小儿哮喘与胃食管返流的研究

为探讨小儿哮喘与胃食管返流（ＧＥＲ）的关系，采用便携式ｐＨ自动记录仪对４１例反复发作的哮喘患儿进行了２４小时食管ｐＨ值监测，以２０例健康儿作为对照组。结果：哮喘组胃食管返流发生率为５３．７％（２２／４１），显著高于对照组（０／２０）；哮喘组Ｂｏｉｘ－Ｏｃｈｏａ综合评分、酸性返流指数、返流≥５分钟次数均显著大于对照组，而ｐＨ值＜４的次数、最长返流持续时间则与对照组差异无显著意义（Ｐ＞０．０５）。提示：反复发作的哮喘患儿胃食管返流发生率较高，哮喘与胃食管返流之间有密切的关系。     

动态24小时食管pH值监测小儿胃食管返流

为了解２４小时食管ｐＨ值监测在小儿胃食管返流（ＧＥＲ）诊治中的作用，研究小儿病理性ＧＥＲ的特点及其诊断标准，对５０例经钡餐造影诊为ＧＥＲ的患儿进行动态２４小时食管内ｐＨ值监测，３０例健康小儿为对照组，复查１３例病理性ＧＥＲ患儿治疗后（９例为手术治疗）的食管ｐＨ值。结果表明，ＧＥＲ组各项返流指标显著高于对照组。对照组中１例为病理性ＧＥＲ，ＧＥＲ组３１例为病理性，另１９例则为生理性。１３例食管裂孔疝（ＨＨ）患儿均有明显的病理性返流，其各项返流指标除ｐＨ值＜４次数外均显著高于单纯病理性ＧＥＲ；ＨＨ组卧位时返流≥５分钟次数、最长返流时间、总ｐＨ值＜４的时间占总观察时间的百分比和平均返流周期均显著大于立位时；单纯病理性ＧＥＲ组卧位时返流≥５分钟次数、最长返流时间和平均返流周期显著大于立位时，而返流次数则小于立位时。提示小儿病理性ＧＥＲ以卧位时明显，伴有食管裂孔疝者返流更为严重。动态２４小时食管内ｐＨ值监测可用于小儿ＧＥＲ的诊断、分析和疗效评定。     

胃源性哮喘患儿雷尼替丁治疗及随访观察

目的探讨胃源性哮喘患儿经雷尼替丁治疗的随访结果。方法对５２例经便携式２４小时ｐＨ自动记录仪确诊的胃食管返流（ＧＥＲ）阳性哮喘患儿加用雷尼替丁治疗３个月,临床随访２年;１７例治疗后第２次复查食道ｐＨ值。结果雷尼替丁治疗的有效率９３６％（４４／４７）,治疗后酸性返流指数、最长返流时间、Ｂｏｉｘ－Ｏｃｈｏａ综合评分低于治疗前,Ｐ＜００５,而ｐＨ＜４的返流次数及返流≥５分钟的次数与治疗前无显著差异（Ｐ＞００５）。结论ＧＥＲ是诱发小儿哮喘的原因之一,ＧＥＲ阳性时胃酸分泌增多,雷尼替丁是治疗胃源性哮喘的有效药物。     

新生儿胃食管反流发病机理的研究

为探讨新生儿胃食管反流（ＧＥＲ）的发病机理，对３８例经钡餐造影诊为ＧＥＲ的患儿进行食管ｐＨ值动态监测和食管动力功能检查，１５例无症状儿作对照组。结果：ＧＥＲ组各项反流指标均显著大于对照组。３８例中１８例为生理性ＧＥＲ，２０例为病理性ＧＥＲ。病理性反流组下食管括约肌压力（ＬＥＳＰ）和屏障压（ＢＰ）均显著低于对照组，而食管功能的其他指标则差异无显著意义。以总ｐＨ值＜４百分时间２．７７％和综合评分８．９２为９５％参考值上限，则ＧＥＲ组病理性反流的检出率为５５．３％（２１／３８），高于对照组的６．７％（１／１５）（Ｐ＜０．０１）。ＬＥＳＰ和ＢＰ的９５％参考值下限分别为８．３９ｋＰａ、８．１５ｋＰａ，对照组无一例ＬＥＳＰ低下，ＧＥＲ组ＬＥＳＰ降低占１５．７％（６／３８），二组差异无显著意义（Ｐ＞０．０５）。提示：新生儿期食管功能已成熟，新生儿ＧＥＲ的发生不单是ＬＥＳＰ降低这一因素，还可能与短暂下食管括约肌松驰有关。     

