all pregnancies. Around 25% of pregnant women experience heartburn daily. Symptomatic GERD usually presents in the first trimester and progresses throughout pregnancy. The treatment goal is to alleviate heartburn and regurgitation without jeopardizing the pregnancy or its outcome. An English language electronic literature search of MEDLINE, EMBASE, and Cochrane Reviews was undertaken to identify randomized controlled trials, observational studies, management recommendations and reviews of GERD and its treatment during pregnancy. The search period was defined by the date of inception of each database. The treatment in a pregnant GERD patient should follow the step-up approach, starting with lifestyle modification as the first step. If heartburn is severe, medication should be started after consultation with a physician (Recommendation Grade C). The preferred choice of antacids is calcium-containing antacids (Recommendation Grade A). If symptoms persist with antacids Sucralfate can be introduced at a 1g oral tablet, 3 times daily (Recommendation Grade C). Followed by histamine-2 receptor antagonist (Recommendation Grade B). Inadequate control while on histamine-2 receptor antagonist and antacid may mandate a step-up to proton pump inhibitors along with antacids as rescue medication for breakthrough GERD (Recommendation Grade C). This article presented the treatment recommendations for pregnant women with typical GERD, based on the best available evidence.     

A pregnant patient with excessive belching

We present a patient that developed severe belching during pregnancy. Esophageal pH‐impedance monitoring revealed frequent supragastric belching, but not gastroesophageal reflux disease (GERD). Thus, severe belching during pregnancy can be due to a behavioral disorder in the absence of GERD. Belching complaints during pregnancy should therefore not always be treated as GERD.     

Functional heartburn, nonerosive reflux disease, and reflux esophagitis are all distinct conditions—A debate: Con

Opinion statement Gastroesophageal reflux disease (GERD) is currently defined as a condition that develops when the reflux of stomach contents causes recurrent symptoms and/or complications. The clinical presentation of GERD has been recognized to be much broader than before, when the typical symptoms of heartburn and acid regurgitation were considered as the main clinical presentation. However, now it is recognized that GERD can present with various other mainly extraesophageal symptoms, abdominal pain, and even sleep disturbance. Moreover, there is an important overlap with functional gastrointestinal disorders such as functional dyspepsia and irritable bowel syndrome. The morphologic spectrum of esophageal involvement in GERD encompasses erosive (erosive reflux disease [ERD]), Barrett’s esophagus (BE), and nonerosive reflux disease (NERD). However, there is still no consensus on whether GERD represents one disease that can progress from NERD to ERD and BE, or whether it is a spectrum of different conditions with its own clinical, pathophysiologic, and endoscopic characteristics. Recently published data suggest that mild erosive esophagitis behaves in a way similar to NERD and that there is considerable movement between these categories. But follow-up data also show that after 2 years, some patients with NERD or GERD Los Angeles A or B went on to develop severe GERD or even BE. A practical approach is to categorize patients with reflux symptoms into “functional heartburn” (ie, reflux symptoms and negative endoscopy and absent objective evidence of acid reflux into the esophagus), NERD (negative endoscopy but positive documentation of acid reflux into the esophagus), and ERD (erosions documented endoscopically). In conclusion, it appears that GERD is a disease with a spectrum of clinical and endoscopic manifestations, with characteristics that make it a continuum and not a categorical condition with separate entities. It is difficult to clearly delineate the spectrum of GERD based on the clinical, endoscopic, and pathophysiologic characteristics, but therapeutic trials and follow-up studies suggest that GERD is not composed of different conditions.     

Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease

Guidelines for the diagnosis and treatment of gastroesophageal reflux disease (GERD) were published in 1995 and updated in 1999. These and other guidelines undergo periodic review. Advances continue to be made in the area of GERD, leading us to review and revise previous guideline statements. GERD is defined as symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus. These guidelines were developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee, and approved by the Board of Trustees. Diagnostic guidelines address empiric therapy and the use of endoscopy, ambulatory reflux monitoring, and esophageal manometry in GERD. Treatment guidelines address the role of lifestyle changes, patient directed (OTC) therapy, acid suppression, promotility therapy, maintenance therapy, antireflux surgery, and endoscopic therapy in GERD. Finally, there is a discussion of the rare patient with refractory GERD and a list of areas in need of additional study.     

Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults - update 2004.

