无效食管运动与胃食管反流病关系的探讨

目的 探讨无效食管运动(IEM)与胃食管反流病(GERD)的关系.方法 对90例GERD全部进行胃镜检查并做食管压力测定和24h食管动态pH监测,其中反流性食管炎(RE)组62例,非糜烂性反流病(NERD)组28例.研究IEM与食管酸暴露及RE的关系.结果 RE组中确诊IEM 30例(48.4％)明显高于NERD组6例(21.4％)(P＜0.05).36例IEM患者33例(91.7％)食管酸暴露阳性,高于食管动力正常患者( 28/49,57.2％)(P＜0.01);远端食管pH ＜4总反流时间、卧位反流时间百分比、＞5 min长反流周期数、最长反流时间、DeMeester评分IEM者明显高于食管动力正常者(P＜0.01),反流周期数前者明显高于后者(P＜0.05).结论 IEM在GERD中较常见,其食管动力障碍中绝大多数为IEM,IEM与食管远端酸暴露及RE密切相关.     

下食管括约肌运动和功能与胃食管反流病

目的　观察胃食管反流病 (GERD)患者与对照组餐前、餐后食管pH情况 ,下食管括约肌(LES )运动模式的变化以及酸反流事件与一过性下食管括约肌松弛 (TLESR )、低LES压力 (LESP)的关系。方法　两组受试者均接受连续性 4h食管压力测定 (分别为空腹和餐后 1、2、3h)和食管pH监测 (GERD组检测 4h ,对照组检测 2 4h)。结果　GERD组酸反流事件明显高于对照组 (P <0 0 5 )。两组间TLESR发生率差异无显著性 (P >0 0 5 ) ,但与空腹比较 ,两组餐后 1h和 2hTLESR发生率明显增多 ;GERD组伴有酸反流的TLESR明显高于对照组 (P <0 0 0 1)。 4 3% (2 9/ 6 8)的酸反流事件发生在TLESR期间。 31% (2 1/ 6 8)的酸反流事件出现于低LESP状态中。结论　GERD是多因素参与的病理过程。LES运动形式变化和功能不全是GERD的重要背景因素。     

Relevance of ineffective esophageal motility with erosive and nonerosive gastroesophageal reflux disease

Introduction: Ineffective esophageal motility (IEM) is a frequent finding in patients with gastroesophageal reflux disease (GERD). It is responsible for delayed acid clearance as it affects esophageal emptying and saliva transport. Since erosive GERD is a more severe disease than nonerosive GERD, it may be associated with IEM, which delays esophageal clearance. Objective : We investigated the role of IEM in patients with erosive and nonerosive GERD. Methods: We enrolled 100 patients with heartburn and a primary diagnosis of GERD referred to the GI motility department of RCGLD of Shahid Beheshti University between January 2002 and January 2005. Based on endoscopic findings, the patients were classified into two groups of erosive GERD and nonerosive GERD. Manometry and 24-hour ambulatory pH-metry was performed in all patients. Results: Seventy-seven patients completed the study: 31 (40.3%) with erosive GERD and 46 (59.7%) with nonerosive GERD. IEM was present in 38.7% of patients with erosive GERD and in 28.3% of those with nonerosive GERD (p=0.18). A low lower esophageal sphincter pressure was present in 45.2% of patients with erosive GERD, and in 45.7% of those with nonerosive GERD (p=0.97). Abnormal acid reflux was present in 32.3% and 41.3% of patients with erosive and nonerosive GERD, respectively (p=0.42). Conclusion: There was no difference in the prevalence of IEM between patients with erosive and nonerosive GERD. IEM could be an integral part of GERD and may not always be associated with mucosal injury.     

