HRM、24 h pH-MII在内镜阴性烧心诊断中的应用研究
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摘要
目的利用高分辨率食管测压(HRM)和24 h食管多通道腔内阻抗pH监测(24 h pH-MII)探讨内镜阴性烧心患者的食管动力及反流特点。方法选取在四川省医学科学院·四川省人民医院消化内科门诊就诊的以反流症状为主的问卷调查量表(GerdQ)评分>8分和胃镜阴性患者303例,分为非糜烂性反流病(NERD)组、高敏感性食管(HE)组及功能性烧心(FH)组。搜集指标:食管远端收缩积分(DCI)、下食管括约肌静息压(LESP)、有效蠕动百分比及食管-胃连接部(EGJ)分型;阻抗基线值、不同性质及性状反流次数及近端反流次数。结果 (1)食管基线阻抗值:NERD组、HE组低于FH组(P<0.05);(2)酸反流:NERD组DeMeester评分、最长反流时间(AET)、立/卧位AET高于HE组、FH组(P<0.05);(3)化学及物理反流:NERD组以酸、液体及混合反流为主,HE组以弱酸、液体及混合反流为主,FH组以非酸及气体反流为主;(4)动力指标:NERD组食管LESP低于HE组、FH组(P<0.05),NERD组和HE组DCI低于FH组(P <0.05),FH组有效蠕动比高于其他两组(P <0.05),NERD组EGJⅡ型比例(29%)多于HE组(9%)、FH组(1%)(P <0.05)。结论 (1) NERD在食管动力及反流事件方面更符合GERD的发病机制;(2) HE患者较FH在食道动力的减弱及反流事件中增多更明显,FH患者在食道动力及反流方面无明显异常;(3)食管HRM联合24 h pH-MII在诊断内镜阴性烧心上更有优势,给临床治疗提供依据和指导。
Objective To use high resolution esophageal manometry(HRM) and 24-h multi-channel intraluminal impedance pH(24 h pH-MII) monitoring to discuss esophageal motility and reflux characteristics of non-erosive reflux disease(NERD) and functional esophageal disease, so as to understand the pathogenesis of NERD and guide clinical treatment. Methods A total of 303 patients manifested as reflux symptoms, with GerdQ score over 8 and negative endoscopic results were selected from Outpatient Department of Gastroenterology, Sichuan Academy of Medical Sciences. The patients were divided into 125 cases of NERD group(pH positive), 108 cases of HE group(pH negative, SI or SAP positive), and 70 cases of FH group(pH negative, SI or SAP negative). The following indexes were collected: the distal contractile integral(DCI) with 5 ml liquid swallowing for 10 times, lower esophageal sphincter resting pressure(LESP), the percentage of effective peristalsis and esophagogastric junction(EGJ) type, impedance baseline value, the times of reflux with different properties and characters, and the times of proximal reflux. Results Esophageal baseline impedance of the NERD group and the HE group was significantly lower than that of the FH group(P < 0.05). For acid reflux, DeMeester score in the NERD group was significantly higher than that in the HE and FH groups, and AET and upright/supine AET in the NERD group were significantly longer than those in the HE and FH groups(P < 0.05). As to physical and chemical reflux, the NERD group demonstrated mainly acidic, liquid and mixed reflux; the HE group demonstrated mainly weak acidic, liquid and mixed reflux; the FH group demonstrated non-acidic reflux and gas reflux. Regarding esophageal motility index, LESP of the NERD group was lower than that of the HE group and the FH group(P < 0.05). DCI and the number of effective esophageal motility in the NERD group and the HE group were lower than those in the FH group(P < 0.05). The percentage of type Ⅱ EGJ in the NERD group(29%) was higher than that in the HE group(9%) and the FH group(1%)(P < 0.05). Conclusions The positive acid exposure of NERD is more in line with the pathogenesis of gastroesophageal reflux disease in esophageal motility and reflux events. The decrease of esophageal motility and the ratio of reflux events are more obvious in the HE group than in the FH group in functional esophageal diseases. FH group is not apparently abnormal in esophageal dynamics and regurgitation. HRM combined with 24-h pH-MII has more advantages in diagnosis of endoscopic negative heartburn, which can provide basis and guidance for clinical treatment.
