腹腔镜胃底折叠术治疗胃食管反流性疾病

目的　探讨腹腔镜胃底折叠术治疗胃食管反流性疾病的可行性及安全性。方法　回顾性分析 2 0 0 1年 6月至 2 0 0 4年 3月对 4 2例行腹腔镜胃底折叠术的胃食管反流性疾病患者的临床资料。结果　 33例行腹腔镜Nissen胃底折叠术 ,9例行腹腔镜Toupet胃底折叠术。术后症状评分由11 5 6± 1 32降到 2 0 4± 1 36 ,食管下段压力由 (7 32± 1 34)mmHg提高到 (18 2 0± 3 4 3)mmHg ,2 4hpH值监测评分由 183 36± 96 76降低到 8 0 4± 2 12 ,均较手术前有明显改善 (P <0 0 1) ,并达到正常范围。无手术并发症 ,无中转开腹及死亡病例。结论　对于严重的胃食管反流性疾病 ,腹腔镜胃底折叠术是一种安全、有效的治疗方法     

GerdQ量表在胃食管反流病诊断中的应用

目的探讨胃食管反流病量表(GerdQ)应用于诊断胃食管反流病(GERD)的价值。 方法对2013年6月至2014年10月在新疆维吾尔自治区人民医院就诊收住并存在反流相关症状的疑似胃食管反流病的1 000例患者进行问卷调查,按照烧心、反流、上腹痛、恶心、睡眠障碍、是否服用OTC药物等6项症状的发作频率进行评分。采用上消化道内镜检查及食管24 h pH监测作为GERD诊断的标准,并与GerdQ分值进行比较,最后计算出诊断GERD的临界值,进而分析GerdQ量表在GERD中的诊断价值。 结果GERD组的GerdQ积分主要集中于7～12分,非GERD组主要集中于6分以下,差异有统计学意义(P<0.05)。以GerdQ分值8为临界值,Youden指数最大(0.51),ROC曲线下的面积0.765,其敏感度为81.32%,特异性为70.21%,阳性预测值83.24%,阴性预测值61.53%。 结论GerdQ量表简单、易行,可作为临床上筛查诊断GERD的有效方法。     

Outcome of nonerosive gastro-esophageal reflux disease patients with pathological acid exposure

AIM: To assess the management and outcome of nonerosive gastro-esophageal reflux disease (NERD) patients who were identified retrospectively, after a 5-year follow-up.METHODS: We included patients with gastro-esophageal reflux disease (GERD) symptoms who had a negative endoscopy result and pathological 24-h esophageal pH-monitoring while off therapy. We interviewed them after an average period of 5 years (range 3.5-7 years) by means of a structured questionnaire to assess presence of GERD symptoms, related therapy, updated endoscopic data and other features. We assessed predictors of esophagitis development by means of univariate and multivariate statistical analysis.RESULTS: 260 patients (137 women) were included. Predominant GERD symptoms were heartburn and regurgitation in 103/260 (40%). 70% received a maintenance treatment, which was proton pump inhibitor (PPI) in 55% of cases. An average number of 1.5 symptomatic relapses per patient/year of followup were observed. A progression to erosive gastroesophageal reflux disease (ERD) was found in 58/193 (30.0%) of patients undergoing repeat endoscopy;72% of these were Los Angeles grade A-B.CONCLUSION: This study shows that progression to ERD occurs in about 5% of NERD cases per year,despite therapy. Only two factors consistently and independently influence progression: smoking and absence of PPI therapy.     

Proton pump inhibitor resistance,the real challenge in gastro-esophageal reflux disease

Gastro-esophageal reflux disease(GERD)is one of the most prevalent chronic diseases.Although proton pump inhibitors(PPIs)represent the mainstay of treatment both for healing erosive esophagitis and for symptom relief,several studies have shown that up to 40%of GERD patients reported either partial or complete lack of response of their symptoms to a standard PPI dose once daily.Several mechanisms have been proposed as involved in PPIs resistance,including ineffective control of gastric acid secretion,esophageal hypersensitivity,ultrastructural and functional changes in the esophageal epithelium.The diagnostic evaluation of a refractory GERD patients should include an accurate clinical evaluation,upper endoscopy,esophageal manometry and ambulatory pH-impedance monitoring,which allows to discriminate non-erosive reflux disease patients from those presenting esophageal hypersensitivity or functional heartburn.Treatment has been primarily based on doubling the PPI dose or switching to another PPI.Patients with proven disease,not responding to PPI twice daily,are eligible for anti-reflux surgery.     

