雷贝拉唑、莫沙必利联合治疗老年人非糜烂性反流病的疗效观察

目的 评价雷贝拉唑和莫沙必利联合应用治疗老年人非糜烂性反流病(NERD)的疗效. 方法对52例NERD老年患者在应用雷贝拉唑和莫沙必利联合治疗前后的临床表现、24h食管pH监测值的变化情况及不良反应进行比较.结果 用药前及用药后每2周进行临床症状观察,发现治疗后临床症状逐渐改善及消失,24h食管pH监测各项指标在治疗后均明显小于治疗前(P＜0.01);两药联用未见明显不良反应.结论 雷贝拉唑联合莫沙必利治疗老年NERD疗效确切.     

Treatment of PPI-resistant gastro-oesophageal reflux: A systematic review

Background and study aims

Several studies have demonstrated the superiority of proton-pump inhibitors (PPIs) in resolving erosive gastro-oesophageal reflux disease (GORD). However, this first line of treatment can fail to control symptoms in around 30% of cases, especially in the presence of non-erosive GORD. In situations where the first line of treatment fails, there is a lack of concordance regarding the best strategy to apply. This study presents a systematic review of the trials which have tested second-line treatments after PPI failure.

High-resolution manometry and impedance-pH/manometry: valuable tools in clinical and investigational esophagology

Both high-resolution manometry (HRM) and impedance-pH/manometry monitoring have established themselves as research tools and both are now emerging in the clinical arena. Solid-state HRM capable of simultaneously monitoring the entire pressure profile from the pharynx to the stomach along with pressure topography plotting represents an evolution in esophageal manometry. Two strengths of HRM with pressure topography plots compared with conventional manometric recordings are (1) accurately delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and (2) easily distinguishing between luminal pressurization attributable to spastic contractions and that resultant from a trapped bolus in a dysfunctional esophagus. Making these distinctions objectifies the identification of achalasia, distal esophageal spasm, functional obstruction, and subtypes thereof. Ambulatory intraluminal impedance pH monitoring has opened our eyes to the trafficking of much more than acid reflux through the esophageal lumen. It is clear that acid reflux as identified by a conventional pH electrode represents only a subset of reflux events with many more reflux episodes being composed of less acidic and gaseous mixtures. This has prompted many investigations into the genesis of refractory reflux symptoms. However, with both technologies, the challenge has been to make sense of the vastly expanded datasets. At the very least, HRM is a major technological tweak on conventional manometry, and impedance pH monitoring yields information above and beyond that gained from conventional pH monitoring studies. Ultimately, however, both technologies will be strengthened as outcome studies evaluating their utilization become available.     

Microscopic esophagitis in gastro-esophageal reflux disease: individual lesions,biopsy sampling,and clinical correlations

Patients with non-erosive reflux disease may show microscopic damage. This study is aimed to describe distribution, sensitivity, and specificity of histological lesions (i.e., basal cell hyperplasia—BH, papillae elongation—PE, dilatation of intercellular spaces—DIS, intraepithelial eosinophils—IE, neutrophils, and erosions) and sampling criteria. Four groups were identified on the basis of symptoms, endoscopy, and pH monitoring: (1) erosive esophagitis (n = 48), (2) non-erosive esophagitis with abnormal pH (n = 59), (3) non-erosive esophagitis with normal pH (n = 12), and (4) controls (n = 20). Biopsies were taken at the Z-line and 2 and 4 cm above it. BH, PE, DIS, IE, neutrophils, and erosions were assessed. A global severity score was calculated on the basis of the above parameters and allowed the distinction of patients from controls with 80% sensitivity and 85% specificity. Lesions were more severe at Z-line than proximally and more expressed in erosive than in non-erosive disease, although more than 70% of latter patients still showed histological damage. Esophageal biopsy seems very attractive in non-erosive disease where it may contribute to diagnosis and play a role in the comparative evaluation of different therapies.     

Gastroesophageal reflux disease is a progressive disease

It is controversial whether gastrooesophageal reflux disease represents a spectrum disease from a nonerosive to a complicated one, or whether it is a categorial disease, i.e. it can be divided into three categories, such as nonerosive gastrooesophageal reflux disease, erosive gastrooesophageal reflux disease and Barrett's esophagus (BE) with little or no transition from one category to the other. This controversy might be of general interest, because it has some implications in the management of the patient. However, literature data concerning the natural history of gastrooesophageal reflux disease are very limited, and in particular very few papers have dealt with the issue of describing the natural history of patients with nonerosive gastrooesophageal reflux disease. Aim of the present review is to reassess these scanty data, and to try to demonstrate that progression from milder to more severe forms of gastrooesophageal reflux disease is possible and documented.     