BACKGROUND: Gastroesophageal reflux disease (GERD) is the most prevalent acid-related disorder in Canada and is associated with significant impairment of health-related quality of life. Since the last Canadian Consensus Conference in 1996, GERD management has evolved substantially. OBJECTIVE: To develop up-to-date evidence-based recommendations relevant to the needs of Canadian health care providers for the management of the esophageal manifestations of GERD. CONSENSUS PROCESS: A multidisciplinary group of 23 voting participants developed recommendation statements using a Delphi approach; after presentation of relevant data at the meeting, the quality of the evidence, strength of recommendation and level of consensus were graded by participants according to accepted principles. OUTCOMES: GERD applies to individuals who reflux gastric contents into the esophagus causing symptoms sufficient to reduce quality of life, injury or both; endoscopy-negative reflux disease applies to individuals who have GERD and a normal endoscopy. Uninvestigated heartburn-dominant dyspepsia - characterised by heartburn or acid regurgitation - includes erosive esophagitis or endoscopy-negative reflux disease, and may be treated empirically as GERD without further investigation provided there are no alarm features. Lifestyle modifications are ineffective for frequent or severe GERD symptoms; over-the-counter antacids or histamine H2-receptor antagonists are effective for some patients with mild or infrequent GERD symptoms. Proton pump inhibitors are more effective for healing and symptom relief than histamine H2-receptor antagonists; their efficacy is proportional to their ability to reduce intragastric acidity. Response to initial therapy - a once-daily proton pump inhibitor unless symptoms are mild and infrequent (fewer than three times per week) - should be assessed at four to eight weeks. Maintenance medical therapy should be at the lowest dose and frequency necessary to maintain symptom relief; antireflux surgery is an alternative for a small proportion of selected patients. Routine testing for Helicobacter pylori infection is unnecessary before starting GERD therapy. GERD is associated with Barrett's epithelium and esophageal adenocarcinoma but the risk of malignancy is very low. Endoscopic screening for Barrett's epithelium may be considered in adults with GERD symptoms for more than 10 years; Barrett's epithelium and low-grade dysplasia generally warrant surveillance; endoscopic or surgical management should be considered for confirmed high-grade dysplasia or malignancy. CONCLUSION: Prospective studies are needed to investigate clinically relevant risk factors for the development of GERD and its complications; GERD progression, on and off therapy; optimal management strategies for typical GERD symptoms in primary care patients; and optimal management strategies for atypical GERD symptoms, Barrett's epithelium and esophageal adenocarcinoma.     

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

Background and Aims: Since the publication of the Asia‐Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed. Methods: A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Results: GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On‐demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non‐GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials. Conclusions: Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.     

The construction of a new evaluative GERD questionnaire--methods and state of the art

Gastroesophageal reflux disease (GERD) is one of the most prevalent diseases worldwide, and it is becoming increasingly important to monitor the effect of various interventions on GERD symptoms. There can be rapid temporal changes in the severity and frequency of patients' symptoms as well as their health status and well-being, all of which could, theoretically, be monitored using diaries or questionnaires. However, current GERD monitoring instruments are not appropriate because they do not assess symptoms daily, they are not sufficiently responsive to short-term changes in health status or they are not adequately validated. To address these problems, the conceptual and psychometric requirements for a GERD symptom assessment questionnaire were identified. A dimension-based scale was designed to reduce the number of symptoms monitored on a daily basis, and the validation process was defined to produce parallel long and short forms of a scale for patients' self-assessment of their GERD symptom response to therapy. These basic principles which underlie the successful development of a new, self-assessed symptomatic reflux questionnaire (ReQuest) are also applicable to the development of validated questionnaires for daily symptom self-assessment in other disease areas.     

The epidemiology of gastroesophageal reflux disease

Symptoms of gastroesophageal reflux disease (GERD) are among the most common encountered in primary practice. Reported symptoms certainly under-represent the true prevalence of this disease in the population, because many patients do not seek care for symptoms of GERD and many physicians do not specifically ask about such symptoms when performing the review of systems. We describe the epidemiology of GERD. We begin by considering the prevalence of GERD as a function of the disease definition used. We then discuss the epidemiology of nonerosive reflux disease. After that, we consider the population risk factors for GERD. Next, we briefly touch on the epidemiology of GERD complications, including erosive esophagitis, strictures, and Barrett esophagus. We will end with a brief discussion of population screening of those with GERD for Barrett esophagus.     