GerdQ量表在胃食管反流病中的诊断价值

目的:探讨以反流症状为主的问卷调查(GerdQ)在诊断胃食管反流病(GERD)中的价值.方法:在接待消化内科门诊就诊患者中,对97例存在反流相关症状者进行问卷调查.按照烧心、反流、非心源性上腹痛、恶心、对睡眠有无影响、是否服用OTC药物6项的发作频率进行记分,总分范围为0-18,最高分可达18分,以内镜检查有否反流性食管炎(RE)及PPI诊断试验为诊断GERD的金标准,并与GerdQ分值进行比较,计算出诊断GERD的临界值.结果:1005例门诊患者中97例患者有反流相关症状,男女比例0.94:1,平均年龄47.37岁.经内镜检查诊断RE45例.以GerdQ分值9为临界值,Youden指数最大(0.41),ROC曲线下面积为最大(取8.5分时ROC曲线下面积最大,为0.727),对GERD诊断阳性符合率86.76%,阴性符合率为48.27%,敏感度为79.73%,特异度为61%.结论:GerdQ量表是诊断GERD的一个良好的筛选试验,可作为初步诊断GERD易行有效的方法.     

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.     

Laparoscopic surgery for gastro-esophageal acid reflux disease

Gastro-esophageal reflux disease is a troublesome disease for many patients, severely affecting their quality of life. Choice of treatment depends on a combination of patient characteristics and preferences, esophageal motility and damage of reflux, symptom severity and symptom correlation to acid reflux and physician preferences. Success of treatment depends on tailoring treatment modalities to the individual patient and adequate selection of treatment choice. PubMed, Embase, The Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for systematic reviews with an abstract, publication date within the last five years, in humans only, on key terms (laparosc* OR laparoscopy*) AND (fundoplication OR reflux* OR GORD OR GERD OR nissen OR toupet) NOT (achal* OR pediat*). Last search was performed on July 23nd and in total 54 articles were evaluated as relevant from this search. The laparoscopic Toupet fundoplication is the therapy of choice for normal-weight GERD patients qualifying for laparoscopic surgery. No better pharmaceutical, endoluminal or surgical alternatives are present to date. No firm conclusion can be stated on its cost-effectiveness. Results have to be awaited comparing the laparoscopic 180-degree anterior fundoplication with the Toupet fundoplication to be a possible better surgical alternative. Division of the short gastric vessels is not to be recommended, nor is the use of a bougie or a mesh in the vast majority of GERD patients undergoing surgery. The use of a robot is not recommended. Anti-reflux surgery is to be considered expert surgery, but there is no clear consensus what is to be called an ‘expert surgeon’. As for setting, ambulatory settings seem promising although high-level evidence is lacking.     

Management of gastro-esophageal reflux disease: Practice-oriented answers to clinical questions

Gastro-esophageal reflux disease (GERD) is a condition which is frequently faced by primary care physicians and gastroenterologists. Improving management of GERD is crucial to maximise both patient care and resource utilization. In fact, the management of patients with GERD is complex and poses several questions to the clinician who faces them in clinical practice. For instance, many aspects should be considered, including the appropriateness of indication to endoscopy, the quality of the endoscopic examination, the use and interpretation of ambulatory reflux testing, and the choice and management of anti-reflux treatments, i.e., proton-pump inhibitors and surgery. Aim of the present review was to provide a comprehensive update on the clinical management of patients with GERD, through a literature review on the diagnosis and management of patients with GER symptoms. In details, we provide practice-oriented concise answers to clinical questions, with the aim of optimising patient management and healthcare resource use.     

