【作者】 刘敏；

【导师】 李建生；

【作者基本信息】 郑州大学 ， 临床医学（专业学位）， 2014， 硕士

【摘要】 背景胃食管反流病（gastroesophageal reflux disease, GERD）是一种常见的消化系统疾病，是由胃内容物反流引起的一系列症状和（或）并发症的一种状态。胃食管反流病是临床上十分常见的一种慢性疾病，质子泵抑制剂（protorn pumpinhibitors, PPI）是目前治疗该疾病最有效的治疗方法，大部分患者症状很快减轻，但仍有部分患者经过4~8周标准化PPI治疗未有效缓解，称为难治性胃食管反流病（refractory gastroesophageal reflux disease, RGERD）。近年来，人们发现联合黛力新治疗具有较好的疗效，而且治疗中具有较高的安全性，值得临床推广。目的联合黛力新、埃索美拉唑及莫沙必利治疗难治性胃食管反流病，通过观察患者的临床症状（烧心、反酸、胸骨后疼痛、反食）积分、治疗有效率、情绪障碍量表总分、食管24小时pH测定及食管测压结果来比较并评价黛力新的联合治疗的疗效，探讨有效的治疗方案。方法选取本院2009年1月-2013年10月门诊及住院诊治的82例难治性胃食管反流病患者作为研究对象，其中男44例，女38例，年龄26~69岁，平均年龄48±6.2岁。诊断标准依据蒙特利尔GERD定义，并结合我国2007年西安胃食管反流病治疗共识意见。将患者随机分为两组，其中观察组41例（含男23例，女18例），年龄26~66岁，平均年龄47.2±6.2岁；对照组41例（含男21例，女20例），年龄28~69岁，平均年龄48.7±6.5岁。所有患者均行内镜检查、24h食管pH值监测、食管测压，均知情同意。观察组和对照组的性别、年龄、吸烟饮酒情况、体重指数（body mass index, BMI）、DeMeester评分、食管下括约肌压力（lower esophageal sphincter pressure, LESP）、食管下括约肌长度（length oflower esophageal sphincter, LESL）等资料的差异不显著（P>0.05），具有可比性。对照组给予埃索美拉唑片20mg/次，每日两次口服，莫沙必利片5mg/次，每日三次口服治疗；观察组在对照组治疗基础上加用氟哌噻吨美利曲辛片（商品名：黛力新，每片含氟哌噻吨0.5mg、美利曲辛10mg）1粒/次口服，早上、中午各一次。2组疗程均为8周。2组患者于治疗前后分别进行GERD症状评分，并采用Zung焦虑自评量表（self-rating anxiety scale, SAS）和Zung抑郁自评量表（self-rating depress scale, SDS）评估精神心理状况，同时对治疗前后食管测酸、测压结果进行对比分析。结果治疗8周后应用胃食管反流性疾病诊断问卷RDQ进行评分，观察组治疗后有34例症状明显好转（RDQ评分<12分），对照组治疗后有22例症状明显好转（RDQ评分<12分），两组治疗后比较P<0.05，差异有统计学意义。观察组治疗后临床症状显效14例（34.15%），有效21例（51.22%），总有效率为85.37%；对照组治疗后显效8例（19.51%），有效17例（41.46%），总有效率为60.97%。观察组总有效率显著高于对照组，两组相比其差异具有统计学意义。观察组和对照组的SDS指数和SAS指数在治疗前差异并不显著（P>0.05）。经过8周治疗后，观察组SDS指数由55.3±8.8降低为42.1±9.1，SAS指数由54.3±8.7降低为41.2±9.2，而对照组SDS指数由55.8±9.1变化为52.6±9.3，SAS指数由53.0±8.9变化为49.3±9.1，各组内患者的SDS指数和SAS指数均有所降低（P<0.05），说明RGERD患者经过治疗后抑郁及焦虑的状况得到了改善；但两组之间相比较，观察组较之对照组的抑郁、焦虑状况改善更为显著，其差异具有统计学意义（P<0.05）。另外，8周治疗后，观察组与对照组DeMeester评分均有所降低（P<0.05），观察组DeMeester评分由29.5±5.6变化为12.1±3.1，对照组DeMeester评分由30.3±6.1变化为13.3±3.6，说明RGERD患者经过治疗后酸反流得到一定程度的缓解；但两组之间相比较，其差异无统计学意义（P>0.05）。两组治疗前后LESP及LESL均无明显变化，组内组间比较差异均不显著（P>0.05）。结论黛力新联合埃索美拉唑及莫沙必利治疗难治性胃食管反流病，可有效改善患者烧心、反酸等症状，提高临床疗效。精神心理因素可能是难治性胃食管反流病发病机制中的重要一环。更多还原