动态24小时食管pH值监测小儿胃食管反流

为了解２４小时食管ｐＨ值监测在小儿胃食管返流诊治中的作用。研究小儿病理性ＧＥＲ的特点及其主仍断标准，对５０例经钡餐造影诊为ＧＥＲ的患儿进行动态２４小时食管内ＰＨ值监测，３０例健康小儿为对照组，复查１３例病理性ＧＥＲ患儿治疗后结果表明，ＧＥＲ组各项返流同于对照组。     

小儿反复呼吸道感染与胃食管返流关系的探讨

目的　探讨小儿反复呼吸道感染（ＲＲＩ）与胃食管返流（ＧＥＲ） 的关系。方法　采用便携式ｐＨ 自动记录仪对３５ 例反复呼吸道感染患儿进行２４ 小时食管ｐＨ 值监测,以３０ 例健康儿为对照组。结果　ＲＲＩ组ｐＨ 值＜ ４的检出次数、返流持续时间≥５ 分钟的检出次数、最长返流持续时间、总ｐＨ＜４ 的时间占总监测时间的百分率、Ｂｏｉｘ－ Ｏｃｈｏａ 综合评分均显著大于对照组（ Ｐ＜ ０－０１） ,ＲＲＩ组胃食管返流发生率为５７－１ ％ （２０／３５）,显著高于对照组（１／３０）。结论　ＲＲＩ患儿胃食管返流的发生率高,两者之间有密切关系。     

窒息后新生儿胃食管测压及双pH监测的研究

目的探讨出生窒息对新生儿胃肠运动功能的影响。方法用多导生理记录仪测定了３５例窒息后新生儿和１７名对照新生儿的食管和胃内压力，并用晶体锑双ｐＨ微电极和便携式２４小时ｐＨ记录仪，对受试者进行了２４小时胃食管双ｐＨ动态监测。结果两组食管及胃内测压差异不显著；双ｐＨ动态监测发现，窒息组反映酸性胃食管返流的各项参数均明显高于对照组，其中酸性返流指数窒息组／对照组为７．１／１．３；返流次数为１３７．４／２８．５；返流＞５分钟的次数５．９／０．７；ｐＨ＜４总时间１５７．０／２０．１；食管廓清时间１．０／０．４，差异均有非常显著意义（Ｐ＜０．０１）。结论窒息后新生儿酸性胃食管返流较对照组明显增加，各项参数已超过病理性胃食管返流诊断标准     

幽门螺杆菌相关性胃炎患儿的食管胃pH值监测及部分胃肠激素研究

目的探讨幽门螺杆菌（Ｈｐ）相关性胃炎患儿的胃肠动力变化特点。方法应用放射免疫分析和食管胃ｐＨ监测技术对５８例Ｈｐ阳性和４７例Ｈｐ阴性慢性胃炎患儿的血清胃泌素、血浆胃动素、十二指肠胃食管返流等进行了对比研究。结果Ｈｐ阳性组血清胃泌素水平高于Ｈｐ阴性组和正常对照组（ｔ值分别为３．３２６、３．８３７，Ｐ均＜０．０１）；Ｈｐ阳性组血浆胃动素水平低于Ｈｐ阴性组和正常对照组（ｔ值分别为２．５９４、４．４３２，Ｐ＜０．０５和０．０１）。Ｈｐ阳性组胃食管返流发生率为２１％，低于Ｈｐ阴性组中的４８％（χ２＝３．８１２，Ｐ＞０．０５）；Ｈｐ阳性组十二指肠胃返流发生率为５０％，高于Ｈｐ阴性组中的１３％（χ２＝７．３８３，Ｐ＜０．０１）。结论Ｈｐ感染可以导致慢性胃炎患儿血中胃泌素水平升高和血中胃动素水平降低；Ｈｐ相关性胃炎患儿胃食管返流的发生有减少的可能，十二指肠胃返流的发生显著增多     

新生儿期胃食道反流的检测与治疗

对５４例新生儿（早产儿２５例，足月儿２９例）进行了６６例次的二乙三胺五醋酸胃食道核素显像研究，检测出胃食道反流（ＧＥＲ）阳性者３５例（６４．８％），其中早产儿阳性率为８０．０／，足月儿为５１．７％（ｘ￣２＝４．７１０．Ｐ＜０．０５）。所有阳性患儿的反流指数均＞３．５％。在ＧＥＲ阳性的新生儿中，８５．０％的早产儿与４０．０％的足月儿临床无呕吐症状（Ｐ＜０．０１）。选择了６例反流阳性者给予吗丁啉抗反流治疗，取得了较满意的效果，且未发现不良反应。提示放射性核素胃食道显像是诊断婴幼儿ＧＥＲ的一种可靠技术，而吗丁啉是治疗该病的有效药物。     