Ultrasonographic study of postcibal gastro-esophageal reflux and gastric emptying in infants with recurrent respiratory disease

AIM: To check the utility of postcibal ultrasonography for the evaluation of reflux in relation to gastric emptying in infants with recurrent respiratory symptoms and to link imaging with clinical data. METHODS: Esophageal reflux (hyperechoic retrograde filling) and gastric emptying (antral areas) were quantified before and after ingestion of a standard formula in 35 untreated infants (13 with chronic cough, 22 with recurrent bronchitis) and in 31 controls. RESULTS: The prevalence of abnormal (≥8 episodes) postcibal refluxes was 74% in patients and 3% in controls. Number, duration of the longest episode and extent of refluxes were significantly higher in patients compared to controls. Number of refluxes was higher in patients with symptomatic refluxes than in those without. Infants with recurrent bronchitis had more refluxes than those with chronic cough and controls. Extent and timing of gastric emptying were similar in patients and controls. CONCLUSION: Esophageal ultrasonography is a useful and physiological test in infants with recurrent respiratory diseases, which have a high prevalence of abnormal postcibal esophageal reflux and a gastric emptying similar to that of normal controls. Esophageal reflux is more severe in subjects with recurrent bronchitis than in those with chronic cough.     

Comparative clinical trial of S-pantoprazole versus racemic pantoprazole in the treatment of gastro-esophageal reflux disease

INTRODUCTION The primary treatment goals in patients with gastroesophageal reflux disease (GERD) are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis, and prevention of complications of esophagitis[1]. Proton pump inhibito…     

Clinical usefulness of adherence to gastro-esophageal reflux disease guideline by Spanish gastroenterologists

AIM: To investigate usefulness of adherence to gastro-esophageal reflux disease (GERD) guideline established by the Spanish Association of Gastroenterology.METHODS: Prospective, observational and multicentre study of 301 patients with typical symptoms of GERD who should be managed in accordance with guidelines and were attended by gastroenterologists in daily practice. Patients (aged > 18 years) were eligible for inclusion if they had typical symptoms of GERD (heartburn and/or acid regurgitation) as the major complaint in the presence or absence of accompanying atypical symptoms, such as dyspeptic symptoms and/or supraesophageal symptoms. Diagnostic and therapeutic decisions should be made based on specific recommendations of the Spanish clinical practice guideline for GERD which is a widely disseminated and well known instrument among Spanish in digestive disease specialists.RESULTS: Endoscopy was indicated in 123 (41%) patients: 50 with alarm symptoms, 32 with age > 50 years without alarm symptom. Seventy-two patients (58.5%) had esophagitis (grade A, 23, grade B, 28, grade C, 18, grade D, 3). In the presence of alarm symptoms, endoscopy was indicated consistently with recommendations in 98% of cases. However, in the absence of alarm symptoms, endoscopy was indicated in 33% of patients > 50 years (not recommended by the guideline). Adherence for proton pump inhibitors (PPIs) therapy was 80%, but doses prescribed were lower (half) in 5% of cases and higher (double) in 15%. Adherence regarding duration of PPI therapy was 69%; duration was shorter than recommended in 1% (4 wk in esophagitis grades C-D) or longer in 30% (8 wk in esophagitis grades A-B or in patients without endoscopy). Treatment response was higher when PPI doses were consistent with guidelines, although differences were not significant (95% vs 85%).CONCLUSION: GERD guideline compliance was quite good although endoscopy was over indicated in patients > 50 years without alarm symptoms; PPIs were prescribed at higher doses and longer duration.     

Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese

Objective. The frequency of gastroesophageal reflux disease (GERD) has not been fully investigated in the Asian population. The aim of this study was to investigate the prevalence of GERD, endoscopy-negative GERD (NERD), and erosive GERD in Japan, and the factors influencing disease prevalence. Material and methods. A total of 2760 subjects (mean age 50.4 years, range 24–84 years) were prospectively enrolled in this multicenter study. GERD symptoms were assessed with the Japanese version of the Carlsson-Dent self-administered questionnaire (QUEST) and upper gastrointestinal endoscopy was performed on all study participants. Results. A total of 495 (17.9%) individuals were diagnosed with GERD by the presence of erosive esophagitis at endoscopy and/or by the presence of GERD symptoms. Erosive esophagitis was diagnosed endoscopically in 195 (7.1%), and symptomatic GERD was diagnosed in 351 (12.7%) based on a QUEST score of over 6. Of these 351 subjects, 300 (10.9%) were considered to have NERD. Male gender, hiatal hernia, and mild gastric mucosal atrophy were significant positive predictive factors of erosive esophagitis by multiple regression analysis. Hiatal hernia was the only significant predictor of GERD symptoms. Traditional Japanese foods, such as sweet cakes and rice cake, frequently exacerbated GERD symptoms. Conclusions. The prevalence of GERD in the Japanese was 17.9% and the prevalence rates of NERD and erosive esophagitis were 10.9% and 8.6%, respectively. The majority of symptomatic patients did not have endoscopically proven esophagitis. Hiatal hernia is the only important predictor of the presence of GERD symptoms.     

Effect of gluten-free diet on preventing recurrence of gastroesophageal reflux disease-related symptoms in adult celiac patients with nonerosive reflux disease

Background and Aim:  In Celiac Disease (CD) the role of a gluten-free diet (GFD) on gastroesophageal reflux disease–related symptoms (GERD-rs) is unclear. The aim of this study was to establish the recurrence of GERD-rs, in CD patients with nonerosive reflux disease (NERD).
Methods:  From a total of 105 adult CD patients observed, 29 who presented with the NERD form were enrolled in the study. Thirty non-CD patients with NERD were studied as controls. Recurrence of GERD-rs was clinically assessed at 6, 12, 18, and 24 months follow-up (FU) after withdrawal of initial proton-pump inhibitor (PPI) treatment for 8 weeks.
Results:  GERD-rs were resolved in 25 (86.2%) CD patients and in 20 (66.7%) controls after 8 weeks of PPI treatment. In the CD group, recurrence of GERD-rs was found in five cases (20%) at 6 months but in none at 12, 18, and 24 months while in the control group recurrence was found in six of 20 controls (30%), in another six (12/20, 60%), in another three (15/20, 75%), and in another two (17/20, 85%) at 6, 12, 18, and 24 months FU respectively.
Conclusions:  The present study is the first to have evaluated the effect of a GFD in the nonerosive form of GERD in CD patients, by means of clinical long-term follow-up, suggesting that GFD could be a useful approach in reducing GERD symptoms and in the prevention of recurrence.     

反流性疾病问卷在胃食管反流病诊断中的价值

目的 探讨以反流症状为主的问卷调查(RDQ)在诊断胃食管反流病(GERD)中的价值。方法 上海、北京等10家医院多中心研究，对128例有烧心、胸骨后疼痛、反酸、反食等四种消化道症状的患者，按症状程度与发作频率为记分标准(5级记分制)，最高分可达40分，取症状6分以上为人选患者，以内镜检查有否反流性食管炎(RE)及24h食管pH检测为诊断(3ERE)的金标准，并与RDQ分值进行比较，计算出诊断GERD的临界值。结果 RDQ分值与RE严重程度呈正相关，食管pH检测异常组DeMeester积分显著高于正常组(20．18／16．84)。以RDQ分值12为临界值，Youden指数最大，ROC曲线下面积(Az)为0．71，对GERD诊断阳性符合率达88．07％，阴性符合率为68．42％，敏感度为94．12％，特异度为50．00％。结论 RDQ调查是诊断GERD的一个良好的筛选试验。     

Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) has been extensively studied in patients with laryngeal signs and symptoms, gastroesophageal reflux being identified in approximately 50%. Few studies have investigated the incidence and significance of LPR in GERD patients. Two-hundred and seventy-six consecutive patients referred with symptoms of gastroesophageal reflux had dual probe 24 h pH, esophageal manometry, GERD and ENT questionnaires. LPR was defined as at least three pharyngeal reflux events less than pH 5.0 with corresponding esophageal reflux, but excluding meal periods. Fourty-two percent of patients were positive for LPR on 24 h pH monitoring and 91.3% corresponded with an abnormal esophageal acid score. Distal esophageal acid exposure was significantly greater (P < 0.001) in patients with LPR but symptoms of GERD and regurgitation scores showed no significant differences between patients with positive and negative LPR on 24 h pH. There was no significant difference between the incidence of LPR in patients with or without laryngeal symptoms. There is a high incidence of LPR in patients with GERD but its significance for laryngeal symptoms is tenuous. Fixed distance dual probe pH monitoring allows documentation of conventional esophageal reflux and LPR.     

