超声内镜联合高分辨率食管测压对难治性胃食管反流病患者下食管括约肌结构和运动功能异常的相关性分析

目的应用内镜超声(EUS)与高分辨率食管测压方法(HRM)检测难治性胃食管反流病(GERD)患者食管下括约肌(LES)结构与运动功能变化,探讨EUS在难治性GERD患者LES结构及运动功能异常评估中的有效性和可行性,以及LES厚度与压力间的关系。方法收集14例经内镜、24 h食管p H检测和经双倍剂量质子泵抑制剂(PPI)治疗8周疗效不明显,诊断为难治性GERD的患者,11例正常志愿者作为对照。运用EUS,记录LES的运动影像,测量LES的环形肌和纵形肌分别在不同时相的厚度;经鼻腔导入HRM测压导管,观察静息及吞咽时食管压力的变化,计算LES环形肌和纵形肌的收缩指数、收缩周期,计算LES基底压平均值与LES厚度间的相关性。结果 14例难治性GERD患者与正常对照组相比,LES的纵形肌厚度较薄(P0.05),而环形肌厚度差异无统计学意义(P0.05),环形肌与纵形肌收缩指数均明显缩小、收缩周期延长(P0.05);LES基底压平均值与最大肌层厚度之间存在正相关(r=0.62~0.70)。结论难治性GERD患者LES存在肌层结构与舒缩功能的异常;LES基底压平均值与最大肌层厚度间存在正相关,LES舒缩能力下降与难治性胃食管反流病的发病有直接关系;EUS获得LES的收缩指数、收缩周期为评估难治性胃食管反流病LES运动功能障碍具有一定的参考价值。     

胃食管反流病患者食管动力学特征研究

目的探讨胃食管反流病的高分辨率食管测压特点。方法回顾性分析2012年8月至2014年7月在新疆维吾尔自治区人民医院微创外科就诊,确诊为胃食管反流病患者的高分辨率食管测压结果,研究对象根据性别、年龄段、BMI分型、胃食管连接处形态等分别分组并进行对比分析。结果 (1)男性患者食管下括约肌(LES)中心至鼻孔的距离较女性长,男性患者LES静息压力、LES残余压均低于女性患者,LES松弛率高于女性患者,差异有统计学意义(P<0.05)。(2)不同年龄各组之间相关指标比较无统计学差异(P>0.05)。(3)纳入本研究的400例胃食管反流病患者当中伴有偏胖及肥胖患者占62%,体重指数在正常范围或偏低者食管体部蠕动成功率约78%,偏胖及肥胖者食管体部蠕动成功率为68%。(4)胃食管反流病患者食管远段LES以上3、7、11 cm处压力及平均压力均比正常人降低,远端收缩积分(DCI)明显低于正常人,收缩前沿速度(CFV)、远段各节段蠕动波传导速度均大于正常人。(5)每个完整吞咽的分析,正常蠕动66.10%,失蠕动16.70%,小蠕动缺损9.60%,大蠕动缺损6.50%,快速同步收缩1.10%。(6)每位患者食管动力学的综合分析显示,蠕动正常162例,占40.50%,大缺损弱蠕动61例,占15.25%,小缺损弱蠕动72例,占18%,频发失蠕动85例,占21.25%,无蠕动12例,占3%,快速收缩/同步收缩8例,占2%。(7)根据胃食管连接处形态,51%伴有食管裂孔疝,LES与膈肌脚完全重叠率4.75%。结论胃食管反流病中男性的食管运动功能差于女性,食管动力学无年龄和体重相关差异性。胃食管反流病与正常人比较,LES压力和食管体部运动功能明显降低,其中频发失蠕动、小缺损弱蠕动和大缺损弱蠕动为多见。胃食管反流病多伴有食管裂孔疝,因而LES功能明显降低。食管体部运动功能无食管裂孔疝相关差异性。     

胃食管反流病各亚型的食管测压分析

目的探讨胃食管反流病(GERD)各临床亚型的食管测压变化,以评价其临床价值。方法收集GERD患者150例,其中非糜烂性反流病(NERD)91例、反流性食管炎(RE)32例、Barrett食管(BE)27例,采用4导液压灌注食管压力检测系统测定患者食管下括约肌压力(LESP)和食管体部运动功能。结果 NERD和RE中,食管体部运动功能障碍的发生率与LESP异常的发生率比较有显著性差异(P<0.05),前者高于后者;而在BE患者中,食管体部运动功能障碍的发生率与LESP异常的发生率比较差异无统计学意义(P>0.05)。GERD各亚型中,食管体部运动功能异常的发生率不同,NERD组最高,RE组次之,BE组最低。各亚型LESP异常的发生率亦不同。结论 NERD和RE的动力异常主要表现为食管体部运动功能障碍而非LESP压力下降,食管体部功能障碍可能在GERD发病中起着更重要的作用。     

