难治性胃食管反流病的反流危险因素调查

目的：收集胃食管反流病（gastroesophageaf reflux disease,GERD）患者的临床信息、胃镜表现以及24 h食管pH-阻抗监测结果,比较难治性GERD和非难治性GERD的反流特点,探讨难治性GERD的预测因素,为临床处理提供依据.方法：入选2008年10月-2012年12月因反酸、烧心、非心源性胸痛、咽痛等症状在复旦大学附属中山医院消化科疑诊为GERD的74例患者.记录患者的年龄、性别、身高、体质量、胃镜结果等.监测患者的食管下段pH和食管阻抗变化.难治性GERD诊断：符合GERD诊断标准,同时经过质子泵抑制剂（PPI）治疗4周（每天至少1次）无效或者deMeester评分下降少于50％;非难治性GERD诊断：符合GERD诊断标准,同时经过PPI治疗4周（每天至少1次）症状改善明显;非GERD诊断：内镜检查未见食管黏膜损害,且24 h食管pH-阻抗监测反流次数和deMeester评分不足以诊断GERD.计数资料正态分布者用r±s表示,菲正态分布者用中位数和百分位数（25th,75th）表示.采用SPSS 17.0软件进行统计学处理.按是否为GERD、是否为难治性GERD分组,比较患者的一般资料和反流特征性因素.结果：（1）难治性GERD患者与非难治性GERD患者的酸反流次数、总反流次数差异无统计学意义;难治性GERD患者的deMeester评分较非难活性GERD患者高,长酸反流次数较非难治GERD患者多（P=0.032,P=0.008）;（2）经Logistic多因素分析发现,难治性GERD与长酸反流次数、非糜烂性胃食管反流病（NERD）呈正相关（P值分别为0.01和0.045）.长酸反流次数增加1次,发生难治性GERD的危险增加36％;NERD患者发生难治性GERD的危险是反流性食管炎患者的4.54倍;（3）不同类型GERD的反流特征：NERD患者的近端反流次数大于反流性食管炎和Barrett食管患者,而近端反流百分比显著大于反流性食管炎患者和Barrett食管患者（P=0.006）.结论：（1）长酸反流次数多和NERD是难治性GERD的独立危险因素;（2）NERD患者比糜烂食管炎患者更容易发展为难治性GERD.NERD患者的近端反流百分比的升高可能与其对PPI的反应差有关.

Risk Factors for Refractory Gastroesophageal Reflux Disease

Objective：This study aims to collect clinical informations,gastrocopy features and 24 h ambulatory esophageal impedance-pH index of patients with gastroesophageal reflux disease （GERD）,and to compare the reflux conditions between refractory GERD and non-refractory GERD,and to provide evidence for the pre-diagnosis of refractory GERD.Methods：From October 2008 to December 2012,74 patients complaining of suspected reflux symptoms or extra-esophageal manifestations were treated in Gastroenterology Department of Zhongshan Hospital.The age,sex,height,weight and the result of endoscopy were recorded.All patients underwent 24 h ambulatory esophageal impedance-pH examination.The definition of refractory GERD：patients with GERD whose deMeester score ＜50％ improvement in the chief complaint after giving once daily for at least 4 weeks proton pump inhibitors （PPIs）.Patients with GERD whose deMeester score ＞50％ improvement in the chief complaint after giving PPIs once daily for at least 4 weeks were not refractory GERD.Patients with normal endoscopy results or 24 h ambulatory esophageal impedance-pH were not GERD.SPSS 17.0 was used to compare the basic conditions and reflux characteristics among GERD,non-GERD,and refractory GERD patients.Results：（1）The times of acid reflux and total reflux of refractory GERD and non-refractory GERD patients had no statistical difference.The deMeester score and long acid reflux times of refractory GERD patients were higher than those of non-refractory GERD patients（P =0.032,P =0.008）;（2）Refractory GERD had positive correlation with total acid reflux longer than 5 min and NERD.When one acid reflux longer than 5 min happened,the risk of refractory GERD increased by 36％.The GERD risk of NERD patients was as 4.54 times as that of reflux esophagitis（RE） patients; （3）The reflux characteristics of different GERD：The total proximal reflux of NERD was more than RE and Barrett＇s esophagus,and the percentage of proximal reflux was more than RE and Barrett＇s esophagus.Conclusions：（1） Acid reflux time longer than 5 min and NERD were the independent risk factors for refractory GERD; （2）The increase of proximal reflux percentage of NERD may have relations with its response to PPI.