胃食管反流性咳嗽的临床分析

目的　探讨胃食管反流 (GER)性咳嗽的临床特征、诊断和治疗。方法　对 4 1例X线胸片、组胺激发试验、鼻部检查正常的慢性咳嗽患者进行 2 4h食管 pH监测 ,并利用症状相关性概率(SAP)来分析咳嗽与反流的相关性。对Demeester总积分≥ 14 72 ,和 (或 )咳嗽与反流SAP≥ 75 %者进行为期 12周的抗反流治疗。结果　 4 1例患者中 ,有 2 6例诊断为GER性咳嗽 ,并给予抗反流治疗 ,完成疗程后 ,有 12例患者咳嗽完全消失 ,咳嗽与反流的SAP(上电极为 0 75± 0 2 1,下电极为0 91± 0 12 )显著高于另 14例对抗反流治疗反应较差或无效的患者 (上电极为 0 36± 0 31,下电极为 0 4 7± 0 30 ;P <0 0 5 )。结论　GER是不明原因慢性咳嗽的一个重要的独立原因。 2 4h食管 pH监测结合症状相关性分析有助于GER性咳嗽的诊断 ,抗反流治疗对其有较好的近期疗效。     

支气管哮喘病人24小时食管pH监测的临床分析

目的　观察哮喘发作期及缓解期患者食管 2 4hpH的变化 ,研究胃食管反流 (GER)病人应用抑酸剂后食管 pH或肺功能的改变情况。方法　对 5 1例哮喘病人进行了研究 ,其中 30例病人比较发作期及缓解 2周后的 2 4h食管 pH指标 ,对 16例伴有GER的哮喘缓解期病人 ,应用奥米拉唑治疗 ,比较治疗前及治疗 2周后肺功能指标。对 15例伴有GER的急性哮喘发作病人应用奥米拉唑治疗 ,比较治疗前及治疗 2周后 2 4h食管 pH的变化。结果　哮喘发作期及缓解期 2 4h食管pH各项指标与正常对照组比较显著升高 (P <0 0 1)。 16例伴有GER的哮喘缓解期病人 ,应用抑酸剂后肺功能有明显改善 (P <0 0 5 )。 15例伴有GER的哮喘急性发作期病人经抑酸剂治疗后 ,13例食管 2 4hpH监测的各项指标明显降低 (P <0 0 1)。结论　哮喘急性发作期及缓解期 ,GER发生率显著升高 ,有GER的哮喘病人肺功能有明显改变 ,对哮喘发作的病人 ,需常规进行食管 2 4hpH监测 ,发现有GER的病人 ,可采取质子泵抑制剂治疗     

胃食管反流与慢性咳嗽关系的临床观察

[目的]探讨胃食管反流(GER)与慢性咳嗽的关系,以及GER所致的慢性咳嗽——胃食管反流性咳嗽(GERC)的临床特征、诊断和治疗.[方法]50例GERC患者(病例组)和30例健康体检者(对照组)纳入研究,行24h食管pH监测来分析慢性咳嗽与GER的相关性.病例组患者随机分为2亚组,A亚组22例,给予雷尼替丁(150mg,2次/d);B亚组28例,给予奥美拉唑(20mg,2次/d)和莫沙比利(5mg,3次/d)口服;疗程均为8周.比较病例组与对照组24 h食管pH监测指标,病例组中A、B亚组疗效和治疗后24 h食管pH监测指标变化.[结果]病例组患者Demeester总积分均≥12.7,各项反流指标均显著高于对照组(P＜0.05).病例组患者治疗8周后24h食管pH监测各项反流指标均较治疗前降低(P＜0.05),B亚组疗效优于A亚组(z=2.332,P＜0.05);且B亚组24 h食管pH监测各项反流指标均较A亚组降低(P＜0.05).[结论]GER与慢性咳嗽密切相关,是导致GERC的一个重要原因,对GERC患者应给予抑酸和抗反流治疗.     