远端收缩积分和无效食管动力与胃食管反流的关系

目的探讨食管高分辨率测压（HRM）下远端收缩积分（DCI）和无效食管动力（IEM）与GERD 患者反流情况的关系。方法共纳入69例 GERD 患者,均完成食管 HRM、24 h pH 联合阻抗监测检查。应用 Pearson 相关分析研究 DCI、无效吞咽次数和 DeMeester 评分的相关性。根据10次5 mL液体吞咽试验发生无效吞咽的次数分成3组,5～10次无效吞咽为 IEM 组（21例）,1～4次无效吞咽为动力异常组（19例）,0次无效吞咽为动力正常组（29例）,采用 t 检验比较3组平均 DCI、残余的有效吞咽 DCI 平均值、DeMeester 评分、酸反流时间、食团暴露时间、近端反流次数的差异。结果69例 GERD患者中,其10次5 mL 液体吞咽平均 DCI 和 DeMeester 评分呈负相关（r＝－0．363,P ＝0．003）,无效吞咽次数和 DeMeester 评分呈正相关（r＝0．374,P ＝0．002）。动力正常组、动力异常组和 IEM 组10次5 mL液体吞咽平均 DCI 分别为（1458．96±545．10）、（986．48±577．50）和（288．50±167．25）mmHg·s·cm, IEM 组低于动力正常组和动力异常组（t＝－11．42、－2．12,P 均＜0．05）。动力正常组、动力异常组和IEM 组残余的有效吞咽 DCI 平均值分别为（1458．96±545．10）、（1187．90±669．40）和（450．78±350．73）mmHg·s·cm,IEM 组低于动力正常组和动力异常组（t＝－8．05、－5．27,P 均＜0．01）。IEM组的 DeMeester 评分为（15．42±8．79）分,高于动力正常组的（6．34±3．45）分,差异有统计学意义（t ＝2．43,P ＜0．05）。IEM 组的酸反流时间、食团暴露时间分别为（54．93±37．07）min、（0．64±0．49）％,分别长于动力异常组的（37．37±22．66）min、（0．52±0．24）％,动力正常组的（21．22±13．98）min、（0．39±0．14）％,差异均有统计学意义（t＝2．36、2．17,2．60、2．54,P 均＜0．05）。IEM 组和动力异常组的总反流次数分别为（67．10±32．94）、（57．26±38．90）次,均多于动力正常组的（44．61±23．84）次,差异均有统计学意义（t＝2．48、2．17,P 均＜0．05）。结论DCI 和无效吞咽次数在一定程度上可预测GERD 患者发生反流的情况,IEM 组食管体部收缩力度最弱,食管对反流物的廓清能力最差。     

无效食管运动在胃食管反流病中发病作用的观察

目的　探讨食管无效收缩 (IEM)在胃食管反流病 (GERD)的发病作用。方法　对GERD病人行食管测压和 2 4h食管pH监测 ,分析IEM在GERD的发生率以及比较IEM与食管酸暴露、酸清除和食管炎的关系。结果　 86例GERD病人中 5 9例 (6 8 6 % )存在非特异性食管动力障碍 (NEMD) ;其中 5 5例 (占 93 2 % )符合IEM诊断标准 ;GERD病的IEM发生率为 6 3 95 %。IEM的GERD患者总的pH <4时间 (% ) (5 91)及立位 (4 4 3)和卧位 (6 92 )pH <4时间 (% )显著大于食管正常蠕动的GERD患者 (分别为 3 16 ,1.6 1,和 4 31) ,尤以卧位明显 (P <0 0 1)。IEM患者平均卧位食管酸清除时间 (EAC)为每次 12 6 3min ,显著长于正常食管动力GERD患者的每次 3 15min(P<0 0 1) ,而立位EAC则与正常食管动力组无差异。 2 7例正常食管动力GERD有 10例 (37% )有糜烂性食管炎 ;5 5例IEM患者有 19例 (35 % )有食管炎 ,二组间食管炎发生比例差异无显著性 (P >0 0 5 )。结论　GERD病的食管动力障碍大多数系IEM。IEM比正常食管动力患者更易发生反流和存在食管酸清除障碍。IEM是GERD病的主要异常表现。     

The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility

Sleeve gastrectomy is an increasingly performed bariatric procedure associated with low morbidity and good short to medium term effects on weight loss and comorbid conditions. Studies assessing the prevalence of post-operative gastro-esophageal reflux disease (GERD), show sleeve gastrectomy may provoke de novo GERD symptoms or worsening of pre-existing GERD. Pathophysiological mechanisms of GERD after sleeve gastrectomy include a hypotensive lower esophageal sphincter, increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach. A reduction in the compliance of the gastric remnant may provoke an increase in transient lower esophageal sphincter relaxations. Time-resolved MRI suggests relative gastric stasis in the proximal remnant and increased emptying from the antrum. A lack of standardisation of technique, along with heterogeneity of studies assessing GERD may explain the wide variability in reported results. Simultaneous and careful repair of an associated hiatus hernia may result in a reduction in the prevalence of post-operative GERD.     