胃食管反流病患者食管黏膜损伤与食管动力学变化及酸暴露的关系

目的探讨胃食管反流病（GERD）患者食管黏膜损伤程度、食管动力学变化及酸暴露三者相互影响及相关性。方法随机选择2010年2月至2012年12月在我院消化内科就诊行胃镜检查确诊为GERD患者65例,男34例,女31例,年龄22～65岁,中位年龄48岁,分为NERD组12例和RE组53例,RE组按洛杉矶分级标准分为A、B、C、D组,选10例健康者为对照组;进行食管压力测定及24 h动态食管pH值监测。结果 B～D组LESP显著低于对照组和NERD组（P＜0.05）,RE各组食管括约肌上10 cm压力、食管收缩幅度、无效食管运动发生率与对照组和NERD组比较均有显著性差异（P＜0.05）,LESP、食管收缩幅度与食管损伤程度均呈负相关（r＝-0.41,-0.48,P＜0.05）。 NERD组和RE各组24 h动态食管pH值监测结果与对照组比较均有显著性差异（P＜0.05）,A组DeMeester评分、酸暴露率和反流周期数均显著低于NERD组（P＜0.05）,A组合计反流时间、食管酸清除时间、最长反流时间与NERD组比较均无显著性差异（P＞0.05）。 DeMeester评分与食管损伤程度均呈正相关（r＝0.56,P＜0.05）。酸暴露组食管收缩幅度和无效食管运动发生率与非酸暴露组比较均有显著性差异（P＜0.05）。结论 GERD食管黏膜损伤与食管括约肌功能不全、食管推进性蠕动功能障碍及酸暴露有关,食管推进性蠕动功能障碍是主要机制。     

食管测压

食管测压广东省人民医院消化科（５１００８０）王启仪译黄光华校食管测压作为食管疾病的一种诊断试验已应用了２０多年。它提供了食管压力，运动协调和动力方面的定性和定量资料。１适应证测压研究用于评估一些出现于与食管有关的症状的病人，如吞咽困难、咽部疼痛、心前...     

24h食管pH监测和食管测压及奥美拉唑治疗试验在食管原性胸痛中的应用

目的 :探讨 2 4 h食管 p H监测和食管测压及奥美拉唑治疗试验在食管原性胸痛中的诊断价值。方法 :对食管原性胸痛 6 8例行内镜、食管测压、2 4 h食管 p H监测及 7d的奥美拉唑 (2 0 mg,2次 / d)治疗试验 ,治疗后症状评分比治疗前降低超过 75 %者则为治疗试验阳性。结果 :食管原性胸痛 6 8例中 5 5例 (81% )符合胃食管反流病 (GERD) ,胡桃夹食管 2例 ,早期贲门失驰缓症 3例 ,弥漫性食管痉挛 3例 ,无效食管运动 (IEM) 5例。GERD5 2例测压分析 ,35例(6 7% )符合 IEM诊断标准。奥美拉唑治疗试验对诊断 GERD的敏感性为 93% ,特异性为 85 %。结论 :GERD是食管原性胸痛的主要原因。 2 4 h食管 p H监测和食管测压是诊断食管原性胸痛的主要检查手段 ,奥美拉唑治疗试验是临床诊断GERD简便而实用的方法。     

高分辨率食管测压联合食管24h pH-阻抗监测在胃食管反流病中的作用

目的探究食管24 h pH-阻抗监测、高分辨率食管测压在胃食管反流病(GERD)中的作用.方法选取某院2017年4月至2019年4月GERD患者72例,其中糜烂性食管炎(EE)39例(E组)、非糜烂性反流病(NERD)33例(N组),同期选取健康体检者30例为对照组,均行高分辨率食管测压、食管24 h pH-阻抗监测.对比三组收缩前沿速度(CFV)、远端收缩积分(DCI)及pH<4次数、最长反流时间.结果E组、N组CFV、DCI较对照组低,差异有统计学意义(P<0.05);E组CFV、DCI较N组低,差异有统计学意义(P<0.05);E组、N组上下电极pH<4次数较对照组高,最长反流时间较对照组长,差异有统计学意义(P<0.05);E组上下电极pH<4次数较N组高,最长反流时间较N组长,差异有统计学意义(P<0.05).结论食管24 h pH-阻抗监测、高分辨率食管测压结果提示酸反流、食管动力障碍为GERD重要发病机制,且EE患者酸反流、食管动力障碍较明显.     