哮喘患者大多有胃食管返流

一些作者认为肺功能异常与胃食管返流(GER)之间有关联。这一观点经对返流者作手术或药物治疗后哮喘持续状态得以减轻甚至消失的报告而得到支持。为确定哮喘患者的GER发生率和检出其特征,24小时食管pH监测对哮喘者出现GER的机制有两种不同的假设:(a)微量胃内容物吸入肺部而引起粘膜渗出性反应;(b)GER激活食管至肺的迷走神经反射弧导致支气管收缩。     

24 h食管pH监测在小儿临床的应用

目的：探讨24h食管pH监测在小儿临床的应用及其意义。方法：对43例患儿进行24h食管pH监测，其中反复呕吐症状为主者29例和以反复呼吸道症状或哮喘发作为主者11例。并对12例诊断为病理性胃食管反流患儿经治疗后进行复查。以11例无消化道症状并排除消化系统疾病和肺支气管疾病儿童作为对照。监测指标有食管pH＜4．0的次数、反流时间≥5min的次数 、最长反流时间、反流时间、立位和卧位pH值＜4的时间占总监测时间的百分比以及Biox-0choa评分。结果：32例存在胃食管反流（GER），占74．4％。各项反应指标的监测结果与对照组的比较和治疗前后反流指标的变化均有显著性差异。结论：通过24h食管pH监测判定反流类型，不仅提高了病理性GER的诊断率，而且不不同临床类型的反流治疗方案的确定提供了根据，尤其是反复呕吐、反复呼吸道病变及新生儿呕吐的病因诊断和疗效观察中具有重要意义。     

抗胃食管反流治疗对缓解支气管哮喘急性发作的临床疗效观察

目的明确抗胃食管酸反流治疗对哮喘症状的协同治疗作用。方法将54例支气管哮喘患者依有无胃食管酸反流症状分为有GER表现组和无GER表现组，对比两组治疗疗效的差异性。结果两组治疗有效率分别为100％和69．23％，经统计学方法处理差异有显著性（P〈0．05）。结论支气管哮喘可合并有胃食管酸反流，经抗胃食管酸反流治疗可提高支气管哮喘的治疗效果。     

含餐8 h食管pH监测与常规24 h pH监测对胃食管反流病的诊断价值比较

目的探讨含餐8h食管pH监测对胃食管反流病(GERD)的诊断意义,并以常规24hpH监测为标准验证其灵敏度及特异度。方法对2003年3月至2006年9月北京大学人民医院消化科221例患者进行食管测压和pH监测。首先由系统计算24h DeMeester积分,≥14.72分诊断为胃食管反流病。入选患者晚餐开始共计8h的监测数据,同样计算DeMeester积分,相同的标准诊断胃食管反流病。比较两种方法的一致性及积分的相关性。结果221例患者经常规24hpH监测诊断胃食管反流病124例,正常97例,含餐8hpH监测方法诊断胃食管反流病120例,正常101例。含餐8h的灵敏度为93.5%,特异度95.9%,经Kappa及Mc-nemar检验2种方法具有良好的一致性,部分结果的差异不具有显著性。2种检测方式DeMeester积分的相关系数为0.929。结论含餐8小时监测法和24hpH监测法具有良好的一致性,有望用于GERD特别是内镜阴性GERD的诊断。     

胃食管反流病与支气管哮喘的相关性研究

[目的]通过观察支气管哮喘伴胃食管反流患者与支气管哮喘未伴胃食管反流患者的食管黏膜病变差异、哮喘严重程度等,探讨胃食管反流与支气管哮喘之间的相关性.[方法]将62例支气管哮喘患者,按照是否伴有胃食管反流分为2组,A组未伴有胃食管反流,B组伴有胃食管反流,对2组患者的胃黏膜病理表现、咳嗽次数及第1秒用力呼气容量(FEVl)、微型呼气流速峰值(PEF)进行比较.[结果]B组患者出现食管黏膜的病理变化,A组部分患者存在潜在食管黏膜变化,B组患者病变程度严重于A组患者,2组比较,差异有统计学意义(P＜0.05);B组36例中10例为轻度哮喘,12例为中度,14例为重度,中重度率为72.2％;A组26例中15例为轻度,8例为中度,3例为重度,中重度率为42.3％,B组患者哮喘程度比A组严重,差异具有统计学意义(P＜0.05);B组患者的FEV1、PEF值低于A组患者,差异有统计学意义(P＜0.05);B组患者的喘、咳次数均高于A组患者,差异有统计学意义(P＜0.05).[结论]支气管哮喘伴有胃食管反流患者病情较为严重,胃食管反流对支气管哮喘患者的肺部功能具有一定的影响.     