Gastroesophageal reflux disease in pregnancy

Opinion statement Gastroesophageal reflux disease (GERD) in pregnancy presents a special challenge for the clinician, predominantly because of the potential side effects of pharmacologic interventions on the fetus. Lifestyle and dietary modifications, change in sleeping posture, and antacid medications are emphasized, as these options pose little risk to the fetus. When these interventions are not successful, sucralfate, a mucosal protectant with little to no systemic absorption, should be considered next. Therapy with H₂ receptor antagonists or proton pump inhibitors can be considered in patients with refractory symptoms; though not approved for this use, they are likely safe, particularly in third trimester. Prokinetic agents should be used with extreme caution or avoided altogether in the pregnant patient.     

An updated review on gastro-esophageal reflux in pediatrics

Comprehensive guidelines for the diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) were developed by the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. GERD is reflux associated with troublesome symptoms or complications. The recognition of GER and GERD is relevant to implement best management practices. A conservative management is indicated in infants with uncomplicated physiologic reflux. Children with GERD may benefit from further evaluation and treatment. Since the publications of the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition guidelines in 2009, no important novelties in drug treatment have been reported. Innovations are mainly restricted to the management of regurgitation in infants. During the last 5 years, pros and cons of multichannel intraluminal impedance have been highlighted. However, overall ‘not much has changed’ in the diagnosis and management of GER and GERD in infants and children.     

Utilization of wireless pH monitoring technologies: a summary of the proceedings from the Esophageal Diagnostic Working Group

Gastroesophageal reflux disease (GERD) can be difficult to diagnose – symptoms alone are often not enough, and thus, objective testing is often required. GERD is a manifestation of pathologic levels of reflux into the esophagus of acidic, nonacidic, and/or bilious gastric content. However, in our current evidence‐based knowledge approach, we only have reasonable outcome data in regards to acid reflux, as this particular type of refluxate predictably causes symptoms and mucosal damage, which improves with medical or surgical therapy. While there are data suggesting that nonacid reflux may be responsible for ongoing symptoms despite acid suppression in some patients, outcome data about this issue are limited. Therefore, this working group believes that it is essential to confirm the presence of acid reflux in patients with ‘refractory’ GERD symptoms or extraesophageal symptoms thought to be caused by gastroesophageal reflux before an escalation of antireflux therapy is considered. If patients do not have pathologic acid reflux off antisecretory therapy, they are unlikely to have clinically significant nonacid or bile reflux. Patients who do not have pathologic acid gastroesophageal reflux parameters on ambulatory pH monitoring then: (i) could attempt to discontinue antisecretory medications like proton pump inhibitors and H2‐receptor antagonists (which are expensive and which carry risks – i.e. C. diff, etc.); (ii) may undergo further evaluation for other causes of their esophageal symptoms (e.g. functional heartburn or chest pain, eosinophilic esophagitis, gastroparesis, achalasia, other esophageal motor disorders); and (iii) can be referred to an ear, nose, and throat/pulmonary/allergy physician for assessment of non‐GERD causes of their extraesophageal symptoms.     

Functional heartburn and non-erosive reflux disease

Gastroesophageal reflux disease (GERD) is a common disorder in Western countries. For many years our attention has been focused on patients with erosive esophagitis, but in recent times we have realized that endoscopy-negative reflux disease is the most common presentation of this illness, affecting up to 70% of these individuals. Patients with the non-erosive form (NERD) are a heterogeneous group including various subpopulations with different mechanisms for their main symptom of heartburn: reflux of acidic and non-acidic gastric contents, mucosal hypersensitivity, intraesophageal distension by gas, intraduodenal infusion of fat, muscle contractions and psychological abnormalities. As to esophageal acid exposure, patients with NERD can be subdivided into those with abnormal and normal pH testing. The latter group includes patients with a positive correlation between symptoms and reflux events, in whom heartburn can be controlled by proton pump inhibitor (PPI) therapy. According to the recent Rome III criteria, they are still in the realm of GERD. An additional group is called functional heartburn, because this typical symptom is associated neither with an abnormal pH test nor with a positive symptom index. Their response to PPIs is very disappointing. Therefore, there is an increasing consensus on the fact that they do not have GERD and should be treated with drugs other than PPIs.     