【Abstract】 BackgroundBeing a type of common and chronic digestive system diseases, Gastroesophageal reflux disease (GERD) refers a series of symptom or complication ofhuman being’s body status caused by the reflux of gastric contents. Proton pumpinhibitors (PPI) are the most effective treatment manners for GERD. By using PPI,although most GERD patients’ symptoms can be released, there are still a partnumber of patients whose symptoms cannot be released effectively after4-8weektreatments. This phenomenon is called refractory gastroesophageal reflux disease(RGERD). Recently, people have found that the new treatment manner of combiningDeanxit (drug name: Flupentixol and Melitracen tablets; composition: Flupentixol0.5mg and Melitracen10mg per tablet) and traditional medicines can improve thecurative efficacy of RGERD. The manner is also proving to be a highly safety and isworthy of popularizing in clinic. ObjectiveTreatment the RGERD combined with Deanxit, Esomeprazole and Mosapride,then discuss the effective treatment by observing the total scores, curative rate, scoresof Emotional disorder scale,24h esophageal pH monitoring and esophagealmanometry of patients’ clinical symptoms such as heartburn, sour regurgitation,retrosternal pain and food regurgitation.MethodsSelect the hospital’s82clinic and hospitalized patients from January2009toOctober2013as subjects, including44males and38females with the age of average48±6.2and range from26to69. The diagnostic criteria of the patients are accordingwith the Montreal definition of GERD and the consensus of the treatment of GERDin Xin’an China,2007. The patients were divided into two groups randomly, with thesample size41in observation group (includes23males and18females whose age ofaverage47.2±6.2and range from26to66) and sample size41in matched group(includes21males and20females whose age of average48.7±6.5and range from28to69). All of the patients had conducted endoscopy,24h esophageal PH monitoringand esophageal manometry with informed consents. Moreover, there was nosignificant difference of the two groups (P>0.05) in age, gender, status of smokingand excessive drinking, body mass index (BMI), scoure of Demeester, loweresophageal sphincter pressure (LESP) and length of lower esophageal sphincter(LESL). In8weeks course of the contrast tests, patients in the matched group aretreated by Esomeprazole (20mg, bid, po) and Mosapride (5mg, tid, po) while patientsin the observation group are treated by appending Deanxit (1tablet, every morningand noon) to that of the matched group. The curative effects of the two groups werereflected by GERD total scores, and the psychological states of the two groups weremeasured by self-rating anxiety scale (SAS) and self-rating depresses scale (SDS).Furthermore, the results of24h esophageal PH monitoring and esophagealmanometry were also contrasted. ResultsAfter8weeks’ treatments, by using the gastro esophageal reflux diseasequestionnaire (RDQ),34patients in the observation group had taken an obviouslybetter changing (RDQ score<12) contrast that of22samples in the matched group.And the effects different between the two groups is significant (P<0.05). Furthermore,the markedly improved sample size was14(34.15%), the improved sample size is21(51%) and the total effective rate was85.37%of the observation group, with thecontrast of that of the matched group were8(19.51%),17(41.46%),60.97%. And thetotal effective rate of the observation group is significant higher than that of thematched group (P<0.05). The differents of SDS and SAS index between the twogroups are not significant (P>0.05). After8weeks treating, the SDS and SAS indexwithin the two groups were significant decreased (P<0.05), which indicate the statesof anxiety and depress have been improved. For the observation group, SDS indexdecreased form55.3±8.8to42.1±9.1, while SAS index decreased from54.3±8.7to1.2±9.2; For the matched group, SDS index decreased form55.8±9.1to52.6±9.3,while SAS index decreased from53.0±8.9to49.3±9.1. Moreover, the differentbetween the two groups is also significant (P<0.05) which indicates that theimproving of the observation group was better than the matched group. In addition,after8weeks’ treatment, the within differences of the two groups are significantdecreased in the Demeester scoure. For the observation group, the Demeester scouredecreased form29.5±5.6to12.1±3.1; For the matched group, the Demeester scouredecreased form30.3±6.1to13.3±3.6. But the betweem and within differences ofthe two groups are not significant in LESP and LESL (P>0.05).ConclusionsThe treatment effect of RGERD could be improved by combining Deanxit，esomeprazole and mosapride. Moreover, the psychological factor is probably animportant influence of the nosogenesis of RGERD.更多还原