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     

特发性肺纤维化与胃食管反流的相关性研究

目的 探讨特发性肺纤维化(IPF)与胃食管反流的相关性,分析其临床特点.方法 选2011年1月至2013年10月中国医科大学附属第一医院住院或门诊IPF患者25例(IPF组),另选非IPF的间质性肺疾病患者23例作对照(非IPF组),两组患者行24 h食管pH值监测,分析胃食管反流特点及其临床特征.结果 胃食管反流阳性IPF组16例,非IPF组8例.IPF组DeMeester评分高于非IPF组,差异有统计学意义[(22.8±21.5)分比(15.7±14.0)分;P＜0.05].IPF组长反流(反流时间持续＞5 min)次数[(3.8±4.1)次]、反流指数(1.8±1.7)高于非IPF组[(2.1±2.1)次;1.3±1.2],但差异无统计学意义.IPF胃食管反流阳性者合计反流时间百分比(pH ＜4.0)[(9.2±5.1)％]、直立位反流时间百分比[(8.5±5.2)％]、仰卧位反流时间百分比[(10.8±10.7)％]、反流次数[(54.2±22.7)次]、长反流次数[(6.3±4.2)次]、最长反流时间[(14.5±15.3) nin]、反流指数(2.5±1.7)和DeMeester评分[(34.9±20.3)分]明显高于阴性者,差异有统计学意义(P值均＜0.05).DeMeester评分与胃食管反流病问卷(GerdQ)评分呈正相关(r=0.667,P＜0.01).IPF患者胃食管反流阳性者典型胃食管反流症状:烧心7例,反流6例,多于胃食管反流阴性者(烧心2例,反流1例).结论 IPF患者胃食管反流阳性率高,但往往缺少典型的胃食管反流症状.在不具备胃酸监测条件的医院,GerdQ可用于评价IPF患者是否存在胃食管反流.     

The association of gastroesophageal reflux with bronchial asthma. Can asthma also trigger reflux?

BACKGROUND/AIMS: The frequency of gastroesophageal reflux (GER) among asthmatic patients was found to range from 34% to 89% at different locations. The aims of this study have been to determine the frequency of GER in patients with asthma in the Saudi environment, to ascertain the main mechanism whereby GER triggers asthma, and to seek any evidence whether asthma can also trigger GER. METHODOLOGY: Fifty asthmatic patients were consecutively recruited as they reported to King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia, in the period from February 2000 to February 2001; their mean age +/- SD was 38.0 +/- 9.8 years. Twenty-two subjects without asthma or GER served as controls; their mean age +/- SD was 29.4 +/- 8.6. Both groups were subjected to a questionnaire, esophageal manometry, dual probe ambulatory 24-hour pH monitoring, and pulmonary function tests. RESULTS: Among the asthmatic group 22 patients (44%) had GER. Accordingly, the asthmatic patients were divided into two groups: asthmatic with GER (n=22), and asthmatic without GER (n=28). Hoarseness of voice and nocturnal symptoms were found to be significant predictors for the presence of GER in asthmatics. Manometry revealed that asthmatic patients with GER had higher gastric pressure (11.4 +/- 4.0 mmHg vs. 8.4 +/- 2.8 mmHg; p=0.006) and lower resting pressure at the lower esophageal sphincter (LES) (21.2 +/- 8.7 mmHg vs. 28.2 +/- 9.3 mmHg; p=0.013) when compared with controls, both factors favoring the occurrence of reflux. With regard to pH data, acid reflux occurred both at the distal and proximal esophagus but the percent total acid exposure time was about 7 times longer at the distal than at the proximal esophagus (5.80 vs. 0.9). In addition, gastric pressure was positively and significantly correlated with distal esophageal acid exposure time and the DeMeester score, negatively correlated with spirometric parameters in asthmatic patients, as well as found to be a significant predictor of the severity of asthma (p=0.006). CONCLUSIONS: Forty-four percent of the sample of asthmatic patients reporting to KFHU had GER. Since distal esophageal total acid exposure time was nearly 7 times longer than at the proximal esophagus, the main mechanism for GER triggering asthma is the vagally mediated reflex initiated by acid in the distal esophagus. In addition, the positive correlation of increased gastric pressure with the distal esophageal acid exposure time and the DeMeester score, its negative correlation with spirometric parameters and being a significant predictor of asthma severity suggest that severe asthma may trigger or aggravate GER.     