原发性胆汁反流性胃炎与胃食管反流病的关系

目的:探讨原发性胆汁反流性胃炎(primary bile reflux gastritis,PBRG)与胃食管反流病(gastroesophageal reflux disease,GERD)之间的相关性.方法:选取我院确诊为PBRG的患者1060例为观察组,无痛胃镜下未查见有PBRG的体检者1060例为对照组,比较两组GERD的发生率;依据内镜下PBRG的诊断标准,将260例PBRG伴有GERD的患者分为轻度、中度及重度3组,对比各组食管黏膜损伤的程度以及GERD症状积分的分布.结果:PBRG组GERD的发生率高于对照组(24.5%vs9.8%,P<0.05).食管黏膜损伤程度加深的发生率随着PBRG程度的加重而增加.PBRG的程度与GERD症状分级无相关性.结论:PBRG与反流性食管炎(refluxe sophagitis,RE)形成存在正性相关,PBRG并非是引起GERD症状的主要原因.     

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。     

Gender difference in gastro-esophageal reflux diseases

The incidence of esophageal adenocarcinoma(EAC) has risen sharply in western countries over the past 4 decades. This type of cancer is considered to follow a transitional process that goes from gastro-esophageal reflux disease(GERD) to Barrett's esophagus(BE,a metaplastic condition of the distal esophagus), a precursor lesion and ultimately adenocarcinoma. This spectrum of GERD is strongly predominant in males due to an unidentified mechanism. Several epidemiologic studies have des cribed that the prevalence of GERD, BE and EAC in women is closely related to reproductive status, which suggests a possible association with the estrogen level. Recently, we revealed in an in vivo study that the inactivation of mast cells by the anti-inflammatory function of estrogen may account for the gender difference in the GERD spectrum. Other studies have described the contribution of female steroid hormones to the gender difference in these diseases. Estrogen is reported to modulate the metabolism of fat, and obesity is a main risk factor of GERDs. Moreover, estrogen could confer esophageal epithelial resistance to causative refluxate. These functions of estrogen might explain the approximately 20-year delay in the incidence of BE and the subsequent development of EAC in women compared to men, and this effect may be responsible for the male predominance. However, some observational studies demonstrated that hormone replacement therapy exerts controversial effects in GERD patients. Nevertheless, the estrogen-related endocrine milieu may prevent disease progression toward carcinogenesis in GERD patients. The development of innovative alternatives to conventional acid suppressors may become possible by clarifying the mechanisms of estrogen.     

Extraesophageal gastroesophageal reflux disease (GERD) symptoms are not more frequently associated with proximal esophageal reflux than typical GERD symptoms

Extraesophageal (EE) symptoms such as cough and throat clearing are common in patients referred for reflux testing, but are less commonly associated with gastroesophageal reflux disease (GERD). Patients with reflux associated EE symptoms often lack typical GERD symptoms of heartburn and regurgitation. Our aim was to compare the frequency of proximal esophageal reflux between esophageal (typical) symptoms and EE (atypical) symptoms. Combined multichannel intraluminal impedance‐pH (MII‐pH) tracings were blinded by an investigator so that symptom markers were relabeled with a number without disclosure of symptom type. We selected 40 patients with at least five reflux‐related symptom events for one of four symptoms (heartburn, regurgitation, cough, or throat clearing). A blinded investigator analyzed all 200 reflux episodes, reporting the proximal esophageal extent of the reflux for all symptoms. The percentage of symptom‐related reflux extending proximally to 17 cm above the LES was similar among all four symptom types. At least 50% of all symptoms were associated with proximal esophageal reflux to 17 cm, with regurgitation having the highest frequency at 60%. Our data indicate that EE symptoms are not more frequently associated with proximal esophageal reflux than typical esophageal symptoms.