胃食管反流病患者食管测压的护理

目的 探讨食管测压对胃食管反流病的诊断价值及护理对策.方法 使用丹麦Medtronic公司生产的高分辨多通道灌注测压系统,测定正常人10例及胃食管反流病患者60例的食管下括约肌(LES)压力,胸腹段长度(LES1)及食管体部动力参数.结果 患者组LES压力,下食管括约肌长度(LES1)及食管体部各段压力明显低于对照组(P＜0.05),有显著性差异.结论 胃食管反流病患者的LESP低下,LES1过短,食管体部动力低下,护理上应指导患者保持乐观的情绪及建立健康的行为方式,以减少反流的发生,提高生活质量.     

胃食管反流病患者食管测压的护理

目的 探讨食管测压对胃食管反流病的诊断价值及护理对策.方法 使用丹麦Medtronic公司生产的高分辨多通道灌注测压系统,测定正常人10例及胃食管反流病患者60例的食管下括约肌(LES)压力,胸腹段长度(LES1)及食管体部动力参数.结果 患者组LES压力,下食管括约肌长度(LES1)及食管体部各段压力明显低于对照组(P＜0.05),有显著性差异.结论 胃食管反流病患者的LESP低下,LES1过短,食管体部动力低下,护理上应指导患者保持乐观的情绪及建立健康的行为方式,以减少反流的发生,提高生活质量.     

胃食管反流病的体表胃电研究

胃食管反流病（GERD）是常见的胃肠动力疾病。文献指出，下食管括约肌（LES）压力和松弛（TLESR）在GERD发病中起重要作用。近十余年来胃电图（EGG）的研究重新受到重视，给无创性研究胃（肠）动力带来希望。本文应用胃电图及食管测压和食管PH监测对病人的胃肠动力进行测定，以进一步探讨其相互作用的机理。     

Comparison of investigation modalities for evaluation of esophageal peristaltic function

We reviewed the recent literature concerning investigations of esophageal peristaltic function. The gold standard for the assessment of esophageal peristaltic function is manometry with pH monitoring. Even with this investigation modality, however, we are in fact doing no more than estimating esophageal peristaltic function from the manometry and pH results. With esophageal fluoroscopy and scintigraphy, where we observe esophageal motility, there are problems with radiation exposure and handling of radioactive agents that make widespread use difficult. In recent years, the development of multichannel intraluminal impedance (MII) manometry has allowed simultaneous measurement of intraesophageal pressure and assessment of esophageal peristalsis. Using MII it is also possible to distinguish whether gas or liquid is passing down the esophagus. When manometry is performed in conjunction with transnasal esophagogastroduodenoscopy, with this unique combination it is possible to measure the intraesophageal pressure while actually observing the swallowing motion at the same time. Assessment of esophageal peristaltic function is now moving from simple measurement of intraesophageal pressure to simultaneous impedance manometry and endoscopic observation of esophageal peristalsis itself.     

Long-term results of laparoscopic partial posterior fundoplication in patients with esophageal reflux and disorders of esophageal peristalsis