支气管哮喘患儿T淋巴细胞及细胞因子的变化

为观察儿童支气管哮喘时Ｔ淋巴细胞亚群分布以及Ｔ细胞活化相关因子及受体的表达状况，应用放射免疫分析等技术，对３４例发作期、２５例缓解期支气管哮喘患儿和１５例正常对照的外周血Ｔ淋巴细胞亚群、血浆及淋巴细胞膜表面白细胞介素－２受体（ＩＬ－２Ｒ）和相关细胞因子等水平进行系统检测。结果：（１）发作期患儿外周血Ｔ细胞亚群ＣＤ３，ＣＤ４及ＣＤ４／ＣＤ８值与缓解期患儿及正常对照比较差异无显著意义，但发作期ＣＤ８高于正常对照（Ｐ＜０．０１）和缓解组（Ｐ＜０．０１）；（２）发作期患儿血浆可溶性ＩＬ－２Ｒ、（ｓＩＬ－２Ｒ）、ＩｇＥ水平明显高于缓解期患儿和正常对照（Ｐ＜０．０１）；（３）免疫电镜观察显示，发作期患儿淋巴细胞膜表面ＩＬ－２Ｒ表达高于正常对照（Ｐ＜０．０５）。提示：（１）哮喘患儿外周Ｔ淋巴细胞亚群的分布发生了变化，哮喘发作期Ｔ淋巴细胞处于激活状态；（２）血浆ｓＩＬ－２Ｒ、ＩｇＥ水平与哮喘病情变化密切相关，可作为临床哮喘病情监测的指标。     

Role of surgical treatment of gastro-esophageal reflux in children with severe asthma]

The relationship between gastro-esophageal reflux (GER) and asthma, and the role of treatment of this disorder in severe asthma cases remain ill-defined. Using esophageal pH monitoring, pathological GER was demonstrated in 57 of 139 children with severe asthma. Among these 57 patients medical treatment of GER lessened the respiratory symptoms in 24 and was without effect in 33. In the latter group, asthma was improved in 29 with surgical treatment of the GER, the results being less satisfactory in those patients without GER digestive symptoms. Our results suggest that there is a place for treatment of GER in selected children with severe asthma. Esophageal pH monitoring appears useful to detect pathological GER and to determine which patients may benefit from surgical treatment.     

Gastroesophageal reflux in steroid-dependent asthmatic youths.

The aims of this study were to evaluate the incidence of gastroesophageal reflux (GER) in chronic allergic steroid-dependent asthmatic children and to assess whether a medical antireflux regimen might improve pulmonary status of asthmatics found to have reflux. Nineteen patients had a determination of lower esophageal sphincter (LES) pressure, pH assessment after acid instillation into the stomach (acid reflux test), and esophagram. After the reflux evaluation, an antireflux regimen was instituted for three weeks; patients were followed with asthma symptom diaries and weekly pulmonary function tests for this period and for another three weeks after finishing the regimen. Gastroesophageal reflux, diagnosed by positive acid reflux test, occurred in nine patients. Five patients had low LES pressure (less than or equal to 12 mm Hg), and two patients had an abnormal esophagram. There were no significant changes in asthma symptoms or pulmonary function tests with the medical antireflux regimen. Although GER does exist in a high percentage of this patient sample (47%), a short-term antacid and positional antireflux regimen does not improve the pulmonary status of these patients.     

Prevalence and treatment of silent gastro-oesophageal reflux in children with recurrent respiratory disorders

Thirty-six infants and children presenting with recurrent respiratory disorders (RRD) as the sole clinical symptom including bronchial asthma (6), recurrent obstructive bronchitis with or without wheezing (18), chronic nocturnal cough (3), recurrent episodes of pneumonia (3), recurrent pharyngitis (3) and recurrent laryngitis (3) were investigated for associated gastro-oesophageal reflux (GER) by oesophagram, endoscopy and continuous 24 h pH monitoring of the distal oesophagus.The pH monitoring criteria were selected on the basis of a preliminary study comparing statistically measurements of 32 variables recorded in 15 patients who all had clinical, radiological and endoscopic evidence of GER and in 8 asymptomatic controls. Although patients with symptomatic GER differed significantly from the asymptomatic ones for 27 variables examined, 6 variables emerged as having the highest value for discrimination (overlap score 0–1). Among these, the Euler-Byrne index (number of reflux pH<4+4 times the number of reflux episodes of more than 5 min), the percentage of total reflux time and the number of reflux episodes 1 h post-cibal scored 0 (no overlap). GER was considered to be present when at least five of these six parameters were abnormal.The overeall incidence of GER in children with RRD was 41% (15) when detected by oesophagram and 61% (22) when diagnosed by pH monitoring criteria. In the children with bronchial asthma or with recurrent laryngitis, the percentage of reflux time during sleep was about 40 times higher than in asymptomatic controls and 2 times higher than in those with symptomatic GER. Of the 22 patients with RRD and GER, 9 were elected to have fundoplication because of poor response to medical antireflux management. All of these, showed complete (6) or partial (3) resolution of respiratory symptoms. Of the 13 patients in whom medical therapy was continued, 9 showed satisfactory improvement with a mean follow-up time of 1 year. Silent GER might be an important contributing factor to the severity of some common chronic respiratory disorders in children.Abbreviation RRD recurrent respiratory disorders - GER gastro-oesophageal reflux     