Optimal acid suppressive treatment for adequate symptom relief and prevention of the complications of gastroesophageal reflux disease: differences in long-term clinical course and pathophysiology among disease subtypes

Gastroesophageal reflux disease (GERD) is a chronic long-standing disease. Most patients with GERD are thought to require long-term treatment with acid suppressants, with proton pump inhibitors being the drugs of choice in managing these patients. However, there has been no consensus about the frequency of spontaneous remission of GERD. Furthermore, the duration of treatment is individually based, and the end-point of treatment is also not clear. As the symptoms of GERD may be intermittent or occur on most days of the week, treatment may be short term, lasting 8–12 weeks, or long term, lasting more than 1 year. Moreover, treatment may be continuous, intermittent, or on-demand. In contrast, maintenance therapy consists of the lowest proton pump inhibitor dose necessary for adequate symptom relief and prevention of GERD-related complications. GERD has been classified into three subgroups based on endoscopic severity: non-erosive reflux disease (NERD), mild erosive esophagitis (EE), and severe EE. Because these three subgroups differ in long-term clinical course and pathophysiology, their treatment strategies should differ. Treatment of severe EE should include two clinical goals: relief of GERD symptoms and prevention of EE-related complications, such as esophageal ulcer bleeding and/or strictures. However, because mild EE, including NERD, rarely progresses to severe EE during symptom-driven treatment, treatment of these patients should have one clinical goal: relief of GERD symptoms.     

Diagnosis of eosinophilic esophagitis after fundoplication for ‘refractory reflux’: implications for preoperative evaluation

A small percentage of patients who carry the diagnosis of refractory gastroesophageal reflux disease (GERD) actually have eosinophilic esophagitis (EoE). The purpose of this study was to describe a series of patients who underwent fundoplication for presumed refractory GERD, but subsequently were found to have EoE. We performed a retrospective analysis of our EoE database. Patients diagnosed with EoE after Nissen were identified. Cases were defined according to recent consensus guidelines. Five patients underwent anti‐reflux surgery for refractory GERD, but were subsequently diagnosed with EoE. None had esophageal biopsies prior to surgery, and in all subjects, symptoms persisted afterward, with no evidence of wrap failure. The diagnosis of EoE was typically delayed (range: 3–14 years), and when made, there were high levels of esophageal eosinophilia (range: 30–170 eos/hpf). A proportion of patients undergoing fundoplication for incomplete resolution of GERD symptoms will be undiagnosed cases of EoE. Given the rising prevalence of EoE, we recommend obtaining proximal and distal esophageal biopsies in such patients prior to performing anti‐reflux surgery.     

Motion - All patients with GERD should be offered once in a lifetime endoscopy: arguments against the motion.

The evidence for the recommendation that patients with gastroesophageal reflux disease (GERD) be offered once in a lifetime endoscopy is weak and is not supported by any clinical trials. GERD is a very prevalent condition, yet only 10% of patients with GERD have Barrett's esophagus (BE). Esophageal adenocarcinoma (EAC) is a rare condition and is uncommon even among patients with BE. A decision analysis found that surveillance of BE patients is performed because of inflated estimates of the rate of progression from BE to EAC. Dysplasia more often regresses to more benign histological findings than to cancer, and transient dysplasia can also lead to a high rate of unnecessary endoscopy. Even though practice guidelines about endoscopic surveillance have been published, there is no consensus among gastroenterologists about appropriate protocols, and many physicians are more aggressive than the guidelines. It has not been proved that surveillance saves lives, in part because BE rarely leads to death from EAC. The favourable results from some specialized centres may not be widely applicable. The recommendation for 'once in a lifetime' endoscopy for GERD patients is premature.     

Non-erosive reflux disease--defining the entity and delineating the management

In the developed world, most patients with gastroesophageal reflux disease (GERD) do not exhibit erosions when examined by standard white light endoscopy. Despite the high prevalence of such non-erosive reflux disease (NERD), relatively little is known of its underlying pathophysiology, hence there is no clear guide to clinical management. To establish areas of agreement or uncertainty in NERD, an international meeting was held in Vevey, Switzerland, in late 2007. The goal was to document current thinking in the areas of clinical presentation, assessment of clinical outcome, pathobiological mechanisms, and define optimal clinical strategies to diagnose and manage NERD. After extensive debates, the modified Delphi technique was utilized to reach a consensus on 85 specific statements. In addition, it was proposed that NERD be defined as 'a subcategory of GERD characterised by troublesome reflux-related symptoms in the absence of esophageal mucosal erosions/breaks at conventional endoscopy and without recent acid suppressive therapy'. Evidence in support of this diagnosis may include responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic findings. Defining the current state of knowledge in NERD should help improve the elucidation and management of this condition in the future.