胃食管反流病伴或不伴食管损伤与食管动力及酸反流之间的关系

目的 研究胃食管反流病(GERD)患者伴或不伴食管损伤与食管动力和酸反流之间的相关性.方法 对符合GERD诊断标准的25例受试者行胃镜检查,随后进行高分辨率食管测压检查,并检测进食标准试验餐后的动态食管pH值变化.比较伴或不伴食管损伤组患者之间的食管动力和餐后食管酸反流时间的差异.同时按DeMeester评分将受试者分为非酸反流组和酸反流组,比较两组食管动力学指标的变化.统计学处理采用t检验和秩和检验.结果 伴或不伴食管损伤组之间下食管括约肌(LES)压力基础值、LES压力残余平均值、食管蠕动传播速度、食管pH＜4的时间和DeMeester评分均差异无统计学意义(P均＞0.05),但是伴食管损伤组的食管收缩幅度明显弱于不伴食管损伤组(31.9 mm Hg比64.2 mm Hg,1 mm Hg=0.133 kPa;Z=-2.37,P=0.02).酸反流组和非酸反流组之间LES压力基础值、LES压力残余平均值、食管蠕动传播速度差异均无统计学意义(P均＞0.05),但酸反流组的食管收缩幅度明显弱于非酸反流组(36.4 mm Hg比71.8mm Hg;Z=2.25,P=0.02).结论 GERD患者LES压力及食管酸反流与食管损伤之间无显著关系,食管蠕动性收缩功能可能与食管损伤及酸反流有关.     

根除幽门螺杆菌与胃食管反流病的关系研究

目的探讨根除幽门螺杆菌（H．pylori）与胃食管反流病（GERD）的关系。方法本研究采用食管内24hpH监测的方法，定量观察H．pylori阳性GERD患者根除H．pylori和单用兰索拉唑治疗3月后食管酸暴露的变化，以及H．pylori阳性慢性浅表性胃炎（CSG）根除H．pylori和姑息治疗3月后食管酸暴露的变化。RE组：反流性食管炎（RE）表现患者60例，按就诊门诊号随机分为治疗组和对照组。治疗组采用丽珠唯三联＋兰索拉唑方案，对照组单用兰索拉唑。CSG组：慢性浅表性胃炎（CSG）患者60例，按就诊门诊号随机分为治疗组和对照组。治疗组均采用丽珠唯三联方案，对照组不采用药物治疗。以上两组待H．pylori根除后，对比研究H．pylori根除组和对照组3月后食管24hpH监测参数。结果RE组：H．pylori根除和单用兰索拉唑治疗3月后两组24h食管pH监测主要观察5项指标均无显著性差异（P〉0．05）。CSG组：H．pylori根除和姑息治疗3月两组24h食管pH监测主要观察5项指标均无显著性差异（P〉0．05）。结论GERD患者根除幽门螺杆菌后食管酸暴露无明显改变，CSG患者根除幽门螺杆菌后食管酸暴露无明显改变，H．pylori感染可能与GERD的转归和发生无关。     

Association between dinner-to-bed time and gastro-esophageal reflux disease

OBJECTIVE: It is generally recommended that patients with gastro-esophageal reflux disease (GERD) refrain from eating within 3 h of going to sleep. In addition to a remarkable lack of supporting clinical evidence, whether GERD patients have shorter dinner-to-bed time is unknown. This study was designed to determine a possible association between dinner-to-bed time and GERD, compared with healthy adults. METHODS: In a matched case-control study, we enrolled 147 GERD patients, and age- and sex-matched 294 controls without GERD symptoms such as heartburn and acid regurgitation during the previous year. Dinner-to-bed time, defined as the time intervals until going to bed after finishing eating dinner, was examined by a self-report questionnaire. Logistic regression was used to calculate odds ratio (OR) and 95% confidence intervals (CI) for GERD. RESULTS: After adjustment for smoking habits, drinking habits, and body mass index, shorter dinner-to-bed time was significantly associated with an increased OR of GERD (p < 0.0001) and the OR for patients whose dinner-to-bed time was less than 3 h was 7.45 (95% CI 3.38-16.4) compared with patients whose dinner-to-bed time was 4 h or more. These observations were consistent in both patients with non-erosive GERD and erosive esophagitis, and there was no significant difference in dinner-to-bed time intervals between non-erosive GERD and erosive esophagitis. CONCLUSION: In this matched case-control study, shorter dinner-to-bed time was significantly associated with an increased OR for GERD.     