BACKGROUND: Gastrosophageal reflux disease (GERD) of long duration is frequently associated with impaired esophageal body motility. This condition has been considered unsuitable for antireflux surgery. METHODS: In order to investigate the outcome of antireflux surgery in the presence of impaired esophageal peristalsis, we studied 67 consecutive GERD patients with poor esophageal body function who underwent laparoscopic partial posterior fundoplication. A standardized questionnaire, upper GI endoscopy, esophageal manometry and 24-hour pH monitoring were performed preoperatively and at a median of 28 months (range, 6-54 months) postoperatively. Esophageal motility was analyzed for contraction amplitudes in the distal two thirds of the esophagus (level 3, 4, and 5), frequency of peristaltic, simultaneous and interrupted waves and total number of defective propagations. In addition, parameters defining the function of the lower esophageal sphincter (LES) were-evaluated. RESULTS: Following antireflux surgery 65 patients (97%) were free of heartburn and regurgitation and had no esophagitis on endoscopy, confirmed by histology. The rate of dysphagia was reduced from 49% preoperatively to 9% postoperatively (p < 0.001). There was significant improvement in esophageal peristalsis after the antireflux procedure. The median DeMeester reflux score was reduced from 33.3 to 1.1 (p < 0.001). Lower esophageal sphincter pressure and intra-abdominal length were normal after surgery. CONCLUSIONS: Partial posterior fundoplication provides an effective antireflux barrier in patients with impaired esophageal body motility in the long term. Postoperative dysphagia is avoided by improving esophageal body function.     

Prokinetic medication after surgical therapy of reflux patients with disorders of esophageal peristalsis: a randomized clinical study

BACKGROUND: Long-standing gastroesophageal reflux disease (GERD) is frequently associated with impaired esophageal body motility. Partial posterior fundoplication improves esophageal peristalsis. The aim of this prospective randomized study was to investigate whether administration of the prokinetic agent cisapride enhances this effect. METHODS: Forty consecutive GERD patients with impaired esophageal peristalsis entered the study and were randomized in two groups: group 1 with and group 2 without postoperative treatment with cisapride (6 months, 20 mg twice daily). Four patients had to be excluded during the study. Esophageal motility was analyzed preoperatively and 6 months after surgery by measuring contraction amplitudes in the distal two thirds of the esophagus, frequency of simultaneous and interrupted peristaltic waves and total number of defective propagations. RESULTS: In both groups esophageal peristalsis was improved significantly following partial posterior fundoplication (p < 0.05; Wilcoxon Test). However, this effect was significantly more pronounced in patients receiving cisapride medication postoperatively (p < 0.05; Mann-Whitney U test). Lower esophageal sphincter pressure, intra-abdominal sphincter length and the DeMeester reflux score were normalized in both groups following antireflux surgery. CONCLUSIONS: Partial posterior fundoplication combined with postoperative cisapride medication seems to be the therapy of choice in GERD patients with impaired esophageal body motility.     

Test of refractory gastroesophageal reflux disease

It should be considered that the causes of refractory gastroesophageal reflux disease (GERD) are multifactorial. Esophageal manometry study is useful when we make distinguish patients with esophageal motility disorders from those with refractory GERD. Endoscopic ultrasonography is also performed to observe the thickness of esophageal wall which represents the disturbance of esophageal motor function. Esophageal pH monitoring is useful to detect the acid clearance disturbance and phenomenon of nocturnal acid breakthrough. Both are occurred at night, and are recently considered to be responsible for refractory GERD. Catheter-free pH monitoring system, Bravo, makes it possible to measure esophageal pH under quite physiological conditions. Genotype of CYP2C19 is sometimes checked in patients with PPI resistance GERD. Intra-gastric pH with omeprazole and lansoprazole depends on patient's genotype of CYP2C19. Monitoring of 24-hour bilirubin, Bilitec, is also useful to detect duodeno-gastro-esophageal reflux.     

Esophageal motility disorders with thoracic pain of unknown origin

35 patients with angina-like chest pain underwent esophageal manometry after a coronary artery disease had been ruled out by angiography. Furthermore, patients after gastric or esophageal surgery, with pathologic upper gastrointestinal endoscopy or with pathologic gastroesophageal reflux as seen on 24-hour-pH-metry were excluded from this study. 29 out of 35 patients (83%) had a normal manometric study, six patients (17%) had a motility disorder; five of these showed an unspecific dismotility pattern and were asymptomatic while the study was done; only one patient presented with esophageal spasm. Since only this latter patient was symptomatic while the study was done, a correlation between symptoms and this motility disorder seems likely. --If pathologic gastroesophageal reflux has been ruled out, esophageal manometry can establish a diagnosis in only 3% of patients with angina-like chest pain without esophageal symptoms (dysphagia, odynophagia, heartburn or regurgitation). We conclude that this complicated examination should not be done in these patients.     

Gastroesophageal reflux patients' defective antioxidative capacity in the proximal esophageal mucosa before antireflux surgery and also after 4‐year follow‐up

Background. Oxidative stress has a role in the pathogenesis of gastroesophageal reflux disease (GERD).