Objective To use high resolution esophageal manometry(HRM) and 24-h multi-channel intraluminal impedance pH(24 h pH-MII) monitoring to discuss esophageal motility and reflux characteristics of non-erosive reflux disease(NERD) and functional esophageal disease, so as to understand the pathogenesis of NERD and guide clinical treatment. Methods A total of 303 patients manifested as reflux symptoms, with GerdQ score over 8 and negative endoscopic results were selected from Outpatient Department of Gastroenterology, Sichuan Academy of Medical Sciences. The patients were divided into 125 cases of NERD group(pH positive), 108 cases of HE group(pH negative, SI or SAP positive), and 70 cases of FH group(pH negative, SI or SAP negative). The following indexes were collected: the distal contractile integral(DCI) with 5 ml liquid swallowing for 10 times, lower esophageal sphincter resting pressure(LESP), the percentage of effective peristalsis and esophagogastric junction(EGJ) type, impedance baseline value, the times of reflux with different properties and characters, and the times of proximal reflux. Results Esophageal baseline impedance of the NERD group and the HE group was significantly lower than that of the FH group(P < 0.05). For acid reflux, DeMeester score in the NERD group was significantly higher than that in the HE and FH groups, and AET and upright/supine AET in the NERD group were significantly longer than those in the HE and FH groups(P < 0.05). As to physical and chemical reflux, the NERD group demonstrated mainly acidic, liquid and mixed reflux; the HE group demonstrated mainly weak acidic, liquid and mixed reflux; the FH group demonstrated non-acidic reflux and gas reflux. Regarding esophageal motility index, LESP of the NERD group was lower than that of the HE group and the FH group(P < 0.05). DCI and the number of effective esophageal motility in the NERD group and the HE group were lower than those in the FH group(P < 0.05). The percentage of type Ⅱ EGJ in the NERD group(29%) was higher than that in the HE group(9%) and the FH group(1%)(P < 0.05). Conclusions The positive acid exposure of NERD is more in line with the pathogenesis of gastroesophageal reflux disease in esophageal motility and reflux events. The decrease of esophageal motility and the ratio of reflux events are more obvious in the HE group than in the FH group in functional esophageal diseases. FH group is not apparently abnormal in esophageal dynamics and regurgitation. HRM combined with 24-h pH-MII has more advantages in diagnosis of endoscopic negative heartburn, which can provide basis and guidance for clinical treatment.
引文
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[9]XIE C. Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux[J]. BMC Gastroenterol, 2017, 17(1):118.
[2]LEE S W. Impact of overlapping functional gastrointestinal disorders on the presentation and quality of life of patients with erosiveesophagitisandnonerosiverefluxdisease[J].MedPrinc Pract, 2015, 24(5):91-495.
[3]LEE S W. Characteristics of symptom presentation and risk factors in patients with erosive esophagitis and nonerosive reflux disease[J]. Med Princ Pract, 2014, 23(5):460-464.
[4]SAVARINO E. Impedance-pH reflux patterns can differentiate non-erosive reflux disease from functional heartburn patients[J]. J Gastroenterol, 2012, 47(2):159-168.
[5]MARTINEZ SD, MALAGON IB, GAREWAL HS, et al. Nonerosive reflux disease(NERD)acid reflux and symptom patterns[J].Aliment Pharmacol Ther, 2003. 17(4):537-545.
[6]WANGF. Ananalysisof342patientswithrefractory gastroesophageal reflux disease symptoms using questionnaires,high-resolution manometry, and impedance-pH monitoring[J].Medicine(Baltimore), 2017, 96(5):e5906.
[7]ROMAN S. Ambulatory reflux monitoring for diagnosis of gastroesophagealrefluxdisease:updateofthePortoconsensusand recommendations from an international consensus group[J].Neurogastroenterol Motil, 2017, 29(10):1-15.
[8]GABBARD S L. Identifying minimal changes in nonerosive reflux disease:is the pay worth the labor[J]. J Clin Gastroenterol, 2016,50(1):11-16.
[9]XIE C. Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux[J]. BMC Gastroenterol, 2017, 17(1):118.