Relevance of ineffective esophageal motility and hyperactive acid sensitization in patients with gastroesophageal reflux

BACKGROUND AND AIM: Esophageal motor abnormalities including ineffective esophageal motility (IEM) and visceral hypersensitivity have been frequently observed in patients with gastroesophageal reflux. The aim of this study was to observe the incidences of hypersensitivity to acid infusion and motor abnormalities in non-erosive reflux disease (NERD) compared with erosive esophagitis. METHODS: We performed upper GI endoscopy, an acid perfusion test and esophageal manometry on 113 NERD patients and 37 erosive esophagitis patients. RESULTS: The frequency of acid sensitization was 69.9% in NERD and 67.6% in erosive esophagitis. The frequency of esophageal motor abnormality in patients with erosive esophagitis (48.6%) was higher than in patients with NERD (25.7%, P = 0.014). The most frequent esophageal motor abnormality was IEM. The frequency of IEM was 15.9% in NERD patients, 42.9% in Los Angeles grade A, 53.8% in Los Angeles grade B and 66.7% in Los Angeles grade C esophagitis (chi(2) = 16.67, P < 0.0001). CONCLUSION: Our results suggest that no difference exists between visceral hypersensitivity in patients with NERD and those with erosive esophagitis, and that IEM occurs in NERD as well as erosive esophagitis patients. The occurrence of IEM is associated with the endoscopic severity of gastroesophageal reflux disease.     

马来酸曲美布汀对伴有无效食管动力的胃食管反流病患者食管运动功能的影响

[目的]观察马来酸曲美布汀对伴有无效食管动力的胃食管反流病患者食管运动功能的影响。[方法]对经内镜、24h食管pH-阻抗监测诊断为胃食管反流病,并行高分辨率食管压力测定(high resolution manometry,HRM),依据芝加哥3.0版标准诊断为无效食管动力的16例患者,给予马来酸曲美布汀0.2g tid、埃索美拉唑20mg、bid治疗2周后复查HRM,比较治疗前后下食管括约肌静息压(LESP)、食管体部各段波幅及时限、吞咽成功率、失蠕动比例、弱蠕动比例以及远端收缩积分(DCI)值等指标的变化。[结果]16例患者治疗前后LESP变化差异无统计学意义(P0.05),在LESP明显降低的7例患者中,与治疗前相比,治疗后LESP明显增加[(1.8±0.9)mmHg(1mmHg=0.133kPa)∶(8.2±5.4)mmHg],差异有统计学意义(P0.05);液体吞咽中,食管中段收缩波幅较治疗前明显增加[(33.7±11.4)mmHg∶(42.7±19.9)mmHg)],P0.05;黏性吞咽中,食管远端收缩波幅较治疗前明显增加[(44.7±18.4)mmHg∶(57.5±23.4)mmHg],P0.05;液体吞咽时,失蠕动比例较治疗前均显著下降,P0.05;液体及黏性吞咽时,DCI值均较治疗前明显增加,P0.05。在液体吞咽时,吞咽成功率较治疗前增加,差异有统计学意义,P0.05。[结论]马来酸曲美布汀可能增加合并下食管括约肌低压的GERD患者的LESP,通过增加食管体部收缩波幅,改善合并无效食管动力的GERD患者食管体部的廓清功能。     

间质性肺疾病与胃食管反流

胃食管反流可以引起慢性咳嗽和哮喘,除此之外胃食管反流和一些间质性肺疾病,如特发性肺纤维化、闭塞性细支气管炎伴机化性肺炎、结缔组织疾病中的系统性硬化相关性肺疾病等也存在比较明显的关系,胃食管反流在上述疾病中高发.虽然胃内容物造成的肺组织损伤在动物实验中已得到证实,但是胃食管反流与间质性肺疾病的明确关系还需要更深入的研究和实验来阐明.本文主要综述近年来关于胃食管反流与间质性肺疾病关系的研究进展.     

