【作者】 陈静；

【导师】 戴宁；

【作者基本信息】 浙江大学 ， 内科学（消化系病）， 2016， 硕士

【摘要】 背景：胃食管反流病(GERD)是一种常见的消化科疾病,其病理生理机制尚未完全阐明,目前较多研究认为GERD是胃食管动力障碍性疾病。随着质子泵抑制剂(PPI)的出现使GERD的治疗得到极大改善,但仍有一部分患者经PPI治疗后症状无改善,被称为难治性胃食管反流病。有研究发现近一半的GERD患者食管体部蠕动功能存在障碍,而在难治性GERD患者中食管动力障碍占多少比例尚无报道。高分辨率食管测压(HRM)是在传统食管测压的基础上发展而来的一种直观和准确的固态测压方法。目前临床上采用10口5m1水吞咽法,然而这种检测方法不符合正常生理习惯,难以诱发出患者食管的动力异常,而且当检测结果缺乏主要动力障碍时,应用常规饮水吞咽很难解释患者的食管症状和疾病的病因。国外有研究发现应用快速多口水吞咽、固体吞咽进行HRM检测能够提高食管动力障碍的检出率。但目前国内缺乏应用连续饮水和固体吞咽进行高分辨率食管测压检测食管动力的研究。目的：应用高分辨率食管测压技术对难治性胃食管反流病患者进行食管测压,分析胃食管反流病患者不同亚组的食管动力特征,进一步分析比较三种试餐(常规饮水、连续饮水和固体吞咽)在检测食管动力障碍中的作用。方法：收集2014年5月至2015年12月于浙江大学医学院附属邵逸夫医院消化内科胃肠动力实验室行高分辨率食管测压检查的难治性胃食管反流患者的临床资料,根据患者症状、胃镜检查及24hpH-阻抗联合监测结果,将患者分为反流性食管炎(reflux esophagitis, RE)组、非糜烂性反流病(non-erosive reflux disease, NERD)组和症状-反流无关联组,应用常规10口5m1饮水、200m1连续饮水和150g米饭固体吞咽进行高分辨食管测压,比较三种方法在检测食管动力障碍的价值。食管动力障碍标准分别是,常规饮水：根据芝加哥分类V3.0标准；连续饮水：两次饮水试餐后均无有效食管收缩；固体吞咽：有效吞咽口数<50%为食管动力障碍。结果：共纳入符合条件的GERD患者51例,其中反流性食管炎(RE)组11例,非糜烂性反流病(NERD)组25例,症状-反流无关联组15例。1.RE组远端收缩积分(distal contraction integral, DCI)明显低于NERD组和症状-反流无关联组(P=0.039)。RE组食管蠕动率明显低于其他两组(P=0.002)。2.RE组和NERD组Demeester评分、酸反流次数明显高于症状-反流无关联组(P<0.001)。RE组和NERD组中位酸暴露时间较症状-反流无关联组明显延长(P=0.001)。3.常规饮水方法测得共有31.4%(16/51)患者有食管动力障碍,其中11例(68.8%)患者诊断为无效的食管动力(ineffective esophageal motility, IEM);5例(31.2%)患者诊断为完全性失蠕动。4.将51例受试者分为完全性失蠕动组(5例)、无效食管动力组(11例)和无食管动力障碍组(35例),其中完全性失蠕动组的酸反流次数明显高于其他两组(P=0.024)。5.200m1连续饮水法共检测出28例(54.9%)食管动力障碍,食管动力障碍检出率明显高于常规10口5m1饮水方法,差异具有统计学意义(P=0.017)。6.150g米饭固体吞咽法食管动力障碍的检出率(33/51,64.7%)明显高于常规10口5m1饮水方法(P<0.001)。其中RE组食管动力障碍检出率(90.9%)和NERD组(68.0%)明显高于症状-反流无关联组(40.0%)(P=0.024)。RE组固体吞咽有效口数明显低于其他两组(P=0.027)。结论：难治性胃食管反流病患者中食管动力障碍常见,包括食管蠕动功能减弱、消失以及无效的食管动力,其中无效的食管动力最为常见。在行HRM检测时应用200m1连续饮水和150g米饭固体吞咽检测方法食管动力障碍的检出率明显高于10口5m1常规饮水方法,其临床应用价值有待进一步评估。更多还原