Inflammation and oxidative stress in gastroesophageal reflux disease

The etiology of esophageal mucosal injury is complex, since it may involve the reflux of gastric acid, bile acid, and pancreatic juice, external factors such as drugs and alcohol, or functional factors such as esophagogastric motility. The mechanism of esophageal mucosal injury has gradually been understood at the molecular biological level. It is particularly important that pro-inflammatory factors, such as inflammatory cytokines (interleukin-6 and -8), leukocytes and oxidative stress, have been demonstrated to be involved in the development of gastroesophageal reflux disease (GERD) including nonerosive reflux disease (NERD). In addition, nociceptors such as acid-sensitive vanilloid receptors, protease-activated receptors and substance P have also been implicated in the pathogenesis of neurogenic inflammation in NERD patients with esophageal hypersensitivity. The development of new therapy with anti-inflammatory and anti-oxidant effects is expected to assist in the treatment of intractable NERD/GERD and the prevention of carcinogenesis.     

The proton pump inhibitor test and the diagnosis of gastroesophageal reflux disease

There continues to be significant controversy related to diagnostic testing for gastroesophageal reflux disease (GERD). Symptoms of GERD may be associated with physiologic esophageal acid exposure measured by intraesophageal pH monitoring or pH-impedance monitoring, and a significant percentage of patients with abnormal esophageal acid (or weak acid) exposure have no or minimal clinical symptoms of reflux. On the other hand, endoscopic lesions are only present in a minority of GERD patients. In clinical practice, presumptive diagnosis of GERD is reasonably assumed by the substantial reduction or elimination of suspected reflux symptoms during the therapeutic trial of acid reduction therapy, the so-called proton pump inhibitor (PPI) test. We aimed to assess the optimal cutoff value and duration of this test in GERD patients with and without esophagitis. We conducted a prospective study of 544 patients, endoscopically investigated and treated for 2 weeks with PPIs at double dose, and for an additional 3 months at standard dose. The status of the patient at the end of the study was used as an independent diagnostic standard. We found esophagitis present in 55.8% and absent in 44.2% of patients (corresponding to a diagnosis of nonerosive reflux disease [NERD]). The test was positive in 89.7–97.8% of the patients according to the cutoff or duration of the test used. The sensitivity of the PPI test was excellent, ranging from 95.5 to 98.8%, whereas the specificity was poor, not exceeding 36.3%. Erosive esophagitis patients responded more favorably to the PPI test and subsequent PPI therapy compared with NERD patients. In conclusion, the PPI test is a sensitive but less specific test. Its optimal duration is 1 week, and the optimal cutoff value is a decrease of heartburn score of more than 75%. NERD patients respond less satisfactorily to PPIs, even when functional heartburn patients are excluded and only ‘true’ NERD patients are considered.     

雷贝拉唑结合氟哌噻吨／关利曲辛治疗非糜烂性反流病伴抑郁、焦虑患者的疗效观察

目的：探讨质子泵抑制剂雷贝拉唑结合氟哌噻吨／美利曲辛（黛力新）治疗非糜烂性反流病（NERD）的,临床疗效。方法：选择109例非糜烂性反流病伴抑郁、焦虑患者并随机分为2组,A组57例,给予雷贝拉唑20mg,早、晚餐前各1次,氟哌噻吨／关利曲辛10．5mg,早、中餐后各1次;B组52例,给予雷贝拉唑20mg,早、中餐前各1次,两组疗程均为6周,疗程结束后通过症状记分,判断疗效。结果：治疗6周后,两组患者的烧心、胸痛、反酸等主要症状的积分比较,差异均有统计学意义;A组显效率为86．5％,总有效率为96．1％;B组显效率为67．3％,总有效率为82．3％。两组比较差异有显著性（P〈0．05）。结论：对伴有抑郁、焦虑的NERD患者,雷贝拉唑结合氟哌噻吨／美利曲辛治疗是有效的治疗方案之一。     

内镜治疗疣状胃炎120例临床观察

目的：比较在胃食管反流病（GERD）治疗变形后的生活方式的临床疗效。方法：384例GERD门诊及住院病人（140例非糜烂胃食管反流病,糜烂性食管炎患者224例,与巴雷特食管没有病人）在我们医院接受治疗,在过去两年,在研究对象。与非糜烂性反流病的患者（NERD）的随机分为4组分别接受了placeo,变形后的生活方式,药物治疗或两者变形后生活方式和药品。糜烂性食管炎的患者（EE）的患者随机分为两组分别接受了治疗的药物或两者变形后的生活方式和药品。其临床症状进行评估后8周的治疗,并用胃镜检查治疗的状态。结果：这4个有效率与NERD组为46．67％,60％,85％,95％。这标志着与NERD的4组有效率分别为23．33％,43．33％,75％,85％。此次与EE的2组有效率分别为88．64％,94．87％分别。显效率两个组与EE的是68．18％,81．41％分别。结论：43％,轻度GERD患者完全可以放心的治疗与变形后的生活方式。严重的胃食道逆流患者需要接受与两个变形后的生活方式和药物治疗。