Habitual rapid food intake and ineffective esophageal motility

AIM:To study non-cardiac chest pain(NCCP) in relation to ineffective esophageal motility(IEM) and rapid food intake.METHODS:NCCP patients with a self-reported habit of fast eating underwent esophageal manometry for the diagnosis of IEM.Telephone interviews identified eating habits of additional IEM patients.Comparison of manometric features was done among IEM patients with and without the habit of rapid food intake and healthy controls.A case study investigated the effect of 6-mo gum chewing on restoration of esophageal motility in an IEM patient.The Valsalva maneuver was performed in IEM patients and healthy controls to assess the compliance of the esophagus in response to abdominal pressureincrease.RESULTS:Although most patients diagnosed with NCCP do not exhibit IEM,remarkably,all 12 NCCP patients who were self-reporting fast eaters with a main complaint of chest pain(75.0%) had contraction amplitudes in the mid and distal esophagus that were significantly lower compared with healthy controls [(23.45 mmHg(95%CI:14.06-32.85)vs 58.80 mmHg(95%CI:42.56-75.04),P < 0.01 and 28.29 mmHg(95%CI:21.77-34.81) vs 50.75 mmHg(95%CI:38.44-63.05),P < 0.01,respectively)].In 7 normal-eating IEM patients with a main complaint of sensation of obstruction(42.9%),the mid amplitude was smaller than in the controls [30.09 mmHg(95%CI:19.48-40.70) vs 58.80 mmHg(95%CI:42.56-75.04),P < 0.05].There was no statistically significant difference in manometric features between the fast-eating and normal-eating groups.One NCCP patient who self-reported fast eating and was subsequently diagnosed with IEM did not improve with proton-pump inhibition but restored swallow-induced contractions upon 6-mo gum-chewing.The Valsalva maneuver caused a markedly reduced pressure rise in the mid and proximal esophagus in the IEM patients.CONCLUSION:Habitual rapid food intake may lead to IEM.A prospective study is needed to validate this hypothesis.Gum-chewing might strengthen weakened esophageal muscles.     

Aging and esophageal motility in patients with gastroesophageal reflux disease

BACKGROUND: Alterations of esophageal contractions may worsen the esophageal lesions caused by gastroesophageal reflux. The impairment of the contractions may be localized only in the distal esophagus or in the entire esophageal body, and may be worse with the aging process. AIMS: To evaluate the proximal and distal esophageal contractions in patients with gastroesophageal reflux symptoms with or without esophagitis. PATIENTS AND METHODS: We studied esophageal motility in 104 patients with gastroesophageal reflux symptoms, 42 with normal esophageal endoscopic examination, 47 with mild esophagitis and 15 with severe esophagitis. The esophageal contractions were measured by the manometric method at 2, 7, 12 and 17 cm from the upper esophageal sphincter, after five swallows of a 5 mL bolus of water. RESULTS: The amplitude and area under the curve of contractions were lower in patients with severe esophagitis than in patients without esophagitis or with mild esophagitis in the distal part of the esophageal body (17 cm from the upper esophageal sphincter). In the proximal esophageal body there was no difference in amplitude or area under the curve. In the entire esophageal body there was no difference between the three groups of patients in duration, velocity of peristaltic contractions, or proportion of failed, simultaneous, non-propagated or peristaltic contractions. There was no difference between the patients with less than 50 years or with more than 50 years of age. CONCLUSIONS: Patients with severe esophagitis had lower distal esophageal contraction amplitude than patients without esophagitis or with moderate esophagitis. There was no effect of aging on esophageal contractions.     

Analysis of clinical features and motility characteristics of ineffective esophageal motility

<正>Objective To clarify the correlation between the clinical characteristics,esophageal motility features and esophageal acid exposure in patients with ineffective esophageal motility (IEM).Methods From January 2016to March 2018,at Peking University First Hospital,22 IEM patients diagnosed by esophagus high-resolution