【Abstract】 Background:Gastroesophageal reflux disease (GERD) is a common digestive disease, the pathophysiological mechanism of which is still unclear. Recently, GERD is recognized as a pathological condition of gastrointestinal motility disorder. With the development of proton pump inhibitor (PPI), the treatment of GERD has been greatly improved. However, there is still a small portion of this diseases, so called refractory GERD, that can not be intervened effectively by PPI. High-resolution manometry (HRM) is a straightforward and precise pressure measuring method developed from the traditional esophagus pressure detection. Current HRM protocols establish diagnoses using normal values obtained from 5 ml water swallows,50ml water drink. However, the disadvantage of this method is that it is hard to induce the gastrointestinal motility disorder in patients due to its low match to normal physiological habit. This protocol often fail to explain the relationship between the symptom and pathogenesis, especially when the test results show no significant motility dysfunction in patients. Some foreign researches showed that HRM based on multiple rapid swallows and solid swallows could effectively identify minor motility dysfunction, thus improve the diagnosis rate of esophageal motility disorder. Nevertheless, so far there is still a lack of evidence focusing on HRM based on mulitple water swallows and solid swallows in China.Objective:To compare the differences of HRM based on three test meal, that is 5ml water swallows, multiple water swallows and solid swallows, for assessment of the esophageal dysfunction in different subgroups of GERD patients.Methods:Patients with refractory GERD who underwent HRM in Sir Run Run Shaw Hospital from May 2014 to December 2015 were enrolled. Based on the symptoms, findings by gastroscopy and the results of PH monitoring within 24h, all the patients were assigned to the following three groups:reflux esophagitis (RE) group, non-erosive reflux disease (NERD) group and symptom-reflux non-association group. The differences of HRM based on three methods, including 5 ml water swallows with 50ml drink,200ml water drink and 150g solid test meal, were compared in the assessment of the esophageal mobility. The esophageal motility disorders,5ml water swallows: according to the Chicago classification of esophageal motility v3.0,200 mL water drink:ineffective contraction after twice multiple water swallows, solid test meal: effectively swallows were less than 50%.Results:Finally,51 patients were enrolled, including 11 RE patients,25 NERD patients and 15 symptom-reflux non-association patients.1. The distal contraction integral (DCI) of RE group was significantly lower than NERD group and symptom-reflux non-association group (P=0.039). The esophageal peristalsis rate of RE group was significantly lower than the other groups (P=0.002).2. The median acidic reflux events and the DeMeester of RE group were significantly higher than those of NERD and symptom-reflux non-association group (p<0.001). The median acidic exposure time of RE group and NERD group were significantly longer than that of symptom-reflux non-association group (p=0.001).3. Esophageal motility disorders were found in 16 of all 51 enrolled patients (31.4%), with ineffective esophageal motility (IEM) in 11 patients (11/16,68.8%), and absent contractility in the rest 5 patients (5/16,31.2%).4. All 51 patients were divided into three groups:no peristalsis group (n=5), invalid esophageal motility group (n=11) and normal function group (n=35). The frequency of reflux in no peristalsis group was significantly higher than that of the latter two groups (P=0.024).5. Based on continuous water swallow with 200ml drink, esophageal motility disorders were found in 28 of all 51 patients (54.9%), which was higher than that of 5 ml water swallows with 50ml drink method, the difference was significant (P=0.017).6. Esophageal motility disorders detection rate was significantly higher using solid test meal (33/51,64.7%) than using conventional method (16/51,31.4%) (p<0.001). The esophageal motility disorders of RE group (90.9%) and NERD group (68%) were significantly higher than that of symptom-reflux non-association group (p=0.024). The effective swallows of RE group in solid test meal was significantly lower than the other two groups (P=0.027).Conclusions:Esophageal motility disorders were common conditions in refractory GERD patients, including fragmented peristalsis, absent contractility and IEM which is the most common type among the three. Esophageal motility disorders detection rate was higher using multiple water swallows (200ml water) and solid test meal (150g rice) than conventional method (10* 5ml water). Further studies are warranted to evaluate the value of them.更多还原