胃食管反流病问卷评分对胃食管反流病患者食管酸暴露的预测意义

目的 确定胃食管反流病问卷(GerdQ)症状评分能否反映胃食管反流病(GERD)患者由24 h食管动态pH监测显示的酸暴露情况,进一步验证GerdQ的临床应用价值.方法 纳入2008年11月至2010年3月因烧心等上消化道症状就诊的门诊GERD病例134例,均完成胃镜检查、24 h食管动态pH监测和GerdQ量表.根据...     

Reflux episode reaching the proximal esophagus are associated with chronic cough

Background/Aims

Gastroesophageal reflux (GER) has been implicated in the pathogenesis of chronic cough. The aims of this study were to evaluate the diagnostic usefulness of multichannel intraluminal impedance combined with pH monitoring (MII/pH monitoring) in patients with suspected symptoms of gastroesophageal reflux disease (GERD) and to assess the correlation between GER symptoms and reflux nature.

Methods

Seventy patients with suspected symptoms of GERD (such as heartburn, acid regurgitation, non-cardiac chest pain, globus and chronic cough) were enrolled. All patients were asked to discontinue medications that would influence esophageal motor function and gastric acid secretion at least one week ago. All subjects underwent MII/pH monitoring.

Results

Forty-five patients (64.3%) were diagnosed with GERD. Among these patients, eleven patients (15.7%) had pathologic acid reflux by pH data and thirty-four patients (48.6%) had pathologic bolus exposure by impedance. Subjects with chronic cough had a higher DeMeester score (p=0.009), percentage of acid exposure time (p=0.007), acid bolus exposure % time (p=0.027), distal acid reflux episodes (p=0.015) and proximal acid reflux episodes (p=0.030) than subjects without chronic cough.

Conclusions

The results of this study showed that the impedance monitoring enhanced diagnostic sensitivity than pH-monitoring alone by 48.6%. In addition, reflux episodes at the distal and proximal esophagus were noted to be important factors associated with chronic cough.     

Significantly Reduced Acid Detection at 10 Centimeters Compared to 5 Centimeters above Lower Esophageal Sphincter in Patients with Acid Reflux

Ambulatory pH monitoring of the esophagus is carried out by positioning a pH sensor 5 cm above the lower esophageal sphincter (LES). There are several techniques to locate the LES, and each method has a different margin of error. This work used dual pH sensors to monitor simultaneously at two different levels (5 and 10 cm above the LES) in order to establish the possible magnitude of error that could arise from inaccurate placement of a pH probe. Thirty-four patients with symptoms of gastroesophageal reflux (GER) were studied. They were grouped as 20 patients with pathological reflux (GER group) and 14 patients with physiological reflux, based on a reflux score derived by Johnson and DeMeester for distal esophageal pH monitoring. When the reflux scores were compared, the difference between the two monitoring levels was statistically significant in the GER group ( p < 0.001) but not in the physiological reflux group ( p = 0.09). In the GER group, the difference in the Johnson and DeMeester score accounted for a change in clinical diagnosis in nine of the 20 patients if the pH probe was placed at 10 cm above the upper margin of LES. Proximal reflux episodes (10 cm above LES) were preceded by distal reflux episodes (5 cm above LES) in 97% (878/901) of cases. Accurate probe placement is essential in the diagnosis of GER.     

Superiority of anti-reflux stent compared with conventional stents in the palliative management of patients with cancer of the lower esophagus and esophago-gastric junction: results of a randomized clinical trial

Palliation of inoperable esophageal cancer with covered stents aims to relieve progressive dysphagia and improve health-related quality of life (HRQoL). Introducing a stent across the esophagogastric junction in lower third tumors may predispose to unchecked gastro-esophageal reflux (GER). Esophageal stents incorporating an anti-reflux valve have been introduced to address this problem. We prospectively compared an anti-reflux stent with a standard stent in the palliation of inoperable lower third esophageal tumors. Forty-nine consecutive patients with malignant dysphagia were randomized to receive a standard (n = 25, group 1) or an anti-reflux stent (n = 24, group 2). HRQoL was assessed before stenting, at 1 week and at 2 months, utilizing European Organization for Research and Treatment of Cancer questionnaires QLQ-C30, QLQ-OES24 and reflux questionnaires. Esophageal pH testing was performed within 1 week of the stent insertion. Detailed statistical analysis was employed to assess general QoL, symptoms and pH scores in both groups. Both groups reported significantly improved QoL, health and dysphagia scores at 1 week and 2 months after stenting. Group 2 patients reported significantly (P < 0.05) better DeMeester symptom, general reflux scores, and normal pH profile at 1 week. At 2 months DeMeester symptom scores were significantly (P < 0.05) better in group 2 compared with group 1. Standard and anti-reflux stents afford comparable relief from dysphagia and improved quality of life in patients with inoperable lower third esophageal cancer. Anti-reflux stents, however, controlled symptomatic and physiologically relevant reflux and should therefore be considered as optimal palliation in this cohort.     