Aim. To investigate the redox balance in proximal esophagus before and 6 and 48 months after antireflux surgery.

Methods. In 20 GERD patients and 9 controls oxidative stress by myeloperoxidase activity (MPO activity) and antioxidative capacity of esophageal mucosa by superoxide dismutase activity (SOD), and glutathione content (GSH) was measured from proximal esophageal samples.

Results. In proximal esophagus of GERD patients compared to controls', antioxidative capacity appearing as GSH level was significantly decreased (P<0.001) at all time points and as SOD levels preoperatively (P<0.001) and 4 years postoperatively (P = 0.01). MPO activity of patients was significantly lower than controls' preoperatively, and 6 months and 4 years postoperatively (P<0.05). MPO activity remained lower than that of the distal esophagus at 6 months and 4 years (P<0.01 for both).

Conclusions. In GERD patients, proximal esophageal mucosal antioxidative defense is defective before and after antireflux surgery. Antireflux surgery seems not to change the level of oxidative stress in proximal esophagus, suggesting that defective mucosal antioxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD.     

Esophageal responses to distension and electrical stimulation

The opossum esophagus contains only smooth muscle in the distal two-thirds; it can be used to study autonomic control of esophageal smooth muscle. Three different preparations of opossum esophagus were used; the esophagus in vivo, the isolated whole esophagus, and isolated strips of the three layers of esophageal smooth muscle. Responses were examined to localized distension and to electrical stimulation. Distension of the esophagus in vivo produced three separate responses: inflation of a distending balloon caused a brief contraction rostral to the point of distension, the on response; maintenance of distension produced shortening of the esophagus, sustained for the duration of the distension, the duration response; and deflation of the balloon caused a single brief caudal circumferential contraction, apparently propagated caudad, the off response. In the isolated whole esophagus distension produced the same three responses. Electrical stimulation in this preparation produced apparently identical responses. Electrical stimulation of isolated strips of the three muscle layers showed that the muscularis mucosae and the longitudinal layer of the muscularis propria always respond with a duration response only. The circular layer of the muscularis propria responds with on and off responses only. These observations suggest that both types of stimuli excite the same afferent nerve fibers in local reflex pathways. Peristalsis can be maintained by these reflexes in the smooth muscle part of the esophagus independent of central nervous connections.     

Gastroesophageal reflux patients' defective antioxidative capacity in the proximal esophageal mucosa before antireflux surgery and also after 4-year follow-up

BACKGROUND: Oxidative stress has a role in the pathogenesis of gastroesophageal reflux disease (GERD). AIM: To investigate the redox balance in proximal esophagus before and 6 and 48 months after antireflux surgery. METHODS: In 20 GERD patients and 9 controls oxidative stress by myeloperoxidase activity (MPO activity) and antioxidative capacity of esophageal mucosa by superoxide dismutase activity (SOD), and glutathione content (GSH) was measured from proximal esophageal samples. RESULTS: In proximal esophagus of GERD patients compared to controls', antioxidative capacity appearing as GSH level was significantly decreased (P < 0.001) at all time points and as SOD levels preoperatively (P < 0.001) and 4 years postoperatively (P = 0.01). MPO activity of patients was significantly lower than controls' preoperatively, and 6 months and 4 years postoperatively (P < 0.05). MPO activity remained lower than that of the distal esophagus at 6 months and 4 years (P < 0.01 for both). CONCLUSIONS: In GERD patients, proximal esophageal mucosal antioxidative defense is defective before and after antireflux surgery. Antireflux surgery seems not to change the level of oxidative stress in proximal esophagus, suggesting that defective mucosal antioxidative capacity plays a role in development of oxidative damage to the esophageal mucosa in GERD.     

Esophageal dysmotility in patients who have eosinophilic esophagitis

The understanding of esophageal motility alterations in patients who have eosinophilic esophagitis (EE) is in its infancy despite the common presenting complaint of dysphagia. A diversity of motility disorders has been reported in patients who have EE including achalasia, diffuse esophageal spasm, nutcracker esophagus, and nonspecific motility alterations including high-amplitude esophageal body contractions, tertiary contractions, abnormalities in lower esophageal sphincter pressure, and other peristaltic problems. Some evidence suggests that treatment of EE will improve motility. Technological advances such as high-resolution manometry and combined manometry with impedance may provide new insight into more subtle motility abnormalities.