Gastroesophageal reflux

Gastroesophageal reflux is common in infants and generally resolves spontaneously within the first year of life as the lower esophageal sphincter mechanism matures. The reflux is only considered a "disease" (GERD) when it becomes symptomatic or causes pathological consequences. GERD is commonly associated with esophageal atresia and there is a high incidence in neurologically impaired children; in both groups conservative treatment is notoriously ineffective. The diagnosis of GER is made on upper gastrointestinal contrast studies, endoscopy and pH monitoring. Medical management comprises antacids, reduction of gastric acid production and prokinetic agents. The indications for antireflux surgery include an established esophageal stricture, associated anatomical defect and failure of medical therapy. Apnoeic episodes secondary to documented GER in the infant, constitute an absolute indication for early surgery.     

24 h食管pH监测在婴儿难治性肺炎中的临床应用研究

目的探讨24h食管pH监测在婴儿难治性肺炎中的临床应用及其意义。方法对57例难治性肺炎患儿进行24h食管pH监测,监测指标包括食管pH〈4.0的次数、反流时间≥5min的次数、最长反流时间、卧位pH值〈4的时间占总监测时间的百分比和Biox-Ochoa评分。结果57例中存在胃食管反流（GER）28例（占49.1%）;有呕吐与无呕吐症状患儿各项反流指标比较差异有统计学意义;伴有胃食管反流患儿经促动力剂治疗者,肺部罗音消失时间和咳嗽持续时间均较未用促动力剂治疗者短,差异有统计学意义（P〈0.05）。结论难治性肺炎患儿经正规抗炎治疗效果不佳者,应考虑是否合并胃食管反流,进行24h食管pH监测,以确定病因并指导治疗。     

健康儿童及病理性胃食管反流患儿食管动力功能研究

目的了解小儿食管运动的生理学,探讨小儿病理性胃食管反流(GER)发生的食管动力学基础。方法对60例健康儿童和62例经食管pH监测诊断为病理性GER的患儿用低顺应性毛细管灌注系统进行食管测压研究,并对健康儿童组不同年龄段之间,两组同一年龄段之间进行食管动力功能比较。结果健康儿童组下食管括约肌长度(LESL)随着年龄的增加而增长,胸内段和腹内段也相应增加(P＜0.01),下食管括约肌压力(LESP)以～1岁组为高(P＜0.05);上食管括约肌长度(UESL)随年龄的增加而增长(P＜0.01),上食管括约肌压力(UESP)以～1岁组和～3岁组为低(P＜0.01)。病理性反流患儿的食管动力功能,除～7岁组食管蠕动传导速度低于同一年龄段健康儿童外(P＜0.05),其余指标两组同一年龄段间的差异均无显著性。结论LESP的抗反流功能与年龄关系不大,LESL、UESL和UESP的功能3岁以后逐渐成熟,小儿病理性GER的发生与LESP、LESL关系不大。     

Nissen fundoplication and Boix-Ochoa antireflux procedure: comparison between two surgical techniques in the treatment of gastroesophageal reflux in children.

Over a period of 19 years an antireflux procedure was performed for gastroesophageal reflux in 59 children. Thirty-two patients underwent Nissen fundoplication and 27 children underwent the Boix-Ochoa antireflux procedure. Six patients died between two and 15 months post surgery of unrelated causes. Follow-up period from six months to 18 years was available in 45 (85%) of the surviving patients. This report summarizes the complications and long-term results with the two surgical procedures and their comparisons. The follow-up evaluation included parental interview and physical examination. Upper GI series and pH monitoring were performed only in children with signs and symptoms of recurrent GER or other post-operative complications. At follow-up with a mean period of 8.7 years following Nissen fundoplication, 87.5% showed good results without any residual symptoms. However, the overall complication rate was as high as 50%. Following the Boix-Ochoa antireflux procedure, 17 (81%) children showed excellent results while four children had recurrent GER. This occurred in two neurologically impaired children and two patients following esophageal atresia repair. No other post-operative complications were encountered with the Boix-Ochoa antireflux procedure. In our experience, the Boix-Ochoa antireflux procedure should be the procedure of choice in the surgical treatment of GER in otherwise normal children while the Nissen fundoplication is preferable in neurologically impaired children and in patients with GER following esophageal atresia repair.