Therapy Insight: treatment of gastroesophageal reflux in adults with chronic cough

Gastroesophageal reflux (GER) is the second most common cause of chronic cough in immunocompetent patients who are nonsmokers, not on angiotensin-converting-enzyme inhibitors and have normal chest radiographs. Identification of GER in chronic cough patients can be difficult; most patients with GER-related cough have no esophageal symptoms and no esophageal test is adequate to make this diagnosis. Post-hoc analysis of four prospective intervention trials has identified a clinical patient profile that can predict the presence of GER-related cough 91% of the time. Clinical practice guidelines from the American College of Chest Physicians and the British Thoracic Society recommend initiating an initial empiric GER therapy trial, with esophageal testing being reserved for nonresponders. The empiric trial should include conservative measures and PPIs twice daily for 3 months. Selected patients who have dysphagia might benefit from the addition of a prokinetic agent. Esophageal manometry and pH testing with impedance monitoring (if available) should be performed in nonresponders while they are on therapy. It can take more than 50 days for cough to respond to medical GER therapy. Surgical fundoplication might be helpful in very carefully selected patients. Careful evaluation and treatment resolves cough in approximately 80% of patients with GER-related cough.     

Effects of anti-reflux surgery on chronic cough and asthma in patients with gastro-oesophageal reflux disease

This two-group prospective study evaluated the effect of anti-reflux surgery (fundoplication) on 24 patients with severe gastro-oesophageal reflux disease (GORD) and concomitant asthma (n=13) or chronic cough (n=11). Twenty-four hour oesophageal pH monitoring and lung function tests (FEV1, FVC) were done before and within 1 year after anti-reflux surgery. A diary was kept by the patient during the 4-week period prior to surgery and during 4-week periods 6 and 12 months postoperatively, with daily monitoring of peak expiratory flow rate, respiratory and reflux symptoms and medication. In non-asthmatic patients, coughing was reduced by 47% and 80% during the day and night, respectively, 12 months after surgery (P < 0.01). Concomitant hoarseness and expectoration were also significantly reduced (P<0.05). No effect on lung function was seen. In patients with asthma, small, non-significant reductions in asthma symptom scores and consumption of rescue medication were seen. Twenty-two patients were completely free from their GORD symptoms after surgery. In conclusion, anti-reflux surgery in patients with GORD had a more favourable effect on concomitant cough than concomitant asthma.     

Abnormal acid reflux in asthmatic patients in a region with low GERD prevalence

Background A high prevalence of gastroesophageal reflux disease (GERD) in asthmatic patients has been reported from North America and Europe. However, only a few data from Asia are available. This study evaluated the incidence of abnormal gastroesophageal reflux (GER) in asthmatic patients in Taiwan.Methods Fifty-six consecutive ambulatory patients with clinically stable asthma (41 men and 15 women; age, 57.7 ± 12.4 years; range, 24 to 74 years) were evaluated prospectively. All patients underwent esophagogastroduodenoscopy, esophageal manometry, and 24-h esophageal pH monitoring.Results Twenty-nine patients (51.8%) had abnormal GER, as defined by 24-h esophageal pH monitoring. There were 42 patients without endoscopic evidence of esophagitis, 10 patients with Los Angeles (LA) grade A esophagitis, and 4 patients with LA grade B esophagitis. The esophageal motility function studies revealed 21 patients with normal esophageal motility, 23 patients with ineffective esophageal motility (IEM), and 12 patients with nonspecific esophageal motility disorders other than IEM. Although the lower esophageal sphincter (LES) basal pressure was higher in the patients without GER, the difference was not statistically significant.Conclusions Abnormal GER seems to be a clinically significant problem in asthmatic patients in Taiwan. The most common esophageal motility dysfunction is IEM. However, the status of Helicobacter pylori infection plays no role in abnormal GER.